Who Mono 44

WORLD HEALTH ORGANIZATION
MONOGRAPH SERIES
No. 44
ENDEMIC GOITRE
ENDEMIC GOITRE
CONTRIBUTORS
F. W. CLEMENTS - J. DE MOERLOOSE - M. P. DESMET

J. C.M. HOLMAl'l - F. C. K E L L Y - P. LANGER - - S. LISSITZKY
F. W. LOWENSTEIN - W. McCARTNEY - J. MATOVINOVIC
S. T. MILCU - J. A. MUNOZ - C. PEREZ
V. RAMALINGASWAMI - J. ROCHE
N. S. SCRIMSHAW - W. W. SNEDDEN
J . B . STANBURY
.€ .
UJ
WORLD HEALTH ORGANIZATION
PAL..\IS DES KATIO:SS
GENEVA
1960
Authors alone are responsible for Yiews expressed in the Monograph Series
of the World Health Organization.
The mention of specific companies or of certain manufacturers' products
does not imply that they are endorsed or recommended by the World Health
Organization in preference to others of a similar nature which are not men-
tioned. Proprietary names are distinguished by initial capital letters.
PRINTED I N SWITZERLAND
CONTENTS
Page
Preface 7
History of goitre - P. Langer 9
Prevalence and geographical distribution of endemic goitre -
F. C. Kelly & TF. T-V. Snedden . . . . . . . . . . . . 27
Health significance of endemic goitre and related conditions -
F. W. Clements . . . . . . . . . . . . . 235
Physiology of endemic goitre - - J. B. Stanbury 261
The study of experimental goitre - S. T. Milcu 279
Pathological anatomy of endemic goitre - M. P. De Smet 315
Etiology of endemic goitre - J. Roche & S. Lissitzky . . 351
Technique of endemic goitre surveys - C. Perez, N. S. Scrim-
shaw & J. A. J\.fuiioz . . . . . . . . . . . . . . . . . 369
Therapy and prophylaxis of endemic goitre - J. 1\fatovinovic
& V. Ramalingaswami . . . . . . . . . . . . . . 385
lodization of salt - J. C. M. Holman & W. ]vfcCartney 411
Principles and problems of endemic goitre control - F. W.
Lowenstein . . . . . . . . . . . . . . . . . . 443
Legislation on iodine prophylaxis - J. De lvfoerloose 453
Index . . 465
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PREFACE
Forty years ago, David Marine, one o f the pioneers o f mass prophylaxis
o f endemic goitre, claimed that " Simple goitre is the easiest o f all known
diseases to prevent . . . It may be excluded from the list o f human diseases
as soon as society determines to make the effort." Society has still not made
that effort, although nothing that has since been learned about endemic goitre
has cast doubt on the fundamental validity o f Marine' s assertion. Public
health authorities in many countries have tended to underestimate the impor-
tance o f endemic goitre as a threat to physical, social and economic well-
being; they have lacked conviction regarding the safety and efficacy o f pro-
phylactic measures; and they have been deterred by administrative and technical
difficulties.
In 1950, the Third World Health Assembly, recognizing the need to
stimulate action, recommended that the JVorld Health Organization should
undertake a study o f endemic goitre and encourage govemments to investigate
the problem within their territories. A study group on endemic goitre was
convened in 1952 and its report was published in a special issue o f the WHO
Bulletin, which also included a number o f original papers dealing with various
aspects o f goitre control.
The scope o f this first WHO publication on endemic goitre was intentionally
limited, its object being to make available a number o f reports 011 studies
carried out in various parts o f the world and not to offer a comprehensive
discussion o f the problem o f endemic goitre conrrol. It was felt, however, that
WHO could render a useful senice to public health workers, as well as to all
those engaged in the study o f goitre, by inviting 11'ell-known goitre workers to
prepare reviews covering all aspects o f the su ject and collecting these together
in a single volume. Plans were drawn up for such a monograph, but by the
date set for publication, only six chapters had been received and important
gaps remained. As an interim measure, it was decided to publish these six
chapters in a second special issue f the Bulletin ( 1958) and to defer publica-
tion o f the monograph until additional contributions had been obtained. This
has now been done. The present monograph comprises the original six chapters,
-7-
8 PREFACE
revised and brought up to date by their authors, together with six new chapters
covering the history, physiology, pathology and etiology o f endemic goitre,
experimental studies on goitre, practical dspects o f endemic goitre control,
and legislation on iodine prophylaxis.
Professor W. J. Darby o f the Division o f Nutrition, Vanderbilt University
School o f Medicine, Nashville, Tennessee, USA, greatlyassisted in drawing up
the plans for this monograph. Valuable technical assistance has been provided
by Dr F. C. Kelly, Director o f the Chilean Iodine Educational Bureau, London,
through all stages in the preparation o f the material, and helpful suggestions
regarding one o f the chapters have been receivedfrom Professor W. H. Sebrell,
[)irector o f the Institute o f Nutrition Sciences, Columbia University, New
York. To them and to all the contributors who have graciously devoted so
much o f their time to this undertaking the World Health Organization remains
deeply indebted.
It is hoped that this monograph will not only serve as a work o f reference
for all those interested in the control o f endemic goitre but will also encourage
the adoption o f active measures in those countries where endemic goitre is a
considerable public health problem but has not yet received the attention it
deserves.
HISTORY OF GOITRE
P. LANGER*
Ancient times
In the light of present knowledge of the etiology of endemic goitre, it
would not seem unreasonable to infer that this disorder may have been
present from time immemorial among the populations of various parts of
the world. Indeed, it seems extremely probable that the etiological agents
known to-day (iodine deficiency, nutritional, hygienic, and climatic factors)
exercised the same infkence in the distant past as they do now.
It is, however, next to impossible to substantiate this presumption
with any historical evidence, and consequently we must content ourselves
with what references to goitre-often very fragmentary-we can find in the
earliest literary sources.
One of the oldest references to goitre is attributed to the legendary
Chinese emperor Shen-Nung (2838-2698 B.c.), who, in his book Pen-Ts'ao
Tsing (A treatise on herbs and roots) is said to mention the seaweed Sar-
gassum as an efficacious remedy against goitre. 36 • 62 However, there are
doubts about the very existence of Shen-Nung as an historical personality.
In the book Huang Ti Nei Ching, dating from the period 2697-2597 B.C.,
two types of neck tumour are recognized: those caused by an " accumulation
of air " (tumours proper?), and those brought about by an " accumulation
of blood " (inflammatory swellings ?). 1 Goitre is like\vise mentioned in the
book Shan Khai Tsing (A treatise 011 waters and d1y lands), from the period
770-220 B.C., which attributes the disease to the poor quality of the water;
and further references are to be found in the literary remains of the Han
dynasty (206 B.C. to A.D. 220) and the Wei dynasty (200-264 A.D.),
where, along with drinking-water, deep mental emotions and "certain
conditions of life in mountainous regions " are arraigned as causes of
goitre. The famous Chinese medical writer Ge-Khun, who lived somewhere
between A.D. 317 and 419, described a mode of treatment for goitre con-
sisting of Sargassum weeds and the weed Laminaria japonica Aresch. The
* Endocrinological Insritute, Slovak Academy Q( Sciences, Brmislara, Czechos!o}·akia
-9-
10 P. LANGER
ancient Chinese even used animal thyroid in the treatment of goitre: thus,
in the book Shen Shi-Fan (420-501 A.D.) mention is made of the use of deer
thyroid for this purpose. 62 Later Laminaria religiosa Aresch was used,
references to this seaweed dating back to the 12th century. Animal thyroid
also continued in use in China, and in the well-known herbal by the emi-
nent Chinese physician Li Shi-Chen (Ming dynasty, 1552-1578) entitled
Pen-Ts'.ao Kang-Mu preparations of pig and deer thyroid are mentioned in
the treatment of goitre. 62 We may well speculate about how much the Chinese
really knew of the function of the thyroid and its relationship to goitre,
References to the treatment of goitre with seaweed and even with animal
thyroid, both of which have now been established as containing iodine,
lend support to the assumption that the disease in question really was
goitre, for it may further be assumed that the recommendation of this
therapy by ancient authors was based on the purely empirical observation
that it was the most efficacious among a whole series of other modes of
treatment then in use. It would indeed be difficult to imagine how seaweed
and sponges could for thousands of years have entered as ingredients into
preparations of remedies against goitre had no favourable results ensued.
Ancient Hindu accounts of medical literature likewise contain references
to goitre. Incantations against goitre from the period around 2000 B.C.
are found in the Atharva-Veda. 5 Galaganda was the name given by the
early Hindu physicians Susruta and Charaka (about 500 B.C.) to tumours
of the neck. These tumours are generally considered to have been
goitres, 15, 31, 36 although Greenwald holds a different opinion in spite of the
fact that the term galaganda is used to this day in India to denote goitre. 24
Tumours of the neck were also known in ancient Egypt, where, according
to the Ebers papyrus (about 1500 B.C.), they were treated surgically.11
Local applications containing, among other components, salt from Lower
Egypt (sea salt?) were used in the treatment of these tumours. It would
nevertheless be difficult to decide whether endemic goitre was known at
that time. According to Mettler, the operations reported in the Ebers
papyrus include thyroidectomy. 51 Wilke, on the other hand, states that
no goitres can be identified, either on mummies or on ancient Egyptian
paintings. 72 In this connexion, however, it has to be borne in mind that
not even the basic proportions of the body are correctly shown in these
paintings. Jantsch 36 notes that, according to Pliny, 61 goitre was widespread
in Africa, but this is obviously an error due to an inaccurate interpretation
of the original text. Greenwald maintains that goitre was unknown in
Africa at that period. 19
From ancient times in Western Europe we possess a few accounts by
Roman authors that agree about the prevalence of endemic goitre in the
Alps. Thus, the poet Juvenal (lst century A.D.) asks: " Quis tumidum
guttur miratur in Alpibus? " (Who wonders at a swelling of the neck in
the Alps ?). 38 The architect Vitruvius (lst century B.c.) writes:" Aequiculis
HISTORY OF GOITRE 11
in Italia et in Alpibus nationi Medullorum est genus aquae, quam qui

bibunt afficiuntur turgidis gutturibus " (The Aequi in Italy and the Medulli
in the Alps have a kind of water, from drinking which they get a swelling
of the neck). 71 With a little imagination Ovid's words " Quodque magis
mirum, sunt qui non corpora tantum Verum animos etiam valeant mutare
liquores " (And what is more wonderful, there are waters that have the
power to change not only the body but also the mind) might be inter-
preted as reflecting the poet's impressions on seeing a cretin. 55 Pliny, too,
in the lst century A.D. touches upon the subject of goitre: "Guttur homini
tantum et suibus intumescit, aquarum quae potantur plerumque vitio "
(Swelling of the throat occurs only in men and in swine, caused mostly
by the water they drink), 58 and in various places in his writings he lists
whole series of remedies against goitre. 59 Ulpianus (2nd century A.D.)
writes: " Tumido gutture praecipue laborant Alpium incolae, propter
aquarum qualitatem quibus utuntur " (The inhabitants of the Alps suffer
from a big neck, caused by the quality of the water they drink). 32 Caesar
is credited with having noted the occurrence of a big neck among the
Gauls as one of their peculiarities. 54 , 65
Works of celebrated physicians of that period often contain descriptions
of neck tumours. Nevertheless, the thyroid was not yet regarded as a
specific organ and was lumped together with the other neck glands. Goitre
was confused with other swellings of the neck (tuberculous glands, lym-
phadenitis, parotitis, etc.), whence the Greek appellation " (3p oyXoK71 A.71 "
(bronchocele) and the very similar expression in Latin " tumor gutturis " or
" guttur tumidum ", which prevailed until the 17th, and to some extent even
until the 19th, century.
In Hippocratic writings (4th century B.c.) one finds the expression
" y oyyp wv71 " (gongrona), which Ambroise Pare (1150-1590) interpreted to
mean goitre (De gongrona ou bronchocoele), and Littre (1840) also translated
as goitre. 35 Another Hippocratic expression " Xolpoi, " (choiron) was
taken to stand for goitre and was subsequently employed in this sense, for
instance by Paulus Aegina (7th century). 31 "Botium" is yet another term
sometimes encountered. Thus, Rogerius Salernitanus (12th century) wrote
De cura botii. The word struma was first used by Albrecht von Haller
(1708-1777) when he remarked t h a t : " Strumis longe plerumque thyreoidam
glandulam vitiari vulgo notum est " (It is generally known that goitre is
mostly an affection of the thyroid gland). 35 These are but a few of the more
important expressions to designate goitre encountered in the literature of
the past, and many more naturally exist in various languages.
In the well-known Hippocratic treatise on Air, water and places,
drinking-water is regarded as a cause of goitre (choiron) 31• Celsus
(25 B.C.-A.D. 45) described a tumour (bronchocele) of the neck situated
" between the skin and the larynx that is fleshy only, or may contain a sort
of honey-like substance, sometimes even containing small bones and hairs
12 P. LANGER
mixed together ", and he recommended incision in its treatment. 15 He

was probably the first to attempt to make a distinction between the various
forms of tumours of the neck. Galen (A.D. 132-200) also described an
operation for goitre, and was even aware of the danger of damaging the
recurrent laryngeal nerve. To the glands of the neck (and therefore to the
thyroid also), he ascribed the role of secreting a fluid into the larynx and
the pharynx.
These views were accepted as late as the 17th and the 18th centuries
(even after the discovery of the thyroid as a specific organ), by such phy-
sicians, for example, as Bartholin (1616-1680), Malpighi (1628-1694), and
Boerhaave (1668-1738). 9 , 36, 66
We find, however, very little definite information regarding endemic
gpitre in the medical works referred to above, or in other writings. A plau
sible explanation for this is advanced by Hirsch, when he remarks that
physicians did not formerly gain their experience in localities where goitre
may have been widespread, and had in any case little interest in the diseases
of populations as a whole.
References to goitre operations are scattered through a great many other
works. Thus Leonidas of Alexandria (2nd century A.D.), Aetius de Amida
(about A.D. 550)-who was personal physician to the Emperor Justinian l -
and after him Paulus de Aegina (A.D. 626-690), all knew about surgical
treatment. They differentiated between cystic and solid goitre, the former
being suitable for operation, but not the latter because of the. copious
bleeding. Medical treatment was also used. Galen (A.D. 132-200) and
after him Oribasius (A.D. 325-403) both knew of the favourable effects of
burnt sea sponge. Aetius de Amida recommended repeated washing of the
neck with sea water, or local applications containing sea salt.
The Middle Ages
In the Middle Ages Rogerius Salernitanus ( Chirurgia Roger ii, 1170), of

the Salerno school, Gilbertus Anglicus of the Montpellier school ( Com-
pendium medicinae, 1240), and Bruno di Longoburgo, a professor at Padua
( Chirurgia magna, 1252), all described surgical operations for goitre. 47
Their works show that all of these eminent teachers knew goitre as such
and had come into contact wi,th it in the course of their medical practice.
The medical treatment recommended by the ancients for goitre had not
been forgotten. Rogerius Salernitanus advised an electuary containing
13 ingredients, among them the ashes of burnt sea sponge. 47 The use of
sea sponge persisted in the literature up to the 19th century. Gabriele
Fallopio (1523-1562) obtained successes even with 4-6 spoonfuls of sea
water, taken daily over a prolonged period. 36 In the Middle Ages goitre
was treated in the Alps with preparations concocted from the hypocotyledon
of Alpine violets growing in a massive knot. 70 The resemblance between
certain tumours on plants and goitre was built into a superstitious belief
in Northern Bohemia that goitre affected those who ate gall-nuts. 7 There are
a great many of these popular superstitions and customs and it is not
possible to deal with them all here. In Bohemia and Germany, for example,
it was held that goitre was the result of strenuous work or of frequent fits
of coughing, and that it occurred in women after a particularly difficult
labour-whence arose the custom of tying a lace round the neck of a
woman in labour. 33 A fairly widespread belief in Europe was that goitre
is brought on by the effects of the moon. In Ecuador it used to be customary
to rub goitres with saliva at the time of the new moon. 31
During the Middle Ages the most advanced thinkers on medical subjects
were the Arabs. One of their greatest surgeons, Albucasis (lOth century)
differentiated between congenital and acquired goitre. Of these only the
latter, in his opinion, was fit for surgery, and then only if it was not too
large_ 15, 36, 45
Endemic goitre was sporadically mentioned. Guy de Chauliac (born
A.D. 1300) wrote: " Botium aegritudo regionalis et hereditaria apud
multos reputatur " (Goitre [botium] is frequently considered to be a local
and hereditary disease), and Lafranchi (died A.D. 1306) considered hard
water, especially that found in the Alpine region and in Lombardy, to be
the cause of goitre. Arnold de Villanova (1235-1312) left a very interesting
piece of advice for those suffering from goitre, viz., that they migrate to
another region if less than 25 years of age. He also described goitre in the
Lucca province. Later, Valescus de Tharanta mentioned goitre as occurring
in the province of Foix. 32• 36 We may also note that Marco Polo, on his
travels across Asia in the 13th century, observed goitre in Yarkand.
Reports of the existence of goitre on the American continent prior to the
arrival of Europeans have recently given rise to controversies. Leon 44
and Lastres 56 take the expression coto or ccotto, used by the natives
before the time of Colombus, as evidence that goitre did exist in parts of
South America at that period. Greenwald, on the other hand, maintains
that goitre did not appear in that region before the 17th or 18th centu-
ries. 18, 24, 27 According to his interpretation the word coro originally
meant " heap " or " bunch ", and was only later applied to mumps or goitre.
The Renaissance and after
Paracelsus (1493-1541) not only described goitre, but also, in his tract
De generatione stultorum, attributed the disease to a deficiency of minerals
in drinking-water.
A vivid description of endemic goitre and cretinism appears in the
treatise Praxeos medicae, by Felix Platter (1536-1614) of Basle. "Where-
fore," he wrote, " t h e disease is frequent in certains regions, in the beginning
they write of Egypt, and in Valesia Canton Bremis, as indeed I have seen it
myself, and in the Carinthia valley called Bintzgerthal many infants are
14 P. LANGER
wont to be afflicted: who besides their innate simple-mindedness, the head

is now and then misformed, the tongue immense and tumid, dumb, a struma
often at the throat, they show a deformed appearance: and seated in solemn
stateliness, staring, and a stick resting between their hands, their bodies
twisted variously, their eyes wide apart, they show immoderate laughter
and wonder at unknown things." a The Zurich chronicler Josias Simmler
(1530-1576) described cretins in the canton of Valais, Switzerland, and
another Swiss chronicler, Johannes Stumpf (1500-1558) recorded the inci-
dence of goitre in the Grisons at Trimmis, Untervaz, Zizers and Igis. The
Dutch physician Pieter van Foreest (died 1597) noted that there were many
cretins in the province of Valtellina, 5, 13 on the Italian side of the Swiss
border. In 1601 Johannes Jessenius, a Prague physician, mentioned the
occurrence of goitre in various regions (in Bohemia?), and added the
strange comment that people considered goitre as a form of adornment. 37
In 1736 Gmelin published accounts of goitre occurring in the Lena river
basin in Russia. 54 In Poland, too, descriptions of goitre attributed to the
poor quality of drinking-water appeared in 17 57. 42 In the l 8th century a
remarkable description of endemic cretinism was given by the naturalist
H. de Saussure of Geneva, who had observed the condition on his Alpine
travels and attributed it to the elevation above sea level and to the quality
of the air. Other noteworthy accounts were given by Malacarne (1778) and
Ackermann (1790), who visited cretins in their dwellings and ascribed the
disorder to advanced stages of rickets. Fodere (1796) recorded cretinism in
Savoy and in the Aosta valley, but rejected rickets as a cause. 13 Endemic
goitre was known in Derbyshire, England, in the first half of the 18th century
under the name o f " Derbyshire neck ". 18
The number of written reports on goitre has multiplied enormously, so
that it is not possible to mention them all. It must, however, be. assumed
that if physicians and even laymen in the past described goitre or any other
tumours of the neck, the swellings must certainly have been strikingly
conspicuous, arresting the attention at first sight. Goitres of the first or
even the second degree, as usually classified to-day,b probably passed
unnoticed, even by physicians, whose interest then lay almost exclusively in
curative practice. Perhaps even to-day there are some medical men who
do not consider as goitres thyroid enlargements that are hardly perceptible
to the eye when the neck is not extended, and refuse to admit that these
growths are caused by the same etiological factors as cause large goitres
and have the same pathophysiological effects, though perhaps in a somewhat
modified degree. Overwhelming testimony from all parts of the world shows,
however, that these small goitres are by far the most frequent, and there are
regions where massive goitres are relatively rare. But even medium-sized
a This translation is quoted from Major, R.H. (1939) Classic descriptions of disease, 2nd ed., Springfield,
Thomas.
b See the chapters Pathological anatomy of endemic goitre on page 315 and Technique of endemic goitre
surveys on page 369 o f this monograph.
goitres, such as occur relatively frequently, may well escape notice in the
normal course of everyday life.
In some regions, it is only when the women remove the head scarf that
they wear knotted under their chin and undo the collar of their dress that
the goitre is exposed and the full extent of the endemic becomes apparent.
Even in our own day, such examinations have revealed a striking frequency
of goitre in regions hitherto considered free from this disease, and no doubt
a similar frequency would have been no less discoverable by these means in
the past, especially in temperate and cold climates. Nor can we ignore the
efforts, often ingenious, of individuals affected with prominent goitres to hide
them from sight, for the deformity attracts notice, brings-and always has
brought-mockery upon the unfortunate sufferer, and may at times induce
him to shun the company of his fellows. This is especially true of cretins.
Cases are known-exceptional, it is true, yet none the less dramatic-of
cretins living in stables among farm animals.
These circumstances must be taken into account \Vhen interpreting older
reports on goitre. Moreover, goitre has never been a killer among diseases,
and this too would go to explain why ancient authors devoted less attention
to it than to other diseases. It is probable that none of them considered
goitre of the first or even the second degree as a disease, especially i f it
presented no clinical symptoms. Quite the contrary, indeed: such goitres,
we believe, were regarded as normal, particularly in women. But there is
one most serious obstacle in the way of a correct interpretation of earlier
works on goitre, and that is, and no doubt will continue to be, the confusion
made between goitre, tuberculous glands, parotitis and other conditions in
the neck.
To fill the gaps left by the lack of literary references we might invoke
the help of the creative arts, notably painting. It is well known that many
eminent painters painted their female models almost exclusively with a
swelling .of the lower part of the neck that appears to us to be goitre of the
first or second degree. A study of goitre in 16th century art was made by
Hunziger, 34 and De Josselin de Jong 12 referred to the appearance of goitre
in pictures by van Eyck, Lucas van Leyden, Rubens and Riemenschneider.
Rolleston likewise detected goitre in paintings by Weyden, Diirer, and
Rubens. 66 We are of the opinion, however, that only the first st ps have so
far been taken to evaluate this rich material. There are cases where a study
of ancient works of art may reveal unexpected details, as, for instance, the
finding of a picture of a cretin in an old psalter. 50 On the other hand, it is
often difficult to decide whether the swelling depicted is to be attributed to
endemic goitre or toxic adenoma, and opinions differ regarding the correct
interpretation.
Original, and in themselves very interesting, views, supported by histori-
cal studies on the prevalence of goitre in various parts of the world 18-28,
have recently been expressed by Greenwald, ,vho arrives at the conclusion
16 P. LANGER
that goitre in many countries is only of recent date. His studies show that
the history of goitre in some lands resembles the pattern seen in infectious
diseases. He postulates an infectious agent for goitre which, he claims, was
present approximately 2000 years ago in the Alps, and only in the Alps,
whence it slowly made its way into the rest of Western Europe and other
parts of the world (America, Africa, New Zealand, the Philippines, Ceylon,
etc.), his view being that goitre spread in these regions only afterthe arrival
of Europeans. In many countries its first appearance was marked by severe
outbreaks, after which it became less active. The disease resembles leprosy
in that it is not, in ordinary circumstances, readily communicable but
generally requires prolonged exposure. According to Greenwald, the older
reports on swellings of the neck in various countries for the most part
describe tuberculous glands or parotitis, and some of the earlier accounts
are not reliable enough for an opinion to be hazarded. He admits the
occurrence in isolated cases of enlargement of the thyroid, but such instances
are not to be confused with endemic goitre. As far as Greenwald's theories
are concerned, it is pertinent to observe that not even the best of historical
studies will ever provide a solution to these problems, and that the infection
theory will have to be corroborated by biological methods.
Anatomy and physiology of the thyroid

In follo ing advances in knowledge of the anatomy and physiology
of the thyroid through the Renaissance period, we find a whole series of
new concepts springing up. Probably the first person to describe the thyroid
was Andreas Vesalius (1514-1564). It consists, he said, of "two glands
(glandulas ad laryngis radicem adnatas) one on each side of the root of the
larynx, which are large, fungus 7like, flesh-coloured, and covered with
numerous vessels. The purpose of these glands . . . is to moisten the lumen
of the trachea ". 51 The first to differentiate the thyroid from the other organs
of the neck, however, was Realdus Colombus (1516-1559), who noted
that: " Dl;lae aliae glandulae haerent laryngi asperaeque arteriae, quae
feminis sunt quam viris crassiores, hinc laryngis pars prominentior in
paucis mulieribus conspicuor est, nam ah earum glandularum crassitie
occupatur et sub. ea habitat" (Two other glands are attached to the larynx
and the rough artery [trachea] and these are larger in women than in men;
in few women, therefore, is the protruding part of the larynx more con-
spicuous since it is rounded out by the thickness of these glands and situated
beneath them). 56 Eustachius (1520-1574) discovered the isthmus of the
thyroid. Casserio (1561-1616) considered the thyroid to be one organ made
up of two parts without any excretory duct. Great credit for ascertaining
the anatomical site, size, and weight of the thyroid is due to Wharton
(1614-1673) whose work Adenographia sive glandularum totius corporis
descriptio (Adenography or a description o f the glands o f the entire body)
(London, 1656), contains this description of the gland: " . . . it contributes

much to the rotundity and beauty of the neck, filling up the vacant spaces
round the larynx, and making its protuberant parts almost to subside and
become smooth, particularly in females, to whom for this reason a larger
gland has been assigned, which renders their necks more even and beauti-
ful ". 22 This extract gives the impression that the author was used to seeing
goitres of the first degree in women, and considered them as normal.
In spite of the fact that anatomically the thyroid was fairly well differen-
tiated, its function was far from being understood. For the most part its
role, with the other neck glands, was supposed to be to humidify the walls
of the larynx, the pharynx and the trachea. At one time it -was even con-
considered, by J. Vercelloni, 1711, and Heister, 1717, to be a receptacle for
worms. 66
Schreger (1768-1833) was the first to notice the special blood supply of
the thyroid, which he surmised to be a vascular shunt cushioning the brain
against a sudden increase in blood flow. Even the anatomist Herbert
Luschka (1820-1874) still considered the thyroid to be an elastic cushion
protecting the larynx, trachea, blood-vessels and nerves of the neck against
direct muscular pressure. 36 Merkel (1857), and prior to him Boerhaave
and Martin, had taught the view that the thyroid strengthens the larynx and
modulates the voice. 69 Towards the end of the 18th century, however,
Albrecht von Haller (1708-1778) had classified the thyroid, the thymus, and
the spleen as ductless glands, secreting a special fluid into the bloodstream,
and De Borden (1776) put forward a theory on internal secretion to the effect
that every gland, and similarly every organ in the body, produces specific
secretions, which enter the bloodstream and bring about the integration
of the entire organism. 66 But the real function of the thyroid remained
hidden until the last decade of the 19th century.
Beside these scientific views flourished a host of non-scientific theses,
fallacies, and popular superstitions and customs. In the Middle Ages goitre
had been regarded as being a visitation of God, and it is so seen for instance
in some legends of the 5th to the 7th centuries. 32 Later, the belief spread that
goitre could be cured by the touch of the monarch. In France, Clovis I is said
to have cured the disease in this manner, and Henry IV, according to his
personal physician Andre Dulaurens (1550-1601), 36 caused 1500 goitres to
regress by touching the patients and using the formula: '' Le roi te touche
et Dieu te guerit." Many English sovereigns practised a similar custom,
and between 1662 and 1682, Charles II is alleged to ha,e "touched" 9200
sufferers from the " King's Evil " or scrofula, ,vith which goitre was often
confused. 2 On 20 March 1710, according to newspaper reports of the
time, Queen Anne again revived the ancient custom of curing goitre by
the imposition of hands. 53 This healing power was supposed to be shared
by every seventh son of a family,7 and it was also thought to reside in the
touch of a corpse's hand, a superstition knO\vn even to Pliny. 00
2
18 P. LANGER
Towards the end of the 18th and the beginning of the 19th centuries,
knowledge about the thyroid made great advances, owing to the efforts of
anatomists, physiologists, and clinicians. Studies on endemic cretinism
showed that goitre may have been associated with more serious disturb-
ances of this kind, even though the deeper relationships between goitre and
cretinism were as yet unknown.
Caleb Hillier Parry (1755-1822) was the earliest to describe exo-
phthalmic goitre, which he first observed in 1786 (the account was published
three years after his death in Unpublished medical writings). 47, 66 In 1835
Robert James Graves (1797-1853) published, in the London Medical and
Surgical Journal a report of newly observed thyroid affections in women,
associated with heart palpitations and, in one case, with exophthalmos.
It is claimed that the first man to connect exophthalmos with goitre
was the great Persian physician, Sayyid Ismail Al-Jurjani (about the year
A.D. 1136). 66 In 1722 the ophthalmologist Charles Saint-Yves (1667-
1736) described 3 cases of exophthalmos accompanied by cardiac pain and
slight goitre, but he failed to see any relationship between these symptoms.
Some authors think that similar cases had been described earlier by
Morgagni (1682-1771), Wiseman (1628-1676), and others. In 1802 Giuseppe
Flajani described two cases of goitre with palpitation of the heart. Carl von
Basedow (1799-1854) reported a case of exophthalmic goitre in 1840, and
drew attention to three main symptoms: goitre, exophthalmos, and tachy-
cardia; and Charcot in 1863 pointed out a fourth one, tremor. In 1886
Moebius set forth the thyrogenous theory of exophthalmic goitre in these
words: " Graves' disease is an intoxication of the organism resulting from
disturbed thyroid activity". The first metabolic studies in patients with
exophthalrnic goitre were made by Friedrich Muller in 1893 and two years
later Magnus-Levy showed an increased metabolic rate in these patients.
This brief historical review of the development of knowledge of thyroid
hyperfunction shows that our basic concepts are much less than a hundred
years old.
Knowledge of thyroid hypofunction-myxoedema, a term introduced
by W. M. Ord in 1878-is of even more recent date, in spite of the claim
that Wolfgang Hoefer described it as early as 1657. 47 The first clear and
correct description of myxoedema was given in 1873 by William Withey
Gull (1816-1890) a s " A cretinoid state supervening in adult life in women". 66
Not only the physicians, but some surgeons also recognized the existence
of hypothyroidism, foremost among them being Theodor Kocher (1814-
1917), J. L. Reverdin (1842-1929), and his cousin A. Reverdin .(1849-1908).
Some of the experimental work that preceded these concepts deserves
mention. A. P. Cooper in 1836 carried out thyroidectomy in puppies,
and later observed the dulling of the faculties it caused. Wilhelm Rapp
noted certain thyroprival symptoms but ascribed them to operational trauma.
Moritz Schiff (1823-1896) was the first systematically to carry out total
thyroidectomy (in 1856-57) on various animals, the majority of which later

perished. In 1884 he repeated these experiments, and found that death
could be prevented by intra-abdominal transplants of the gland. 66 These
and a host of other experiments showed that the thyroid plays an essential
role in the organism. Nevertheless, there were some who categorically
denied any function to the thyroid (Munk, 1887; Drobnick, 1888; Arthaud
and Magon, 1891), and attributed deficiency phenomena to the injury of
adjacent organs, especially the nerves. 65 However, the decisive factor in
the final appraisal of the significance of the thyroid came from the work
of surgeons. In 1883, at a congress of German surgeons in Berlin, Kocher
reported the changes following total thyroidectomy, the overall picture
of which he termed cachexia strumipriva. He attributed this condition
directly and with absolute certainty to total extirpation of the thyroid, an
operation which, from then on, he rejected completely. He stressed the
close relationship between cachexia and cretinism, and saw in the loss or
impairment of thyroid function a cause common to both. The differences
between the conditions, he felt, lie in the fact that cretinism is congenital
and hereditary. In September 1882, before the Geneva Medical Society,
J. L. Reverdin described his 14 cases of thyroidectomy and, a few months
before Kocher, laid stress on the consequences that supervened 2-3 months
after the operation. He asked whether some unknown function of the
thyroid that had been excised did not enter into play, and from then on
decided to discontinue the practice of total extirpation. He recollected
that in one case he had removed one lobe only and the ill effects had failed
to appear. In April-May 1883, in the Rerne medicale de la Suisse Romande
he noted that the changes he had found to follow thyroidectomy were
identical with the myxoedema of English authors, and termed them
"myxcedeme operatoire ". The long drawn out polemic between Kocher
and Reverdin as to who had priority in these observations was recently
summarized (1951) in detail by Bornhauser. 5
The 19th and 20th centuries
The 19th century witnessed substantial progress in biological and

medical research, supported more and more by objective and precise
methods. The number of reports on endemic goitre grew rapidly and great
interest was shown in ascertaining the actual prevalence of goitre and
cretinism in various regions. The first of these epidemiological studies
was, in all probability, dictated by military needs: this was when Napoleon
ordered a systematic investigation of goitre because of the large numbers
of young men from certain regions who were rejected by recruiting boards
as unfit for military duties. He might haye been prompted to this step by
the vivid impression made on him by the populations stricken by cretinism
which he saw at the time of his march into Italy through the Valais. 13
20 P. LANGER
In 1845, a special commission was appointed by King Carlo Alberto

of Sardinia to study the extent of goitre throughout his Kingdom (the
provinces of Savoy, Nice, Piedmont, Genoa and the island of Sardinia)
and recommend means of combating it. 68 A similar commission was set
up in 1864 by the French Government. Ten years later this commission
submitted its report, in which it was recorded that 370 403 persons in
France above the age of 20 had goitre, and that in addition there were
approximately 120 OOO cretins and idiots (the total population of France
at that time was around 36 million). At this period, government depart-
ments in several countries began to show interest in the prevalence of goitre
and cretinism. Statistical reports, based chiefly on conscription records,
appeared. In 1881, for example, Sormani published the results of the
examination of over 2 million recruits carried out between 1863 and 1876,
out of whom 42 863, i.e., 2.09 % had been declared unfit because of goitre. 32
Thus, the widespread character of endemic goitre became evident. Neverthe-
less, all the writings from this period are characterized by the lack of a
uniform criterion for the evaluation of goitre (this still holds true today
in spite of the great progress that has been achieved). Differences between
the findings of various observers were considerable, and it was practically
impossible to make comparative studies without running the risk of reaching
paradoxical conclusions. Moreover, most of the studies, being based on
military statistics, included only males, who are much less affected by
goitre than females.
During the last 50 years, hundreds of epidemiological studies on endemic
goitre have been carried out in all parts of the world, and attempts have
been made to correlate prevalence with geophysical and geochc:mical
features, as well as with various other environmental factors. These studies
are reviewed country by country by Kelly and Snedden in the chapter
Prevalence and geographical distribution o f endemic goitre (pages 27-233),
and no attempt will be made to summarize them here.
Realization of the world-wide character of endemic goitre and of its
public health importance focused attention on its etiology and on methods
of mass prophylaxis. As early as 1867, Saint-Lager 67 had listed 43 different
views on the causes of goitre, expressed by 378 authors. Nineteen of these
views attribute the disease to various properties of water, to its origin, or
to deficiency or excess of certain minerals; 11 to properties of the atmos-
phere (humidity, temperature, chemical composition, lack of sunshine
or electricity, etc.); 6 to faulty nutrition, poverty and insanitary living
conditions; and the remaining 7 to sundry other causes, such as alcoholism
and consanguinity in marriage.
The view that goitre is caused by drinking certain kinds of water had
been widely held since ancient times, as has already been mentioned. It
was generally thought that a high content of certain minerals, particularly
calcium salts, was the factor principally involved. A strong advocate of
this theory was Boussingault who, in 1831, drew attention to the significance
of a limestone soil in the Cordilleras of New Grenada (now Colombia). 6
Further studies 16, "'6 suggested that the goitrogenic action of the limestone
was due more to the magnesium than to the calcium salts. The part played
by minerals in the production of goitre is still unsettled, but experimental
work by Hellwig 30 and others has shown that, under certain conditions,
calcium can exert a goitrogenic action.
A relationship between iodine and goitre seems to have been suspected
soon after Courtois isolated this element in 1811 from ashes of the seaweed
Fucus vesiculosus. 1 0 By 1816, iodine had already been used in the treatment
of goitre by Proust, 64 and in 1820 Coindet (1774-1848) independently
recommended iodine preparations for this purpose. He was prompted to
make this suggestion through his discovery that Fucus vesiculosus had been
used by Richard Russell (1700-1771) in England for the treatment of goitre
and that in 1819 iodine had also been found by Andrew Fyfe (1795-1891)
in sea sponges, long famed as a goitre remedy. He suspected that iodine
was the active substance in both cases. On 25 July 1820, he gave a lecture
to the Swiss Society of Natural Sciences in Geneva, in which he described
the pathological anatomy of goitre, stressed that the thyroid was an organ
sui generis, albeit of unknown function, and reported the first results of
iodine therapy. 8 Soon, however, the use of iodine in the treatment of goitre
met with marked opposition because of its toxic side-effects (cachexia,
cardiac upsets, disturbed menses, subacute and eve:1 chronic intoxication).
Coindet laid emphasis on correct dosage, for he himself noticed no untoward
effects in his 150 patients, whom he kept on low doses. He interrupted
medication at the very first sign of intoxication, and later adopted an inter-
mittent form of therapy. Jean-Louis Prevost (1790-1850), howeyer, found
that with Coindet's regime certain ill effects still appeared, in spite of every
care, and he conceived the idea of a steady reduction in dosage. At the
same time, he observed that amounts as low as 0.9-2.0 mg produced a
noticeable effect on goitre, from which he deduced that goitre might be
caused by a deficiency of iodine or bromine in water and that prophylactic
doses of these elements might help prevent its onset. In 1846, together with
the Italian, A. C. Maffoni, he put forward for the first time the theory that
endemic goitre is due to iodine de:ficiency. 63
The iodization of salt as a method of preventing goitre was first suggested
by Boussingault in 1833 (as described by Kelly & Snedden on page 43 in
their chapter on the Prevalence and geographical distribution o f endemic
goitre). In 1849, Grange, in a letter addressed to the French Academy of
Sciences, recommended the iodization of kitchen salt in the ratio 1: 10 000. 17
During the next two years, the French chemist Chatin published a series of
papers describing the results of systematic iodine determinations on air,
water, soils, and animal and vegetable foods from various localities in
France. On the basis of his :findings, he was able to divide these localities into
22 P. LANGER
four zones, in which the incidence of goitre was inversely proportional to

the iodine content of the environment. As a protection against goitre, he
recommended the supply of foodstuffs from non-goitrous regions, the
drinking of wine and pure, running water, the consumption of good food
of animal origin, and finally the use of iodized salt. Cha tin's work was
repeated several times, but with varying results. This is not surprising in
view of the extraordinary difficulties involved in the micro-determination
of the iodine content of natural substances. Some investigators (e.g.,
Nadler, 1861) considered Chatin's results to be faulty because they them-
selves failed to detect iodine in the atmosphere, in water, or in foodstuffs. 14
A tribunal appointed by the French Academy of Sciences reported unfavour-
ably and Chatin's findings fell into oblivion.
Thus far, there had been no real experimental evidence to connect
iodine with thyroid metabolism, but, in 1895, Baumann demonstrated that
the thyroid contains a surprisingly large amount of iodine and succeeded
in isolating from the thyroid a substance which he called " thyroiodine ",
containing 10 % of iodine. When used in physiological experiments, this
substance brought about the same effect as thyroid itself. 3 Oswald pursued
the study of the chemical composition of the active substances of the
thyroid and isolated thyroglobulin in 1899, and Kendall in 1919 isolated
crystalline thyroxine, 39 which C. R. Harington later (1926) prepared in
synthetic form. 29 These studies were decisive in showing iodine to be
an essential component of thyroid hormone and paved the way for a renewed
interest in iodine therapy and prophylaxis.
The more recent work on the etiology, pathological anatomy and phy-
siology of endemic goitre is discussed elsewhere in this monograph and
will not, therefore, be considered here. Attention is particularly directed,
however, to the pioneer studies of McCarrison in India on the goitro-
genic action of polluted water (see pages 157 and 364) and to those
of Astwood, Clements, Greer and others on goitrogens in the diet, especially
in vegetables of the Brassica genus (see pages 66, 194, 281 and 359). A
review of the history of cretinism and a discussion of its relationship to
endemic goitre will be found in the chapter by Clements (page 245).
Mass prophylaxis o f endemic goitre
Increased knowledge of the geographical distribution of endemic goitre
and of its frequency and intensity in various regions, together with a deeper
understanding of thyroid function and the causation of some of its disorders,
has led to a full realization of the social significance of goitre and of its
impact on the health of the community. Although the recommenda-
tions made in the last century by Boussingault, Grange, Chatin and others
for preventing goitre by the use of iodized salt were largely ignored, the
concept of mass prophylaxis by administering minute doses of iodine has
steadily gained acceptance during the last forty years.
Present-day practice in the prophylaxis of goitre is based on the teachings

of David Marine, who in 1915 declared t h a t " endemic goitre is the easiest
known disease to prevent ". In the same year, Hunziger proposed that
goitre prophylaxis with iodized salt be carried out in Switzerland.
The first large-scale trials with iodine were carried out in 1916-1920 by
Marine and Kimball in Akron, Ohio, USA, when they gave to about 5000
schoolgirls, aged between 11 and 18, a daily dose of 0.2 g of sodium iodide
in water for 10 days each spring and autumn (4 g of sodium iodide per
year). 41 , 48, 49 The results of these trials demonstrated conclusively the pro-
phylactic value of iodine and the absence of side-effects, despite the rela-
tively high doses. Mass prophylaxis ,vith iodized salt was first attempted in
Michigan in 1924. In five years, the goitre rate fell from 38.6 % to 9 % ;
no toxic effects at all were observed. Nevertheless, the fear of Jod-Base-
dow and other side-effects has lingered on and continued to hamper the
introduction of iodized salt on a community scale in other areas. Thus,
the US Department of Agriculture Bureau of Chemistry insisted on every
container of iodized salt being marked with a skull and cross-bones because
iodine was considered to be a poison. It was also feared by some surgeons
that the use of iodized salt would bring an epidemic of exophthalmic
goitre in its train. Many families refused, on various grounds, to use
iodized salt, and an attempt to enforce its use by federal legislation failed.
In spite of these difficulties, the consumption of iodized salt gradually
increased in the USA, and during the 1920's the iodization of salt began
to be practised also in Switzerland and in the Valtellina province of Italy;
Canada, the Netherlands, New Zealand, Poland and certain parts of
Germany followed a little later, and, more recently. iodized salt has also
come into use in some states of Central and South America.
Further details of the early trials with iodized salt and of the adminis-
trative and legal problems encountered will be found in Kimball .n and in
the chapters specifically devoted to these questions in this monograph
(see pages 386, 404, 411 and 443).
In concluding this historical survey-which makes no claim to being
a comprehensive study of the subject-it should be pointed out that to
date no serious objection has been raised against iodine prophylaxis although
the universal and absolute validity of the iodine-deficiency theory has often
been questioned. Today, ,ve possess an abundance of reports from all
parts of the world on the favourable effects of iodine prophylaxis, and
if this method were universally adopted, it would appear possible at least
to achieve a great reduction in endemic goitre in the world, if not to eradicate
it completely. This requires, however, concentration of effort and a long-
term, co-ordinated follow-up of the effecb of prophylactic treatment.
24 P. LANGER
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PREVALENCE AND GEOGRAPHICAL
DISTRIBUTION OF ENDEMIC GOITRE
F. C. KELLY, B.Sc., Ph.D., F.R.I.C. *&
W. W. SNEDDEN, M.A., B.Sc., Ph.D. *
Goitre, as this survey shows in detail, occurs with varying intensity in

almost every country; few countries appear to be entirely free from it. The
disease has been observed in the far north, in the tropics, and in the far
south; it occurs quite independently of climate, season or weather. More-
over, in its incidence goitre makes no distinction of race, nationality, colour,
creed or class; the North American, the European, the Chinese, the Hima-
layan Indian, the Turkoman, and the peoples of Central and South America
all suffer from it under certain conditions-some severely, some moderately,
some but mildly.
Without doubt the most notorious goitre centres of the world are
located in high mountain regions-in Alpine valleys, in the Pyrenees, on
the slopes of the Himalayas, and along the Cordillera of the Andes. But
goitre is also known to occur with considerable intensity in comparatively
low-lying areas and even at sea level; for example, it is seen around the
Great Lakes basin between Canada and the USA, in the plains of Lombardy,
in the ice-excoriated parts of Finland, and in the low-lying Netherlands.
Seven relief maps a showing the distribution of endemic goitre in different
areas of the world will be found in the appropriate sections of the text
(Fig. 1-7). These maps indicate only where goitre has been found but not
the severity of the endemic.
Students of iodine geochemistry have a ready explanation for these
diverse phenomena. They say that the types of terrain in which goitre is
for the most part found, be they at high altitude or low, are just those
which have been subjected either to flooding or to intense glaciation and
from which most of the soil iodine has been washed out and carried through
the rivers to the sea. During the last Ice Age, earlier soils were swept away
* Chilean Iodine Educational Bureau, London, England
a These maps have been kindly prepared by Mr C. Dutton, :',;itrate Corporation of Chile Limited.
-27-
28 F. C. KELLY & W. W. SNEDDEN
and new soil-making materials were generated by the grinding-up of virgin

crystalline rock containing, at the most, one-tenth the average iodine
content of mature agricultural soils. As the ice cover receded, replenishment
of the iodine in glacial and postglacial soil materials began-a process
which is still in progress. The time since the start of this replenishment,
that is, the time since the disappearance of the great inland ice-sheets, is
estimated to be 10 OOOto 20 OOOyears for the central and northern parts
of Scandinavia and the northernmost part of North America, and corre-
spondingly longer for the southern parts of the glaciated areas of Europe
and North America. This accords with the fact that the frequency distribu-
tion of goitre in North America and in a number of countries in Europe,
Asia and Australasia shows a close correlation with the areas and extent of
quaternary glaciation where soils have not yet been sufficiently saturated
with postglacial air-borne oceanic iodine (see Geochemistry o f Iodine 312).
The number of goitrous people in the world is not known; but if t h e
statistics available for some countries may be taken as a guide, the total is
probably not far short of 200 .million. Although the geographical distrib u-
tion of goitre has not apparently altered in the last hundred years, the
intensity of the disease has substantially declined in certain countries-
particularly those which have enjoyed rising standards of living and an
enlightened outlook on public health. The endemics in. Switzerland, the
USA and New Zealand, for example, have been largely eliminated within
the past thirty-five years through the prophylactic use of iodized salt.
Nevertheless, there are many countries where the prevalence of goitre
is still exceedingly high and a matter of serious public concern, and many
others where the people live so near the critical level of iodine intake that
whenever the slender resources of the thyroid gland are abnormally taxed,
as, for example, during the nutritional privations of war, epidemic outbreaks
of goitre result. Statistics for the year 1952 show that in eight states of
Mexico there were over 2 million goitrous people out of a total population
of about 10 million; in El Salvador, 329 OOOpeople out of I 856 OOO are
affected; Pinotti 230 estimates that there are 11 500 OOO cases of goitre in
Brazil; in Finland, 2000 operative cases annually out of a population
of 3.5 million account for 30 OOOdays of hospital attendance; in Sweden
there are said to be 300 OOO people with goitre in a total population of
7 million; Matovinovic 480 estimates that some I 400 OOO persons suffer
from the disease in Yugoslavia; Hungary has a goitre population of
500 OOO; 520 and in Italy, Cerletti .7°2 reckons that no less than 5 million
persons are affected, that is, rather more than 10 % of the total population.
In England and Wales, in 1944, there were estimated to be some 500 OOO
cases of thyroid enlargement in schoolchildren and young adults; 866 and
Taylor 885 has pointed out that the loss sustained by England, Wales and
Scotland through failure to iodize salt must be immense if calculated in
terms of demands made on the medical services and loss of working time.
PREVALE:KCE AND GEOGRAPHICAL DISTRIBUTION 29
In India, there are said to be about 9 OOOOOO goitre sufferers; and in the
USA, the number of men rejected for military service on account of goitre
was no less in the Second World War than in the First-namely, five in
every thousand examined. It is said 59 that 1 OOOOOO working men in the
USA have hypothyroidism unbeknown to them or their physicians.
These and other similar facts are marshalled country by country in the
following pages. The survey is divided into two parts, the first covering
the Americas and Europe, and the second, Africa, Asia and Oceania.
THE ..\_,IERICAS
North America
Canada; United States of America : }.foxico
Central America
Guatemala; Honduras; EI Salvador; Nicaragua; Costa Rica; Panama; Cuba;
Dominican Republic
South America
Colombia; Venezuela; Ecuador; Peru; Bolivia; Chile; Argentina; Paraguay; Uruguay;
Brazil
EUROPE
Northern Europe
Iceland; Finland; Sweden; Norway; Denmark; Estonian SSR, Latvian SSR and
Lithuanian SSR; Netherlands
Eastern Europe
Poland; USSR (excluding Es onian SSR, Latvian SSR and Lithuanian SSR); Romania;
Bulgaria; Yugoslavia; Albania; Greece
Central and southern Europe
Austria; Hungary; Czechoslovakia; Germany; Switzerland; Italy, Sicily and Sardinia;
Malta; Spain; Portugal
Western Europe
Belgium; England and Wales: Scotland; Northern Ireland; Ireland; France
AFRICA
North-west and West Africa
Algeria; Morocco; Madeira and Canary Islands; French \Vest Africa: Gambia;
Sierra Leone; Liberia: Ghana; Nigeria: British Cameroons: Cameroun; French
Equatorial Africa; Angola
North-east and East Africa
Egypt; Sudan; Ethiopia and Eritrea; British Somaliland; l ' ganda; Tanganyika
Central and South Africa
Belgian Congo and Ruanda-l.:rundi; the Rhodesias: Cnion of South Africa; Caprivi
Strip; South-West Africa; Bechuanaland; Swaziland; Basmolar.d: Seychelles and
Madagascar
ASIA
Eastern Mediterranean
Turkey; Lebanon; Israel; Iran
Central Asia
Afghanistan; Pakistan; Kashmir; Nepal; Tibet; India; Assam; Ceylon
Far East
Burma; Thailand; Indo-China (Cambodia, Laos and Viet Nam); Malaya; Indonesia;
Sarawak; North Borneo; China; Korea; Taiwan; Japan; Philippine Islands
OCEANIA
Australasia
New Guinea; Australia and Tasmania; New Zea.land
Pacific Ocean
Fiji Islands; Tonga (Friendly Islands); Cook Islands; Hawaiian Islands
The occurrence of endemic goitre has been recorded in all the above
countries. So far as can be ascertained there is no published information
relating to countries not named above.
Among those who have previously dealt comprehensively with the
geographical distribution and prevalence of endemic goitre on a continen-
tal or world scale are: Hirsch, 8 Saint-Lager, 12 Bircher,1 Clemow, 4 McCarri-
son,9 Eggenberger ,6 De Quervain & W egelin, 5 Pfluger, 11 McClendon, 10
Greenwald,7 the Chilean Iodine Educational Bureau, London,3 and the
Oficina Educacional del Y odo, Santiago, Chile. 2
PART I - T H E AMERICAS AND EUROPE
North America
Canada
Proceeding through Canada from west to east, centres of goitre are first
encountered in British Columbia. Some 50 or 60 miles a from Vancouver,
going inland from the head of Howe Sound, the disease is found in the
Pemberton valley and in the area watered by the Lillooet and Birkenhead
rivers. An interesting account of this district has been given by Keith, 22
who relates that fifty years ago European settlers in Pemberton Meadows
suffered so severely from goitre, both in themselves and among their cattle,
pigs and horses, that they almost decided to leave the valley. Writing in
1949, MacDermot 23 records that owing to the administration of supple-
mentary iodine in food and drinking-water, Pemberton Meadows is now
a healthy and thriving community.
a 1 mile l.6 km.

FIG. 1. NORTH AND CENTRAL AMERICA
The red harching indicares the areas where endemic goitre has been found.
The coastal valley of Bella Coola, 270 miles north-west of Vancouver,

is also peculiarly sensitive to the disease. Other areas of considerable
prevalence in British Columbia lie to the east and north-east of Vancouver.
These are the valley of the Lower Fraser river, the town of Kamloops,
around Lake Okanagan at Keremeos, Penticton and Vernon, and thence
northwards, including such places . as Armstrong, Enderby and Salmon
Arm. Farther east, goitre occurs in the neighbourhood of the Arrow Lakes
and in the valleys towards the Selkirk Mountains. To the north there are
centres in the Cariboo Mountains, at the town of Prince George, and all
along the Grand Trunk Pacific Railway as far as Edmonton in Alberta.
In Alberta, Walker 29 has seen a great deal of goitre in a strip of territory
running due south from Edmonton to the northern border of the United
States. Places affected are: Leduc, Wetaskiwin, Lacombe, Eckville, Red
Deer, Big Valley, Olds, Didsbury, Calgary, High River, Champion and
Cardston. It is also prevalent in the southern districts irrigated by the South
Saskatchewan river from Lethbridge and Taber through Medicine Hat to
Gull Lake.
Another part of Alberta where goitre is fairly common lies to the north-
west of Edmonton in the area drained by the upper waters of the Peace
and Athabaska rivers, and including such centres as Sexsmith, Peace River
and Barrhead. An early account of goitre in this general area is given by
Dr John Richardson, 24 surgeon and scientist on Franklin's famous expedi-
tion to the polar seas in the north-west of Canada between 1819 and 1822.
" At Edmonton ", he notes, " the disorder attacks those only who drink
the water of the river. The inhabitants of Rocky Mountain House, sixty
miles nearer the source of the river, are more severely affected than those
at Edmonton; but at Carlton House, a considerable distance below Edmon-
ton, the disease is known only by name." Other writers who refir to former
and more recent occurrences of goitre around Edmonton and in the basins
drained by the two branches of the Saskatchewan river are Simpson, 26
Hector, 20 and T. H. Whitelaw (personal communication to F. J. Shep-
herd 2 5 ) .
In Saskatchewan there are accounts of goitre at Saskatoon. According
to Binning, 16, 17 a prevalence among schoolchildren of 12.3 % in 1934 has
been greatly reduced by the administration of iodine in various forms.
Goitre is also found farther south, in. the country immediately surrounding
the town of Regina. Other centres are at Qu'Appelle, between Regina and
Indian Head; at Bethune, Govan, Raymore, Cu par and ltuna, north of
Regina; and in a strip of country running from Shaunavon eastward to
Weyburn (Jackes 21).
Goitre studies of schoolchildren have been made at widely separated
places in Manitoba. At Dauphine, in the west of the province, 74 % of the
children were affected. In the south, 21 % of children at Morden had goitre.
At Winnipeg the goitre rate was 50 %, and in the towns of Birds Hill and
PREVALENCE AND GEOGRAPHICAL DISTRIBUTION 33
Stonewall, both in the Winnipeg area, 85 % of the children were sufferers.

The Indian School at Waugh, in the extreme east of the province, was free
from goitre. These particulars are taken from the publications of Hamilton
& McRae 19 and of Abbott. 13 Evidence of iodine deficiency among people
in Winnipeg has also been noted by Edward. 18
The land areas surrounding the five Great Lakes lying across southern
Ontario and the states of Wisconsin, Michigan, Ohio, Pennsylvania and
New York in the north-eastern United States have long been recognized as
notoriously goitrous. Goitre literature abounds in references to the disease
in this area, in both animals and man. Edward 18 observed it in the Japanese
Prisoners of War Camp at Angler on the north shore of Lake Superior.
Sixty years ago, Springle 27 and Adami 14 recorded goitre, or " grosse
gorge", as common throughout the Laurentian mountains of Quebec
especially in the counties of Terrebonne, Berthier, and St. Maurice. The
disease was also frequent in the lower-lying country around Montreal at
such places as Vaudreuil and Beauharnois. More recently, Greenwald
(personal communication to WHO, 1958) has expressed the opinion that
goitre is probably still common in the Montreal area and along the
St. Lawrence to at least eighty miles below Quebec. In a nutrition survey
of the Indian people inhabiting the townships surrounding James B a y - t h e
southern extension of Hudson Bay-undertaken by the National Com-
mittee on Community Health, small goitres were found in 5.3 % of 728
subjects examined. The majority were in young women (Vivian et al. 28) .
Since 1945 all salt sold through the Hudson's Bay Posts has been iodized.
Canada, as a whole, adopted compulsory iodization of table salt in 1949. 34
In the Province of Newfoundland, goitre was observed but once only
among 868 unselected people from St. John's and five outports, who were
examined for clinical biochemical evidence of abnormalities due to defective
nutrition (Adamson et al.15). The fact that consumption of fish is high
no doubt accounts for iodine sufficiency in Newfoundland.
United States of America
Although in recent times goitre has been largely overcome through the
increasing use of iodized salt, the disease is still recognized as a serious
regional health problem in the USA. Starr 59 reported in 1958 that among
4500 men in industry in southern California 7 % had thyroid deficiency.
Projecting these findings, he estimates that one million working men in the
USA have hypothyroidism unbeknown to them or their physicians.
Considered in broad outline, and geographically from east to west, the
goitre centres of the USA are found throughout the whole length of the
Appalachian range, in all states bordering on the Great Lakes, westward
through North Dakota, and into the far western states of Montana, Idaho,
Utah, Oregon and Washington where the incidence is particularly heavy.
Except for isolated pockets of high incidence in Kansas-especially where

it borders on Missouri-and in the New Orleans district of Louisiana, the
great central plains are comparatively goitre-free, as also are the states on
the Atlantic seaboard and the southern states of Mississippi, Alabama,
Georgia and Florida.
The first reliable index of the over-all prevalence of goitre in the USA
resulted from the examination of 2 510 701 men drafted for military service
during the First World War. Nearly 12 OOO men had simple goitre and
31 % of these were rejected because their necks were so large that the collar
of the military tunic could not be buttoned around them. The frequency
of the disease was greatest among recruits from the States of Washington,
Oregon, Montana and Idaho in the north-west and from the region of the
Great Lakes. It was least in men drafted from the southern and Atlantic
coast states and most frequently seen in those of Scandinavian origin.
Later, between the years 1923 and 1929, systematic goitre surveys of
elementary schoolchildren were made in various states by the US Public
Health Service. The results revealed a general distribution very much the
same as that shown by the earlier military survey, except that whereas the
examination of drafted men disclosed the highest incidence in the states
o f the Pacific North-West, the surveys of the Public Health Service indicated
the greatest incidence to be in certain areas of the Middle West, that is, in
Ohio, Indiana, Illinois, Michigan, Iowa, Wisconsin and Minnesota-states
grouped around the Great Lakes.
Goitre rates in these areas were found to be high. For example, in the
town of Cincinnati (Ohio), 26 % of the boys and 40 % of the girls were
classed as having simple thyroid enlargement. In the State of Minnesota
the endemic was even more severe, 41 % of boys and 70 % of girls from
13 different localities showing evidence of thyroid enlargement. Conditi, -
in Michigan and Wisconsin were no better; rates of 40 %, 60 %, 70 % and
even 100 % were reported among boys and girls from certain localities in
these states.
Throughout the eastern states, although some moderately high per-
centages are recorded by the Public Health Service, there is on the whole
much less goitre than there is around the Great Lakes and in the Far West.
The State of Connecticut gave rates of 7 % in boys and 29 % in girls, and
Massachusetts 9 % in boys and 22 % in girls. There is almost no goitre in
territories east of the Blue Ridge Mountains. Indeed, South Carolina is
famed for the fact that her fruits and vegetables have a high iodine content
and that, in consequence, goitre incidence there is negligible.
As regards the Far West, statistics collected by the Public Health
Service in the State of Colorado revealed thyroid enlargement in 25 % of
boys and 30 % of girls. Utah is a notoriously goitrous state, very high rates
being found in the locality of Salt Lake City. In Oregon, thyroid enlarge-
ment prevailed in 22 % of boys and 38 % of girls. Goitre is endemic to a
PREVALE CE AND GEOGRAPHICAL DISTRIBUTION 35
considerable extent in the coast towns of Oregon, exemplifying the fact that
proximity to the sea does not necessarily guarantee freedom from the
disease. Darby and his colleagues 35 found almost no goitre among the
Navajo Indians scattered throughout the arid lands of north-eastern
Arizona.
The goitre situation in the Middle West-particularly in Ohio and Michi-
g a n - h a s greatly improved in recent years owing to the introduction of
iodized salt and the official encouragement given to its use. Brush &
Altland 32 have reviewed the results of thirty years of goitre prevention with
iodized salt in this area. Their survey carried out in four Michigan counties
in 1951 showed a goitre rate of I .41 in 53 785 students, compared with a
rate of 38.6 % in 65 537 students from the same counties examined in 1924.
Similarly, in Ohio the problem of enlarged thyroid is not nearly so acute as
it was 35 years ago. A survey of 22 402 children in four Ohio counties,
completed in the spring of 1954 (Hamwi 41 ) , showed only 4.05 % with
enlarged thyroids. This compares with a prevalence of 32.3 % among
21 580 children examined in the same counties in 1925.
Some idea of the significance of goitre in the USA may also be gained
from the medical examination records of registrants for military service
during the Second World War. Referring to the occurrence of thyroid
disease among 13 million men examined up to January 1944, Rowntree 58
says that during peacetime all doubtful cases were considered significant,
with the result that the rate was 5 per 1000, but, as manpower for the fighting
forces became scarcer, only the more outstanding clinical pictures were
labelled actual disease-a fact ,vhich resulted in a recorded rate of 0.6
per 1000. Hyperthyroidism, in both war and peace, was more frequent than
hypothyroidism, he adds.
Details of the US Public Health Service investigations quoted above are
taken from Olesen.-52 · ·03 Other authorities consulted are Adolph & Pro-
chaska (Nebraska), 30 Altland & Brush (Michigan), 31 Cavanagh (\Vashing-
ton), 33 Daft (Michigan & Ohio), 3.1. Darby (Navajo Reserve), 35 Foote (lower
San Joaquin Valley, California), 36 George & Flory (lower Rio Grande
Valley, Texas), 37 Greenwald (West Virginia), 38 Greenwald (Ohio & West
Virginia), 39 Grollman & Gryte (western North Carolina),* 0 Hamwi et al.
(Ohio), 41 , 42 Hull (Colorado),± 3 Johnson (Kentucky),H Jordan & Canuteson
(Kansas), 45 Kenyon, Kelly & Macy (Great Lakes),± 6 Kimball (Ohio &
Michigan), 47 Mahorner (southern states), 48 Mahorner & Barrow (Deep
South), 49 Marine (Ohio ), 50 Miller (Great Lakes), 51 Pennington (Kentucky), 54
Phillips (Texas), 55 Phillips (south-western Virginia);56 Richards (Utah), 57
Rowntree (recruits ), 68 Starr (southern California). 59
Mexico
In the upper basin of the Rio Grande del Norte begins a great Central
and South American zone of goitre comparable with the vast endemics
of the Alps and Himalayas. It extends through Mexico and the Central
American Republics into Colombia and Venezuela, along the Cordillera
of the Andes through Ecuador and Peru as far as Chile and western
Argentina.
According to Stacpoole, 62 the greatest goitre authority in Mexico,
endemic centres are found in all Mexican states bordering the Pacific
except lower California. Goitre also affects the mid-central and southern
parts of the country. The north-central gulf-coast of Tamaulipas and the
Caribbean regions of Campeche, Yucatan and Quintana Roo are practically
exempt. Most of the goitre centres are situated in the mountains, but there
are stretches along the Pacific coast where the disease is also to be found.
Up to the end of 1952, Stacpoole and two colleagues had examined more
than one million children and adults in eight mid-central states, with a
total population of over 10 million. The results of the survey (see Table I)
TABLE I. PREVALENCE OF GOITRE IN EIGHT STATES OF MEXICO
Total Cases Prevalence
I
State
I population
I of goitre
I (%)
Distrito federal 3 309 367 165 468 5
Puebla 1 691 950 406 066 24
Michoacan 1470837 385 359 26
Mexico 1443681 425 886 30
Guerrero 952 037 261 811 27
Hidalgo 861 521 303 282 35
Morelos 291119 135 661 46
Tlaxcala 290 592 108 972 37
Total .. 10 311104 2 192 505 20

·I
I I I
indicate that in these eight states there are more than two million people
afflicted with goitre, that is, a rate of about 20 % for the whole area.
The survey covered 3756 towns and villages within 858 townships.
Rates of more than 80 % were common in many places and in some com-
munities upwards of 90 % of the population were found to be goitrous.
According to law, all municipalities in which more than 20 % of the
population are affected by goitre are obliged to use iodized salt exclusively,
and energetic measures are being taken to overcome the administrative
difficulties that prevent enforcement of the law. Since 1950 prophylaxis
by means of iodized sweets has been carried out among 50 OOOchildren in
45 schools in the Federal District and in 80 schools in the State of Morelos.
The result has been an average drop of 16 % in goitre prevalence among
children in these schools.
PREYALENCE AND GEOGRAPHICAL DISTRIBUTION 37
More recent experience in Mexico 60 confirms the existence of very high

goitre rates in certain provinces and has proved the prophylactic reliability
of salt iodized with iodate instead of iodide. Stacpoole 63, 6" has devised a
new salt-iodizing plant, capable of producing 5 tons per hour, expressly
designed to serve local requirements in severely endemic areas. In his
description of this process he gives an account of some of the difficulties
encountered with producers and purveyors of salt during the installation
and initial operation of the machine at Pinotepa Nacional, Jamiltepec, in
the province of Oaxaca, where in some localities goitre affects 80 %-90 % of
the population.
Historical aspects of goitre in Mexico and Central America are dealt
with by Greenwald. 61
Central America
Since the establishment of the Institute of Nutrition of Central America

and Panama (INCAP) in 1949, extensive surveys have been made to deter-
mine the prevalence of endemic goitre in Central America. As a result,
it has been shown that the disease is a serious public health problem
in Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica and
Panama.65, 66, 67
Guatemala
A survey made in 1938 by Herrera 70 confirmed earlier findings by
Guerrero (1908) and by Diaz (1918) that goitre is a serious condition in
Guatemala, affecting 50 % of the people in some localities. Dr Herrera estab-
lished seven goitrous zones involving 16 departments: (1) Chimaltenango,
Sacatepequez, Solola, the northern part of Escuintla and Suchitepequez,
and the southern part of Quiche as far as Totonicapan and Quezaltenango;
(2) El Progreso and the south-west part of Zacapa; (3) the north-west part
of Jutiapa and part of Jalapa; (4) the north-west of Quezaltenango and
San Marcos; (5) the south of Huehuetenango; (6) the north-west of Hue-
huetenango; (7) the north-west of Santa Rosa. The Department of El
Progreso showed the highest prevalence.
The most modern statistics are those compiled by Mahorner 73 and by
Scrimshaw and his co-workers in INCAP. 71, 75· 76 They have found an over-
all prevalence of 38.5 % in the Departments of Guatemala, Escuintla,
Chimaltenango and Sacatepequez, some regions of which showed rates
varying between 60 % and 74 {. Interested also in the history of goitre,
Borhegyi & Scrimshaw 68· 69 have marshalled evidence from archaeological
and other sources pointing to the fact that goitre existed in Guatemala
hundreds if not thousands of years before the conquest of the country by
the Spaniards in 1524.
Nodular goitres are common in the highlands of Guatemala; by con-

trast, nodular goitres are uncommon in El Salvador. Deaf-mutism and
idiocy are frequently found in association with iodine deficiency in the
highly endemic areas of Guatemala. These sequelae were not observed
in El Salvador. Writing of conditions in Guatemala as he encountered
them in 1950, Kimball 72 says: " I have never seen such degeneration;
feeblemindedness and deafmutism were very frequent."
Energetic official action is being taken to combat goitre in Guatemala
by means of iodized salt. Both iodate and iodide in doses of equivalent
iodine content have been tested and found equally effective. Experiments
on Guatemalan children reported by Scrimshaw and his colleagues 74, 77
show that after 32 weeks of treatment the goitre rate was reduced from 51 %
to 16% with iodate, and from 60% to 23% with iodide.
Honduras
In common with most other Central American countries the over-all
prevalence of goitre in Honduras is high. As part of the INCAP goitre
survey, Borjas and Scrimshaw 78• 79 examined a total of 12 292 school-
children and 352 adults, comprising nearly 1 % of the population in all
15 departments, and found that nearly one-fourth (22.6 %) of these people
had pathologically enlarged thyroid glands. Slightly less than 14 % of the
goitres were readily visible with the head in normal position and fewer
than 1 % had discrete nodules. The highest rates occur in the Ajuterique
and Lejamani districts of the Department of Comayagua (73 % and 74 %
respectively) and in the La Venta area of Morazan Department (64 %). 71
El Salvador
Goitre is endemic in all 14 departments of El Salvador. 81 During 1952
nearly 35 OOO schoolchildren of all ages from public and private schools
in urban and rural areas were examined by a goitre survey team under the
auspices of INCAP. Glands were not considered enlarged unless they were
definitely four to five times the " n o r m a l " size. 65 , 80, 82
Of 8000 children examined in the capital (San Salvador) only 1.1 %
were found to have thyroids more than four to five times the normal size.
Among the 26 400 children examined in the remainder of the country the
average rate was 22.8 %, with variations between 8.5 % and 38. 7 %, depend-
ing on the department. Deaf-mutism, idiocy and cretinism were not ob-
served. The worst affected department was Ahuachapan.
On the basis of these studies, it is calculated that 119 OOO children in
El Salvador out of a total school population of 673 OOO are affected with
goitre. If these average figures for schoolchildren can be taken as reasonably
representative of the population as a whole, El Salvador would have 329 OOO
PREVALENCE AKD GEOGRAPHICAL DISTRIBUTION 39
goitrous people out of a total population of 1 856 OOO (Cabezas, Pineda &
Scrimshaw 6 5 ) .
Nicaragua
An examination of 2427 children carried out in 1954 under the auspices
of INCAP gave the results shown in Table II (N. S. Scrimshaw-personal
communication, 1954):
TABLE II. CASES OF GOITRE AMONG CHILDREN IN NICARAGUA
Number of Number Percentage

Department District children with with
examined goitre goitre
Carazo Santa Teresa 157 85 54.1
Diriamba 223 44 19.7
Jinotepe 438 57 13.0
Masaya Nindiri 90 20 22.2
Masaya 224 32 14.3
Managua San Rafael del Sur 117 62 53.0
El Saito 51 23 45.1
Las Maderas 72 28 38.9
Montelimar 47 12 25.5
Managua 457 98 21.4
Tipitapa 35 2.9
Matagalpa Matagalpa 355 81 22.8
C. Darfo 161 7 4.4
Total 2 427 550 22.6
These statistics indicate an average goitre rate of 22.6 { In the districts

of Santa Teresa (Carazo) and San Rafael del Sur (Managua) the rate
exceeds 50 % .
Costa Rica
Goitre statistics for Costa Rica are fe,v, but they are sufficiently disquiet-
ing to justify the official introduction of preventi; ce measures. Garcia 85
found a rate of 10.6 % among male patients in a mental hospital. He also
refers to a series of 1000 autopsies in which 45 goitres were noted. In-
vestigations in the canton of Puriscal by Urcuyo s. revealed 27 cases of
thyroid abnormality among 1000 people examined : 6 of these cases were
in men and 21 in women.
More recent surveys by INCAP (N. S. Scrimshaw-personal communi-

cation, 1954) revealed an average rate of 12 % among 24 OOO children
examined. The following are the figures for five of the seven provinces:
Alajuela, 17 %; Cartago, 12 %; Heredia, 15 %; Limon, 6 %; San Jose, 8 %.
Lack of iodine in drinking-water, monotonous diet, and hardness of
water are considered by De Girolami & Fallas Diaz 84 to be the causes
of the Costa Rican endemic. Cases of cretinism and deaf-mutism are of
.sporadic occurrence.
Panama
The Peruvian expert, Dr Arce Larreta, examined a total of 3540 persons

in the Province of Chiriqui as part of the IN CAP survey. 71 He found goitre
rates as follows: 2.5 % in children up to 6 years of age (808 examined);
50 % in children of school age (1682 examined); and 75 % in adults of 18
years or over (1050 examined).
More recently Reverte Coma 88-91, 93 has carried out extensive goitre sur-
veys throughout Panama. In Herrera and Chame the following percentage
prevalences were noted:
Pre-school children Schoo/children Adults
Herrera 6.80 60.81 46.85
Chame 1.05 21.18 17.81
Many cases of cretinism and deaf-mutism were found. Reverte Coma 92

has also studied the " Anne Boleyn " syndrome, the name given by Maraiion
and his school to the simultaneous existence of goitre and polydactylism in
a patient. He estimates that cases of polydactylism on the Panama Isthmus
number 1 in every 2000 or 3000 inhabitants, the majority being from areas
where goitre is endemic.
Cuba
Zones of endemic goitre do not apparently exist in Cuba. Nevertheless,
sporadic cases occur with more than usual frequency in the regions of Sagua
de Tanamo, Moron, and Ciego de Avila. Three of these, all in one family,
have been described by Schutte et al. 94
Dominican Republic
According to Purcell 96 numerous cases of simple goitre are found in
Santo Domingo. He mentioned El Cerado, El Pinar, Los Arroyos, El Coco
and Los Naranjos as the districts most affected.
De Leon 95 refers to the frequency of goitre among the country people
in the mountainous zone of Jarabacoa. Women, and children between the
ages of 10 and 14 years, are especially prone to the disease. The condition
is accompanied by under-development, sexual immaturity, idiocy and
cretinism. Sterility and other manifestations of reproductive failure are
common among women. The goitre seen in these areas is characteristically
benign; toxic phenomena are never seen. La Pelada, El Salto, Manabao,
Pinarquemado, Boma, La Pena and Vera Bellica are the most affected
sections in this area. If iodine treatment is applied in childhood excellent
results are obtained. Nothing can be done medically to alleviate goitres
in patients over the age of 20 years.
South America
From earliest times the continent of South America has presented a
fruitful field of study for the goitre investigator. Crotti 97 recounts how the
first explorers of New Granada (now Colombia) were astonished to find
the banks of the Rio Magdalena inhabited by a race of " heavy and stupid
savages of sluggish habit who passed their days in sleep." Among the goi-
trous Indians of the Peruvian plateau, cretinism had reached such a degree
in those days that it required nothing less than a papal bull from Paul III
(d. 1549) to convince the missionaries that these were indeed men with
souls to be evangelized. On the other hand, painstaking historical research
has convinced Greenwald 98 that goitre was unknown in the Inca Empire
and did not appear there (i.e., in Colombia, Ecuador, Bolivia, Peru, Chile
and Argentina) until after the Spanish conquest of these countries. This
is in line with the views of Bengoa. 117
Today, the disease is found in almost every country of South America.
Summaries of the history, prevalence and geographical distribution of
goitre in South American countries up to the year 1950 have been made
by the Chilean Iodine Educational Bureaux of London and Santiago. 2• 3
Orr 99 and Kimball 72 are two other authorities who have written interesting
general accounts of goitre in South America.
Colombia
Endemic goitre in Colombia is a problem of long standing. Mutis 110
reported in 1794 that he had seen goitrous people on the upper Magdalena
. River in 1760, that is, more than thirty years prior to the date of the written
· record. In 1797 Gil de Tejada 103 wrote about the cause and cure of the
disease in Santafe (Bogota). Francisco Jose de Caldas, noted Colombian
naturalist and patriot, repeatedly mentions goitre in his writings (1808).
Apparently he was the first to attribute the disease to the quality of the
local drinking-waters-some excessively charged ,cvith lime and others
with calcium sulfate, iron, and decaying vegetation. About the same time
(1810) Camacho studied the distribution and extent of the Colombian
endemic and observed that the disease was frequent in the convents of
The red hatching indicates the areas where endemic goitre has been.found.
Bogota, where well water of exceptional hardness was used for drinking
and cooking purposes (Socarras 115).
A special interest attaches to the story of goitre in Colombia because it
was there that the famous French scientist, J. B. Boussingault, 100 , 101 put
forward for the first time (1831) the recommendation that domestic salt
supplies should be iodized to prevent goitre. The circumstances are these.
In 1824 von Humboldt 109 described the occurrence of goitre in the Andean
plateau and referred to the striking fact that the inhabitants of goitrous
localities recognized that salt from certain natural deposits was more
beneficial than that from others. The following year, a young doctor
named Roulin, 114 who had recently come to Colombia from Paris full of
information and ideas about Coindet's new iodine treatment of goitre, 3 noted
this and was instrumental in having samples of the salts analysed by Bous-
singault. On analysis Boussingault made the significant discovery that
those salts instinctively preferred by the goitrous peoples contained most
iodine. This prompted his recommendation.
Although almost 130 years have passed since Boussingault's advice
was given, it is only recently that active steps have been taken to stamp out,
by means of iodized salt, the serious degree of goitre which is still found
throughout almost the whole length of the valleys of the Magdalena and
Cauca rivers. The decision to introduce iodized salt has been taken as a
result of several new and detailed goitre surveys.
The first of these inquiries, published by Socarras 115 in 1942, showed
that 10 % of 153 OOOprospective recruits for military service examined over
a period of five years were rejected because of simple goitre. In January
1945, the Department of );utrition of the Co-operative Health Service
(Servicio Cooperativo Interamericano de Salud P{1blica) began a four-year
survey of the geographical distribution and frequency of simple goitre
among schoolchildren from 7 to 14 years of age throughout the entire
country. Few, if any, more complete surveys of this kind have ever been
made anywhere in the world. The results, published in summary form by
Parra 111-113 and in great detail by Gongora y Lopez, Young & Iregui, 107
are shown in Table III. They cover 183 243 children in 14 departments and
show an average goitre rate of 52.62 ' , the highest figure being 81.14 %
for the Department of Caldas.
Commenting on this survey Parra 11 1. 112 mentions that the departments
with the lowest goitre rates (Atlantico, Bolivar and :Magdalena) border on
the sea coast, where there is a higher consumption of foods of marine
origin. He also refers to the fact that during the last thirty years simple
goitre has been invading areas formerly untouched by it, e.g., the Depart-
ments of Caldas and Antioquia. This is because the regional supply of
salt from iodized sources has gradually been almost completely replaced
by cheaper salt of extremely low iodine content from large mines near
Bogota. Another interesting conclusion drawn from the survey is that in
T A B L E Ill. PREVALENCE OF SIMPLE GOITRE A M O N G COLOMBIAN

SCHOOLCHILDREN, 1945-48
I
Department Children Positive Percentage
I examined
I cases
1. Antioquia 20 058 9 374 46.73

2. Atlantico 4 425 1 012 22.84
3. Bolivar 8 097 2 333 28.81
4. Boyaca 8 025 4 691 58.45
5. Caldas 25 280 20 511 81.14
6. Cauca 6 234 4 960 79.56
7. Cundinamarca 34 665 15 909 45.89
8. Magdalena 5 572 ,: 1 364 24.47
9. Huila 6137 4 246 69.18
10. Nariiio 12 892 4 844 37.57
11. Norte de Santander 4130 1 684 40.77
12. Santander 10 523 4 993 47.45
13. Tolima 10 941 6 635 60.64
14. Valle del Cauca 26 264 13 879 52.84
Total ...... 183 243 96 435 52.62
I I I
places with soft or semi-hard water the goitre incidence is less than in
localities where the water is hard or very hard.
Where the endemic has been of long duration-100 years or more-the
physique of the people is substandard and there are evidences of retarded
mental development and of cretinism.
Goitre preventive measures involving the iodization of the salt supply
for the entire country have been given official sanction, and Gongora y
Lopez & Young 106 have given a full description of the approved process
for iodizing the salt produced from the natural deposits found at Zipaquira.
The average daily intake of salt per head is said to be 15 g, and the
level of iodization adopted is 1 part of iodine in 25 OOOparts of salt. That
iodized salt is effective in reducing the degree of goitre in young Colombian
children is already evident from the results of a two-year trial recorded by
Gongora y Lopez & Mejia. 105 Beginning in May 1950, a total of 8062
children from seven different localities in the Department of Caldas were
given iodized salt regularly. As controls, 797 children from two other
zones in Caldas and 1648 children from the city of Bogota were given no
iodized salt. At a resurvey in April 1952 the number of cases of goitre in
the iodized salt group had diminished by 57.6 % compared with the rates
obtaining in 1945-48. The goitre rate among the children not getting iodized
salt was the same in 1952 as was found in the 1945-48 survey.
PREVALEKCE AND GEOGRAPHICAL DISTRIBUTION 45
Among those who have made recent contributions to knowledge of

Colombian goitre are Gomez-Afanador 104 who in a series of 244 cases
found 82 % to be simple goitres, 10 % hypothyroid and 8 % hyperthyroid;
Thonnard-Neumann 116 who refers to the goitre problem in his assessment
of the poor nutritional status of the Colombian people; and Correa &
Castro 102 who describe the natural history of the disease in Cali.
Venezuela
From the Rio Magdalena in Colombia the goitre belt extends eastwards
into Venezuela through the basins of the Meta and Apure rivers, and more
particularly along the Cordillera of Merida, affecting such places as Pam-
plona, La Grita, Tovar, Merida, Trujillo and Barquisimeto, and continuing
as far as Valencia and Caracas.
The most authoritative account of endemic goitre in Venezuela is
contained in the comprehensive health survey of that country by Bengoa. 117
He is of the opinion that goitre did not exist in Venezuela prior to the
colonization, owing to the typical nomadic tendencies of the indigenous
tribes of the Caribbean countries. When the people began to live in settled
communities, however, goitre began to develop. Indeed, Bengoa refers
to the tradition that from the time of colonization practically everybody
in Trujillo was goitrous, a fact which in those days marked out foreigners
and people without goitre as rare individuals.
The intensity of the goitre endemic in several towns of the Republic is
seen in the following tabulation, which shows the percentage rates among
students examined in the year 1941.
Locality Goitre rare Localiry Goitre rate
( {) (%)
La Grita. 47 Pregonero 12
Guarico. 28 Cuicas 11
Monte Carmelo 25 Tovar 5
Chejende 18 Carvajal 2
Merida 13 Campo Elias 2
Biscucuy 12 Mucuchies 1
These rates are for cases of obvious goitre. Bengoa, 117 from whose book
the data are taken, says that only isolated cases of cretinism and deaf-
mutism are encountered, and that the goitre problem in Venezuela as a whole
does not have the same serious social significance as in some other South
American countries. Nevertheless, he commends it to the notice of official
public health authorities, with the proposal that iodized salt should be
introduced to diminish the present intensity of the condition.
Heedful of this red light, the Instituto Nacional de Nutrici6n organized
a series of field surveys and laboratory studies in 1951 which confirmed
the high goitre rates existing along the Venezuelan Andes and foothills
from San Cristobal at the southern end of the ridge through Trujillo,
Tocuyo and the Carabobo area almost as far as the non-goitrous zone o f
Caracas. For instance, in the county o f Bailadores in the state of Merida
84.5 % of 718 adults and 83 % of 641 schoolchildren examined by Roche
et al.1 24 • 125 were found to have abnormally palpable thyroids. Garcia 122
encountered rates of between 22 % and 96 % among groups of men, women
and children from different localities in Palmira and Pifiango, two districts
situated in the mountainous region to the north-east of Merida between
the states of Zulia and Trujillo. In Manuare valley (Carabobo state)
Rodriguez 12rl,129 records an incidence of 36.3 % in the 381 persons he
examined, almost 16 % of the total population of the district.
Radio iodine clearance. has been studied by Roche and his colleagues
on the inhabitants o f the mountainous regions of Bailadores and Tabay
in the far-west of the country and on goitre subjects from Manuare and
San Joaquin in the state of Carabobo. 118 -121 , 126, 121
Some 500 miles to the south-east, Roche 123 made similar investigations
in the savanna ofKakuri near the sources of the Ventuari river in the Amazon
territory of Venezuela. Here, the 24-hour thyroidal uptake of 131 1 was
measured in 53 well-nourished Indians who had had little or no contact
with white men and who, with one exception, had thyroids that were either
non-palpable or normal in size. The average 131I uptake was 70.8 % of the
administered dose; 45 of the cases had uptakes of more .than 50 % of the
dose. Uptakes of six controls, members of the expedition, were within
normal limits. If it be assumed that the demonstrated thyroidal avidity
for iodine signifies iodine deficiency, the findings would suggest that such
deficiency may exist without giving rise to the symptom of goitre.
Ecuador
From Colombia, the South American goitre zone passes southwards

along the Cordillera into Ecuador, touching such centres as Quito, Cuenca
and Loja.
More than 120 years ago, von Humboldt (1824) 109 and Boussingault
(1833) 101 mention goitre as being endemic in Ecuador. In Llano Anciso
a case was seen in which the swelling was 14 inches (36 cm) long and 8
inches (20 cm) across. Although this is exceptional, conditions predispose
to the appearance of such phenomena. There are one or two areas, however,
where goitre does not occur because the local sources of food salt are
sufficiently rich in iodine.
In recent years the Ecuadorean goitre problem has been carefully
studied by Sanchez & Paredes 132 and by Arcos. 130 Sanchez & Paredes state
that most goitre is found in the central Andean spine running lengthwise
through the middle of the country. The littoral zone to the west and the
upper Amazonian area on the east side-both of which are comparatively
low-lying-are less affected. These authors claim that the native Indians
PREVALE'.\CE A:'.\iD GEOGRAPHICAL DISTRIBUTION 47
and half-castes are most vulnerable to the disease because of their extreme
poverty and poor nutritional status. This coincides with the opinion of
Arcos, who maintains that goitre persists in the rural areas of Ecuador,
particularly in the narrow Andean valleys, owing to lmv standards of living
and the lack of adequate medical and social services. Arcos confirms that
the disease is very extensive in the Province of Cotopaxi (formerly called
Leon), especially among Indian races. He thinks, too, that thyroid deficiency
is the greatest single cause of decadence among these peoples.
Precise statistics are not available in respect of the Ecuadorean popula-
tion; but it is believed that goitre affects both sexes equally. It is particularly
evident at puberty and adolescence. Thyroid enlargement is also known to
occur among domestic animals in Ecuador (Sanchez & Paredes 132). Horses,
pigs and lambs are affected.
An exhaustive review of the history and folklore of endemic goitre in
Ecuador is given by Le6n. 131 He refers to the occurrence of the disease in
the times of the Inca Empire, when it was known by the Quichua term
ccotto or coto meaning a mound or protuberance, and traces its development
during and after the Spanish colonial era. The frequency of goitre through-
out the Ecuadorean highlands has not only had its repercussions on the
medical, biological and social life of the people, but has also influenced the
national plastic and pictorial arts.
Peru
Although goitre, cretinism and deaf-mutism have long been a burden on
public health in Peru, only recently have medical officials been able to
convince the Government of the preventive possibilities in iodized salt and
the need to make its use compulsory. The Ministry of Public Health in
Peru has now organized a campaign for the prophylaxis of endemic goitre
by means of salt iodized at the rate of 1 part of iodine in 10 OOOparts of salt.
The location and intensity of the present-day endemic in Peru was first
clearly defined by Salazar 143 in a series of maps, on which occurrence is
plotted department by department. Most affected are those departments
covering the central higher parts of the country. Moving from north to south,
the following are the ten departments with the highest rates: Arnazonas
(28.79 %), Cajamarca (3.63 %), Libertad (6.38 ), Ancash (14.36 %),
Huanuco (19.96%), Junin (5.09%), Huancavelica (8.77%), Ayacucho
(4.28 %), Apurimac (9.88 %) and Cuzco (4.92 %). Cases of goitre in the
remaining 13 departments of the country occur in 2 % of the population or
less.
Burga, 134• 135 who is in charge of the Peruvian goitre campaign, has
drawn special attention to the differences between goitre conditions in
different parts of the Department of Amazonas. There, the goitre rate in
low-lying areas-namely, 90 1 -is much greater than in the higher parts of
the Department, and cretinism, mental deficiency and deaf-mutism are
48 F. C. KELLY & W . W. SNEDDEN
correspondingly serious. The drinking-water is from streams. In the

highlands, on the other hand, Burga found a rate of 30 %, mostly among
adolescents. Here the water-supply comes from wells. Goitre in newborn
babies is common, and the disease is also seen in domestic animals, par-
ticularly dogs.
In later and more comprehensive surveys covering the whole of Peru,
Burga 136 has confirmt:d his earlier opinions, namely, that serious endemic
goitre is confined to the region of the Sierra, that it is not found on the coast,
and that in the rising and foothill country between these two zones the
disease has an intermediate severity, being wholly absent in some localities.
Burga's studies relating prevalence to altitude are among the best in the
goitre literature. Moving inwards from the coast to an ascent of the Cor-
dillera one first encounters cases of goitre at 250-850 metres above sea-level;
at an elevation of 1000-3000 metres the frequency increases, attaining average
rates of 15 % to 25 % and above. At this level, the disease is characterized
by the presence of cretinism, myxoedema, and a general state of hypo-
metabolism extending also to domestic animals. At an even greater height,
over 3300 metres, the goitre rate tends to diminish again, until it recedes
to an almost insignificant figure in places of highest altitude. In these
zones, cretins and cases of myxoedema are rarely seen and it is difficult to
find any animals with thyroid enlargement. These conclusions of Burga
and his team 136• 142 are based on the examination of many thousands of
men, women and children in 84 provinces of 14 districts of Peru.
A feature mentioned by Monge 141 is. the unusually large size of the
goitres found in Urubamba Province near the town of Cuzco in the southern
part of Peru. It appears, too, that toxic goitre (Basedow's syndrome) is
not uncommon in this area.
Those interested. in historical aspects of goitre in Peru are commended
to the writings of Lastres 138•140 and of Greenwald & Lastres. 137
Bolivia
Our knowledge of the distribution of goitre in Bolivia is due, in the main,

to the modern investigations of Balcazar, 145 Fernandez, 146 and Ibafiez. 147
As with other South American republics, records of the Bolivian endemic
are several centuries old. Following the Spanish conquest of the Incas early
in the sixteenth century and the reorganization of the country as a depen-
dency of the Viceroyalty of Peru, known politically as the Audiencia of
Charcas, Viceroy Francisco de Toledo (1569-1581) sent a commission of
" empiricists " from his seat of government at Sucre to Zudafiez, capital of
the province of the same name in the Department of Chuquisaca, to cure
the goitre there, so serious had it become.
Significant, too, is the fact that the Bolivian word for goitre, "coto ",
has given rise to the place-name Cotoca, a township in Cercado Province,
Department of Santa Cruz, in the east of the country. Similarly, in Tacua-

remboti and in Tarija, where goitres are very abundant, the words "cotudos"
and " cotos " are in common use to describe the peoples there. (See also
Leon 131 under Ecuador.)
Worthy perhaps of passing mention is the local belief in certain places
in Bolivia that goitre co-exists with an abundance of alder trees which, so
it is conjectured, absorb all iodine from the soil and render it iodine-deficient.
Exact numerical statistics are not available but, from his personal obser-
vations, Balcazar has assigned the following degrees of prevalence to eight
of the nine departments of the country, arranged in order as nearly as pos-
sible from north to south. He says that over-all rates of 40 { or more are
not uncommon in some provinces.
Beni. Very abundant, especially in the Provinces of Cercado and Vaca
Diez, and in parts of Iteiiez.
Santa Cruz. Abundant. A rate of 17 % among schoolchildren in the
capital city. Many cases in the Provinces of Valle Grande, Chiquitos and
Cordillera.
La Paz. Low incidence in the Yungas Provinces, but very prevalent in
practically all the others. Very common in the peninsula of Copacabana
(Lake Titicaca).
Cochabamba. Frequent in many provinces. Abundant in Independencia,
the capital of Ayopaya Province. Grave foci in Pasorapa, Toyota and
Emereque.
Oruro. Sporadic cases in several cantons.
Potosi. An extraordinary number in Millares. Many cases in Taco-
bamba, Ancoma and Potobamba. Grave foci in Condes and frequent cases
in many other places.
Chuquisaca. Zudaiiez Province is wholly goitrous. Many other places
affected.
Tarija. Very prevalent. Main foci are in the capital and in the Provinces
ofCercado, Mendez, Aviles, Arce and O'Connor.
The goitre problem in Bolivia is bound up "·ith lack of education, poor
housing, deficient nutrition, generally low standards of living and the
prevalence of venereal disease, alcoholism and indulgence in coca.
The Bolivian Government plan to iodize all food salt used throughout
the country and to ensure this end propose to create a salt monopoly.
Chile
Compared with other South American republics, Chile is not a goitrous
country. During his travels from Argentina over the Andes into and
throughout Chile in the years 1820 and 1821, Schmidtmeyer 16:3 especially
noted that " t h e inhabitants of Santiago, however, do not exhibit the same
4
enlargement of the neck and head as the Mendozines: . . . I observed it in

women inhabiting cottages within a few leagues of Santiago, and in the
midst of irrigated grounds, but nowhere else in Chile during a journey of
above a thousand miles, along both the sea shore and the foot of the Andes."
Strain 164 also came across only a few isolated cases on his journeys through
Chile in 1849; he was told by the people whom he met that goitre was
unknown in Chile until about 20 years before that time, when, according
to tradition, the disease made its appearance simultaneously with the
introduction of the Italian poplar tree from Mendoza. Gilliss, 159 another
traveller, writes in much the same sense.
On the other hand, there are those who believe that the disease prevailed
to a considerable extent in the colonial era, but has largely declined with
improved conditions and the advance of time. Romero 162 says that in
Santiago during the sixteenth century a connexion existed between the
prevalence of goitre among the aristocracy and the fact that they had their
own private sources of highly purified drinking-water, whereas the poorer
people obtained water from relatively impure public supplies. Fashionable
painters of the time performed marvels in disguising the goitres of ladies
who commissioned them to paint their portraits; elegance decreed the use
of ribbons of black velvet around the neck and other aids to concealment.
Some men, less concerned perhaps, allowed an unaesthetic and considerable
tumour to show above the neckerchief.
Places considered to be mildly goitrous today lie in the area watered by
the Aconcagua river, particularly around Los Andes and San Felipe.
P. Martini (cited by Romero 162) of Los Andes mentions having seen goitre
on the mountain road through the Cordillera to Juncal in Argentina.
Feferholtz & Ortiz 158 say that goitre is especially prevalent in Boco near
Quillota, which is to the north-east of Valparaiso.
Farther south, cases are occasionally found along the valleys of the
Maipo and Cachapoal rivers, and at La Punta, a settlement just north of
Rancagua in O'Higgins Province (Cabello & Zuniga; 150 Zuniga 166). In
this neighbourhood, also, goitre has been noted at Dofiihue. At Teno near
Curico, Alvarez 149 records a series of 111 cases, of which only 2 were men.
He also observed a number of cretins and dwarfs. There are no established
foci of endemic goitre in the Concepcion area. Suazo Figueroa 165 examined
the reports of nearly 2500 biopsies and autopsies and found indications of
the disease in only 45 persons (i.e., 1.8 %), of whom 8 were men.
The most recent and most comprehensive surveys are those carried
out by Donoso and his colleagues 148• 153-157 on 39 433 schoolchildren
distributed over 287 schools in the six departments of the Province of
Santiago, and on 8332 pupils belonging to 119 schools in the six departments
of the Province of Coquimbo. The over-all goitre rate in these two pro-
vinces is 10 %-11 % ; but, as Table IV shows, rates of 20 %, 30 % and nearly
40 % are the rule in some districts.
TABLE IV. PERCENT AGE OF THYROID ENLARGEMENT AMONG SCHOOLCHILDREN

IN THE VARIOUS DISTRICTS OF THE SIX DEPARTMENTS
OF THE PROVINCE OF SANTIAGO, AND OF THE SIX DEPARTMENTS
OF THE PROVINCE OF COQUIMBO, CHILE
Department Percentage with Department Percentage with

and district enlarged thyroid and district enlarged thyroid
Province of Santiago
Santiago , Talagante
Lamp a 22 Isla de Maipo 15
Til-Til 25 Talagante 13
Quilicura 13 Penaflor 5
Curacavi 36 Mai po
Maipll Paine 25
Florida 3 Buin 27
Renea 7 San Antonio

Colina 25 Cartagena 0
Puente Alto 19 ' San Antonio

La Granja 23 Santo Domingo 13
Pirque 32 Navidad 11
San J. de Maipo 37 San Bernardo

Conchali 10 Calera de Tango 21
San Miguel 4 San Bernardo 15
Cisterna 5 Meli pi Ila

Las Condes 10 El Monte 8
Quinta Normal Melipilla 14
Nunoa 0 Al hue 36
Providencia 6 Maria Pinto 13
Barrancas San Pedro 3

I
12
Santiago
Province of Coquimbo
La Serena Ovalle
La Serena 4 Ovalle 14
La Higuera Monte Patria 20
Elqui Punitaqui 30
Vicuna 3 Samo Alto 34
Paihuano 2 Combarbala
Coquimbo Combarbala 27
Coquimbo 2 II lapel
Andacollo 21 I lapel 17
Salamanca 38
Los Vilos 9
Ofhgr interesting Chilean contributions to goitre knowledge are those

by Covarrubias, 152 who writes on the relation between the thyroid gland
and pregnancy, and by Cid Krebs 151 and Oberhauser Bund & Cid Krebs, 161
who. have studied the iodine content of soils and waters in relation to goitre
pre alence in the ;Province of Santiago.
Argentina
Nowhere in the west of South America is goitre more widely diffused
than in those provinces and territories of the Argentine Republic bordering
the eastern slope of the Cordillera-namely (from north to south), Jujuy,
Salta, Tucuman, Catamarca, La Rioja, San Juan, Mendoza, Neuquen,
Rio Negro, and Chubut. In this great 1500-mile strip of territory goitre
has been known since the Spanish conquest and it is of interest that one of
the earliest and most impressive appeals for official intervention to deal
with the menace relates to this area. Writing of Mendoza Province in
1820 Schmidtmeyer 189 says:
The greatest number of the inhabitants of this state are afflicted with that unseemly
and injurious disorder, the goitre, which prevails in so many parts of the world, and
for the prevention of which little progress seems to have hithertho been made: yet the
disease is such, as may justify an appeal to governments as well as to individuals, for
farther and if possible more effectual efforts, for the discovery of its cause, and for the
means gradually to remove it. It cannot be supposed, that Providence should have
destined so many countries of the earth permanently to produce this evil, and the numer-
ous inhabitants compelled to reside in them, to be for ever subject to it: mental or bodily
faculties are generally more or less affected by it, and those who have been in the vallies
of Swisserland [sic] and Savoy know, how often they are lost by this severe visitation,
which, however, can only be viewed as one of the very many imperfections which meet
us at every step, and are intended to draw forth our labours and our exertions for their
removal.
Towards the centre of the country goitre is endemic in the Provinces
of San Luis and Cordoba; and a very high prevalence is found in the
Territory of Formosa and the Provinces of Corrientes and Misiones, all of
which are eastern areas adjoining Paraguay, Brazil and/or Uruguay.
The precise rates in the various provinces and territories are not known;
but some idea of the intensity may be gathered from surveys which have
been carried out from time to time, particularly on schoolchildren. Thus,
in some departments of Jujuy a goitre rate of 100 % was observed by E.
Sola (cited by De Salas & Amato 170) in 1931. Later (1938), Lobo et al.1 73
encountered 77 goitres in every 100 schoolchildren in the area of San
Pedrito. Salta is no less goitrous. An examination of 1278 schoolchildren
by Lewis 172 in 1924 revealed 87 % in boys and 88 % in girls. Lobo et al.
found from 15 % to 45 % in Salta schools examined in 1938, and Ofiativia 180
has described goitrous cretinism in the Province as recently as 1959. In
Tucuman rates of 65 % in boys and 60 % in girls have been recorded by
Lewis, and the 1938 survey (Lobo et al. 173) disclosed an average rate of
23 % for the whole province, with a maximum figure of 33.5 % in Chicli-

gasta. Statistics (1939-45) 171 for Catamarca record a rate of 100 % in a
school at Andalgala; and Lobo and his colleagues found 32.68 % of goitre
in 1500 children examined in La Rioja schools.
According to a 1937 census of schools in 16 different places in Men-
doza,170 goitre rates varied from 28 ,;; to 88 % among young children, the
average rate being 43.5 %- In subsequent studies, Perinetti and collabora-
tors 185, 186 found 24 150 cases of thyroid enlargement among 52 548 children
examined (i.e., 46 %) Of these, 60 , were palpable goitres, 36 % visible,
and 4 % nodular. Data of a similar kind are available for the Territory
of Formosa and the Provinces of Corrientes and Misiones, in all of which
goitre frequencies of the order of 50 \ and above are found among children
of school age. 1s7, 181, 182, rno
Analytical researches by Mazzocco and Arias Aranda,177, 178 and by
De Salas & Amato,170 prove that goitre in Argentina is definitely traceable
to iodine deficiency in the waters, soils and foods of the affected districts.
An iodine therapy campaign was launched in the northern provinces of
Argentina in 1924 and again in 1938, control being exercised through
physicians and teachers. Tablets containing 5 mg of iodine were distributed
by the Public Health Service and iodized sweets were also used. Excellent
results were obtained, but on the basis of this experience it was decided that
if tablets are adopted as the prophylactic vehicle, it is preferable to issue
them in 10-mg iodine strength. These may be given with safety even to
quite small children. No cases of intolerance were encountered.
The Argentine Government is now tackling the goitre problem on a
broader basis, and strong moves are being made towards the general
introduction of iodized salt in all the seriously affected zones. Indeed, a
law has already been passed making this practice compulsory in the Pro-
vince of Mendoza.
Official concern is also reflected in the foundation of a Goitre Institute
in the Faculty of Medicine at the University of Cuyo, yfendoza, under
the direction of D r H. Perinetti. Here, important field and laboratory
studies of iodine-deficiency goitre have been carried out by Argentinian
scientists, in collaboration with a team of experts from the famous Boston
school of thyroidologists. The expedition, led by Dr J. B. Stan bury of the
thyroid clinic of the Massachusetts General Hospital, demonstrated by
means of radioactive iodine the great avidity of the thyroid of goitrous
Argentinian patients for artificially administered iodine.191-193 This uptake
is related to the degree of iodine deficiency and is inversely proportional
to the amount of iodine excreted in the urine. Attention was focused
mainly on people below the age of 35 years, all of whom had goitres; usually
these were diffuse, but a few were multinodular and of great size.
Goitre literature pertaining to Argentina is extensive. In addition to
the sources already cited, papers by the following authors have been con-
sulted in preparing the foregoing summary: Bustos, 168 De La Barrera, 169

Maccarini, 174·176 Olascoaga, 179 Perinetti, 183, 184 Romero, 187 and Schiavone. 188
Paraguay
Goitre is extensive in the mountainous districts of Paraguay and has
been a public health problem for many years. It is recorded by Burton 194
that at one time there was goitre in almost every home in Asuncion. A
reference in Schmidtmeyer's journal 189 suggests that the disease has been
known in Paraguay at least since 1820.
Under the auspices of the Servicio Cooperativo Interamericano de
Salud Publica, the present frequency of goitre in Paraguay has been deter-
mined from a study of recent hospital statistics and by the clinical examina-
tion of more than 44 OOO children between the ages of 6 and 16 years in
towns covering the most densely populated areas of the country. 195 , 197, 198
Pena 197 and Isasi Fleitas, 195 the two doctors chiefly responsible, found
an average rate of 23.5 % among children, the frequency in girls being
four times that in boys. Children of families in comfortable circumstances
were less affected than those from working-class homes. The hospital
records show that the great majority of persons admitted for operative
treatment were between the ages of 16 and 45 years.
In view of the prevalence of goitre more or less throughout the whole
country, and the frequency of complications such as myxoedema and
cretinism, iodized salt is officially recommended not only for children and
pregnant women, but also for domestic animals in the endemic zone.
During the three years 1946-48, tablets of Oridine, each containing 10 mg
of iodine, were administered to children in four schools at the rate of one
tablet per head weekly for about 20 weeks .in each year. Before treatment
the goitre rate was 26.1 %; at the end of the first year's treatment it was
16.7 %; by the end of the second year it had fallen to 8.2% and at the end
of the third year it was down to 4.8 %. 195
Uruguay
A searching inquiry in 1935 led Perez Fontana, Bennati & Volon.terio 203
to conclude that goitre is not seriously endemic in Uruguay. Subsequent
studies by Proto 204 and by Bauza 199 and Bauza, Cervifio & Salveraglio 200, 201
suggest, however, that certain areas are suspect and that the existence of
a mildly goitrous zone must be acknowledged in the Departments of Salto,
Tacuaremb6 and Rivera towards the north of the country. Among school-
children, Bauza et al. 01 found visible goitres to the extent of 6 % in Salto
2
and 17 % in Rivera; among older students, the proportion was 5.9 % in

Salto and 14 % in Rivera.
Elsewhere, sporadic occurrences have been noted i n various places:
for example, in the Departments of Lavalleja, Rocha and Cerro Largo to
the east and north-east of the country, and in the Department of Colonia
on the west side. In the capital, Montevideo, situated on the south coast
of the country, goitre does not occur. 201, 202
Thyroid enlargement accompanied by mental retardation among child-
ren in certain schools in the Department of Rivera (e.g., at Sauzal) has
obliged the local education authorities to prolong the period of a child's
attendance at school.
There does not appear to be any absolute deficiency of iodine in the
soils and waters of Uruguay. Likewise, the thyroid glands of human
subjects, cattle and dogs, examined post mortem, show a normal iodine
content. It seems, therefore, that the cause of goitre in Uruguay must be
sought in some goitrogenic factor in food which is responsible for creating
a relative deficiency of iodine.
Determinations of the calcium content of normal and pathological
human thyroid glands by Perez Fontana and his colleagues 203 showed
that hyperthyroid glands had a low calcium content, whereas the calcium
in hypothyroid glands was considerably augmented. There \Vere insufficient
data to establish a correlation between the amount of calcium in drinking-
water and foods and the content of calcium in the thyroid.
Brazil
Endemic goitre is a problem of exceptional gravity in parts of Brazil.
Pinotti 230 estimates that no less than 11 640 OOOpeople in a total population
of approximately 62 OOOOOO are affected. The disease is particularly
rampant in the southern States of Rio Grande, Santa Catarina, Parana
and Sao Paulo, the south-eastern States of Rio de Janeiro and Minas
Gerais, and the great central and western States of Goias and Mato Grosso.
In the north and north-eastern parts of the country, goitre is perhaps less
noticeable; even so, the intensity in Maranhao and Piaui is considerable
(11 %) and there is a prevalence of around 9 % in the vast territory of Ama-
zonas and Rio Branco.
Pinotti's 230 summary is given in Table V.
Goids and Mato Grosso.
Towns especially affected with goitre in the interior of these states are
Natividade, Conceicao, Arrayas, Goias, Goiania, and Cuiaba in the far
west. Silva & Borges 232 examined about half the children and young students
regularly attending public and private educational establishments in the
urban and rural zones of Cuiaba, Goiania and G o i a s - i n all, 6803 persons
of ages ranging from 7 to 21 years. The prevalence was very high in all
three zones, being 72 ;,; in Cuiaba, 66.6 ' in Goiania and 81 % in Goias.
The rates were higher among coloured than among white children, in girls
than in boys, in the country than in the towns, in public than in private
schools, and in lower than in upper economic groups.
56 F. C. KELLY & W . W . SNEDDEN
TABLE V. PREVALENCE OF GOITRE IN VARIOUS REGIONS OF BRAZIL
j
Percentage Total number
Region and population
I with goitre affected
Central : 2 200 OOO

Mato. Grosso
53.8 1 1 5 0 OOO
Goias
South: 20 OOOOOO I
Sao Paulo
Pa ran a
27.7 5 500 OOO
Santa Catarina
Rio Grande do Sul
South-East: 16 OOOOOO
Minas Gerais
Espirito Santo 27.0 4 300 OOO
Rio de Janeiro
East : 6 500 OOO
Sergipe
0.9 60000
Bahia
Nor1h: 2 300 OOO
Amazonas
Para
Rio Branco 9.4 210 OOO
Amapa \
Rondonia
North-East: 15100 OOO
Maranhao
11.8 350 OOO
Piaui
Ceara
Rio Grande do Norte
Paraiba 0.6 70000
Pernambuco
Alagoas I
I
Total: 62 100 OOO
I I
11 640 OOO
Sao Paulo
An extensive study of endemic goitre among infants, schoolchildren
and college students in different parts of the State of Sao Paulo has been
made by Dr Arruda Sampaio. 205 - 209 Between 1940 and 1947 he examined
more than 22 OOOindividuals and found rates of from 5 % to 10 % in littoral
districts, gradually increasing as he passed up through the valley of the

Parahiba river into the highlands of the interior, where rates of 60 %,
70 % and even 90 % were encountered along the Serra da Mantiqueira,
which dominates the hinterland between the towns of Sao Paulo and Rio
de Janeiro.
Goitre here is of the simple type. Its prevalence increases with age in
zones which have ah average or low proportion, being about 20 % higher
in children between the ages of 12 and 15 years than in those between
8 and 10 years. In heavily affected zones the goitre rate reaches a maximum
even at pre-school age. Arruda Sampaia 209 mentions foci of endemic
cretinism in the areas of his study and also refers to a case of almost total
colour-blindness in a goitrous patient which successfully responded to
iodine treatment.
Another considerable goitre centre in Sao Paulo lies 50 to 100 miles
north-west of the capital and comprises the inland towns of Campinas,
Botucatu, Piramb6ia and Anhembi. Here, a goitre inquiry has been made
by Dr A. Lyra and Dr A. De Melo e Albuquerque 226 on behalf of the
Diretoria do Servi(.:o do Interior. They examined 850 boys and 712 girls
from 5 schools in this region and found an average rate of 38.58 % among
. boys and 44.80 % among girls. In a later publication, De Melo e Albu-
querque 216 refers to a rate of 70.6 % among 3030 children examined by
him at Campinas.
Parana, Santa Catarina and Rio Grande do Sul

More than twenty years ago Duarte Nunes 218 reported that physical in-
capacity due to thyroid insufficiency ,vas of frequent occurrence among
army recruits examined by him in the military hospital at Curitiba. Men
·with goitres were indolent, lazy and easily tired. After physical effort,
tremor of the limbs was a marked feature. For these reasons Duarte Nunes
recommended that anyone suffering from goitre be excluded from the
Brazilian army.
This matter has recently (1955) been re-examined in great detail by
Paes de Oliveira et al. 227 , 228 Inspection of more than 120 OOO young men
of military age (19-20 years) drawn from nearly 200 municipalities in the
States of Parana, Santa Catarina and Rio Grande do Sul revealed that from
50 % to 80 % of recruits were rejected for service on account of ill-health
and physical disability. Among the causes of rejection goitre stands high,
rates of 25 % being common in the upland areas of southern Brazil.
Minas Gerais
The goitrous districts of Minas Gerais lie from 100 to 200 miles due north
of Rio de Janeiro at Barbacena, Ouro Preto, Sahara, Congonhas and
Conselheiro Lafaiete. The endemic presents a complex of symptoms
similar to that described in other grossly affected areas goitre, cretinism,

deaf-mutism and mental debility. Chemical examination of the local
water-supply and vegetable foods clearly proves that the country is deficient
in iodine. The antithyroid effects of the commonly used foods in Minas
Gerais have been examined by Lopes. 224
Dr Lobo Leite, 220-223 who is the recognized goitre authority in this area,
found an average rate of 44 % in the town of Lafaiete (Queluz) and sur-
rounding rural districts. With the co-operation of school officials he
established a prophylactic centre for the purpose of distributing iodized
chocolate to the schoolchildren twice a week. A rate of 44 % at the begin-
ning of the scheme in 1940 had by 1942 declined to 27 %- These two years
of iodine prophylaxis also had the effect of greatly improving the mental
alertness of the children. Many obtained higher marks and a larger number
were promoted than before the iodine treatment was introduced. The
preventive dose was ten times greater than the calculated need, but there
were no harmful results.
Additional evidence of the goitre rate among the general population
in Minas Gerais is provided by De Paula 217 and also by Pinto Viegas, 231
who found 252 records of thyroid disease among the case-sheets of 2500
miscellaneous patients in a doctor's private practice-a rate of 10 %-
Rio de Janeiro
So great is the intensity of the endemic in the interior of the State of
Rio de Janeiro that nearly all the inhabitants are affected and any person
without goitre is regarded as abnormal. In 1944, out of every 1000 persons
examined and treated by the Servic;o de Endocrinologia e Policlinica
General, there were 387 with disorders o f the thyroid gland (Peregrino 229).
Amazonas and the North-East

So far as we have been able to ascertain, no records of endemic goitre
in the Amazon area existed before 1956. About that time Lowenstein 225
became aware of the disease in the rubber-producing locality of Belterra, a
community established by Henry Ford in 1934 south and slightly west of
Santarem on a plateau overlooking the river Tapajoz, one of the largest
southern tributaries of the Amazon river; it lies about 500 miles west of
Belem. Here, in 1956, Lowenstein found dental caries and endemic goitre
to be without doubtthe main nutritional problems in a sample of 84 families
(413 persons) he examined.
One year later, Lowenstein made follow-up visits to 75 of his original
84 families to find that owing to higher wages granted in the interim, and
consequently affording improved nutritional conditions, goitre rates had
markedly regressed. Nevertheless, a level of 10 % to 20 % is even now
characteristic of this settlement.
Northern Europe
Iceland
Endemic goitre does not occur in any part of Iceland, nor has it ever
been known to have occurred there; goitre in schoolchildren has never
been detected and even sporadic cases of simple goitre are rare. But hyper-
thyroidism, including exophthalmic goitre, appears to be relatively frequent
(Sigurj6nsson 233•235). In short, whenever diffuse goitrous enlargement of
the thyroid does occur in Iceland it is almost always accompanied by
thyrotoxicosis. Thus, of 50 diffuse goitres examined by Sigmj6nsson, 38
were associated with Graves-Basedow disease, 10 were cases of simple
hyperthyroidism, and only 2 were considered to be without definite symptoms
of thyrotoxicosis.
The absence of simple iodine-deficiency goitre in Iceland is undoubtedly
due to the fact that the iodine intake of the population is high because of the
large consumption of fish and fish products. This leads to an unusually high
concentration of iodine in the thyroid and is the reason why in Iceland the
human thyroid is exceptionally small.
In the adult Icelandic male the average thyroid weight is about 14 g and
in the female, 11.6 g. This is about half the accepted normal weight (25 g)
of the non-goitrous thyroid in other countries. Correspondingly, the average
iodine content per gram of dry substance is 4.01 mg in glands from males
and 3.43 mg in those from females. This is double the average iodine
content (2 mg per gram of dry substance) of normal glands from other
non-goitrous countries. It is clear, therefore, that the rotal amount of
iodine in Icelandic thyroids is more or less the same as that found in normal
thyroid glands elsewhere, namely, from 8 mg to 12 mg.
Finland
Wahlberg 256·2·58 distinguishes four goitre belts in Finland, extending
northwards from the coast of the Gulf of Finland into the central part of
the country which has the most lakes. The most easterly of these belts
starts in the neighbourhood of Viipuri and continues north-eastwards
around Lake Ladoga and across the Karelian Isthmus. Farther west, the
second belt runs northwards from !vliehikkala (St.-1,lichel) towards Jiippila.
The third region lies immediately east of Lake Paijanne and the fourth west
of it, Lake Paijanne thus intervening between these two goitrous areas.
There is a definite but not very severe endemic in Helsinki (Jarvinen &
Leikola 242• 243) and a considerable number of cases occur on the Aland
Islands (Lamberg et al. 218) . Only the coast of the Gulf of Bothnia and the
south-western part of the country lie outside the endemic zone.
O n the basis of statistics obtained from the medical examination of
military conscripts oYer a period of ten years, Wahlberg concludes that
incidence depends on geological conditions. The above-mentioned four
belts of high frequency are in that part of the country which was not sub-
merged at the end of the Ice Age-areas which, compared with others,
have a higher calcium and lower iodine content of soils and waters.
The prevalence of goitre in Finland in relation to environmental iodine
supply has been investigated by Adlercreutz, 2 6• by Virtanen & Vir-
3 2 37
tanen, 255 by Vilkki, 254 and by Jarvinen & Leikola. 243 With the aid of radio
active iodine, Lamberg and his colleagues have carried out numerous
metabolic and diagnostic studies in various endemic goitre areas of
Finland. 245- 248 , 260 Adlercreutf analysed a total of 74 samples of water
from 60 different places in Finl:md and reached the conclusion that, generally
speaking, there is a positive correlation between the occurrence of goitre
and a low iodine content of water. He found several exceptions, however,
notably at Veteli, a town in the Department of Vaasa, where a water supply
containing little iodine serves both a definite goitre area and its non-goitrous
surroundings, and at Vartsila, where goitre is associated with a water of
high iodine content. Likewise, the observations of Lamberg et al. are
consistent with the concept that endemic goitre in Finland is due chiefly
to iodine deficiency, although contributory factors, such as naturally
occurring goitrogens and hereditary and constitutional defects, are also
operative. Jarvinen & Leikola touch upon the part played by abnormally
high calcium and chlorine content of drinking water in the absence of
sufficient iodine.
The daily iodine intake fron;i food and the urinary iodine excretion of
men, women and girls from goitrous and non-goitrous rural areas have been
compared by A. I. Virtanen and E. Virtanen, thus:
Goitrous area Non-goitrous area
men women girls men women girls
Total iodine in daily diet (f.L g) . . . 53 56 52 68 62 70
Urinary iodine (f.L g per litre) . . . . 20.3 21.7 20.0 26.3 24.0 27.0
The recent study by Vilkki 254 deals with the iodine content of foods
generally consumed in Finland and, in particular, with the iodine content
of milk from two contrasted areas-namely, Turku, where the goitre rate
is comparatively low, and Kuopio, where the rate is distinctly above the
average for the country. Milk consumed in the Kuopio area, where goitre
is prevalent, contains approximately 40 % less iodine than milk from Turku,
where the prevalence is low. The average iodine intake per person per day
from all food sources is about 50 /.Lg in the high-goitre area and about
70 /.L g in the area of low prevalence. Thus, the mean iodine supply in Finland
is considerably below the minimum level of 100 /.Lg per head per day recom-
mended by the W odd Health Organization.
On the question of the actual incidence of goitre in Finland, Wahlberg
records that the endemic is responsible for 2000 operative cases annually
out of a population of 3 Yi million. .These account for 30 OOO days of
hospital attendance and give r ise to numerous cases of chronic heart disease.
For the purpose of assessing the goitre situation in Finland, 1000 consecutive
parturients and their 1015 children (15 twin pregnancies) were examined
by Hiilesmaa 239 in the First and Second Women's Clinics at the University
of Helsinki. Enlarged thyroids were found in 141 of these 1000 women;
but if one includes the cases in which nodules (adenomata) were detected
in non-enlarged thyroids, then the percentage of abnormal thyroids in this
series of mothers rises from 14.1 to 28.4, as the following tabulation shows:
1Yumber o f Number with Number without
cases nodules nodules
With goitre 141 91 50
Without goitre 859 143 716
Total examined 1000 234 766
Of 1015 infants born to these 1000 women, 139 were found to have goitre.
The high proportion of cases with thyroid nodules is considered one of
the chief characteristics of endemic goitre in Finland. Out of 952 cases of
non-toxic simple goitre examined by Jarvinen .and Leikola 243 at Helsinki
University Third Medical Clinic and in the medical wards of Kivela Hospital
no less than 483 (51 %) had one or more thyroid nodules, the smallest being
pea-size.
Mortality from coronary disease among men is higher in Finland than
in any other European country. Statistics suggest that cardiovascular
symptoms are more prevalent in the eastern goitrous part of the country
than in the western goitre-free areas. On post-mortem examination Uotila
et al. 253 found that goitre was commoner, and the average weight of the
thyroid higher, in 250 persons who died of coronary sclerosis than in 250
persons who died from other causes. They conclude that goitre and arterio-
sclerosis may have a pathogenic relationship, possibly through hypo-
thyroidism and the overproduction of thyroid-stimulating hormone by the
pituitary gland. According to Roine et al. 250 this parallelism between the
geographical distribution of goitre and cardiovascular disease may be related
to the significantly larger intake of iodine, ascorbic acid, and vitamin E in
the non-goitrous west than in the goitrous east of the country.
Iodine deficiency in animals is frequently encountered in Finland.
R. Moberg (personal communication, 1949) says that the deficiency is so
acute in the Karkkila district that saucers containing alcoholic tincture of
iodine are customarily placed under the rafters of stables and cow-houses-
a practice that is claimed to yield especially good results in overcoming
reproductive failures. Haaranen 235 has compared the thyroid weights of
pigs from north-east Finland, where goitre is prevalent, with those from
comparable animals reared in a non-endemic coastal area. The former were
more than double the weight of the latter. Peltola & Vartiainen 249 were
unable to prevent or alleviate thyroid enlargement in cattle from endemic
areas and consider therefore that iodine deficiency in food is not the sole
cause of goitre among animals in Finland.
Goitre prevention throughout the whole of Finland by means of iodized

salt is strongly advocated by Wahlberg, Uotila & Turpeinen; 259 but if this
measure is not immediately practicable on such a large scale, it should
certainly be applied at once in the most seriously affected areas-namely
Tavastehus, Viipuri (Vyborg), St.-Michel and Kuopio. A comparison by
Jussila 244 of goitre rates among schoolchildren showed that the frequency
had fallen markedly between 1928/29 and 1953/54 in areas where the
standard of living had risen and in communities reached by propaganda for
iodine prophylaxis. No change was seen in poorer districts with a low
standard of living.
Sweden
According to Greenwald, 261 the first report of goitre in Sweden dates
from 1815 and refers to its endemicity i n and around Falun in Kopparberg.
Today the disease has a fairly widespread distribution clearly defined by the
exhaustive studies of Hojer. 26 2- 266 From Vasternorrland and the northern
and eastern parts of Jamtland the goitre belt extends southwards through
practically the whole of Gavleborg and all Kopparberg, except the
north-western tip, into Varmland, Vastmanland and the northern part
of Ostergotland. The southern goitre area extends from the Ostergotland
plain into the Counties ofJonkoping, Kalmar and part of Kronoberg.
Goitre-free or almost goitre-free areas are the plains of Skane, Halland
and Vastergotland, the district of Bohuslan and the plain of Dal, as well as
the slopes of the tableland lying south-west of the city of Jonkoping. The
most northerly part of Norrland and the islands of Oland and Gotland in
the Baltic are also goitre-free.
Hojer and his survey team examined 29 OOO people in 180 different
places and found that, in the most severely goitrous areas, the goitre rate
averages about 25 % ; but that there are many places where 15 % of the
population are affected. They concluded that in all Sweden there must be
not less than 300 OOO people with goitre.
An interesting feature of Hojer's investigation is the way in which he
has been able to correlate goitre occurrence with the topographical lie of
the land. His fullest account 264 contains many explanatory sketches and
diagrams showing the kind of terrain in 'which goitre is most likely to be
found. Deep valleys with overhanging mountains, and areas at the foot
.of large slopes, are notorious goitre grounds. Plains and high plateaux are
less affected.
In so far as Norrland rivers are concerned, Hojer confirms McCarrison's
thesis that goitre frequency gradually increases along a river valley as one
passes from the source of the river to its mouth. These north Swedish
rivers rise in goitre-free regions, pass through areas of sporadic occurrence
and eventually flow into lands of considerable goitre intensity. In south
Sweden, however, matters are quite the reverse. It is true that the Eman
river runs from end to end entirely through endemic goitre areas, but
in the case of the Svartan and Stangan rivers, goitre is more prevalent
in the upper reaches than in the lower. Similarly, rivers in the County of
Blekinge, and those of Halland, flow from goitre areas into districts almost
goitre-free.
According to Hojer's observations, wherever the prevalence of human
goitre in Sweden is high, say, from 15 % to 30 %, one may almost certainly
expect to find goitre among domestic animals-horses, cows, sheep, dogs,
and cats. Where goitre is of sporadic occurrence, Hojer occasionally saw
domestic animals affected, but in goitre-free districts he never found any
goitrous animals.
Toxic goitre is not unknown in Sweden. As might be expected, its
distribution closely· corresponds to that of simple endemic goitre (Sall-
strom 2 6 7 ) . This is in accord with experience in many other countries. As
regards cretinism, Hojer found about one case among every hundred per-
sons in districts where goitre is endemic. A special study carried out in
southern Sweden on the extent of mental deficiency in districts with varying
degrees of goitre shows that mental deficiency increases with increasing
prevalence of goitre.
The iodine content of milk from various districts in Sweden has been
determined by Sjostrom. 269 His results lend support to the iodine-deficiency
theory of goitre causation. Sjostrom 268 also determined the amount of
iodine in water samples from sixty of Sweden's major water works; in this
instance, however, he did not correlate the resultant data with goitre
prevalence.
Prevention of goitre by iodized salt is officially recommended in Sweden
and instructions on how to obtain and use the salt have been circulated by
the Royal Medical Department to all public health administrations and
municipal medical officers.
Norway
The most goitrous districts of Korway are found in a belt extending
from the interior of Telemark County north-eastward for about 120 miles
into Hedmark County where the country around Lake : v!josa is particularly
affected. Long recognized as goitrous, this zone was surveyed by Johannes-
sen 272 in 1891. He tried to relate goitre occurrence with geological con-
formation and mentions strong endemicity in the country surrounding
Tyrifjord, Randsfjord and Mjosafjord, and in such places as Lier, fodum,
Ringerike and Toten.
Kjl0stadP 3 in a survey carried out in 1921, found a great deal of goitre
among schoolchildren in towns in central Telemark. In some places the
rate was 80 ; , 901 or even 100 Typical percentages, for girls and boys
respectively, were: B0, 45 and 55; Sanda, 74 and 96: Brunke berg, 38 and
25; Flatdal, 55 and 44; Krokan, 29 and 80: Sandnes, 56 and 42; Utb0en,
64 F. C. KELLY & W. W . SNEDDEN
45 aQd 57. It is interesting that in several of these places the goitre rate was
higher in boys than in girls; but the over-all figures for 537 girls and 510
boys in the Holla, Lunde, B0, Seljord and Kviteseid areas were 57.5 % in
girls and 55.8 % in boys.
Studies by Nicolaysen 278• 279 and by Lunde 274-276 refer to goitre
among schoolchildren in towns bordering the Oslo Fjord and in the neigh-
bouring area of Sandsvaer just south of Kongsberg. At Vittingfoss, for
example, the rate was 55 %, at Berg 38 %, and at Komnes 40 %- Consider-
ably farther north, Nicolaysen found goitre in isolated districts throughout
Gudbrandsdal in Opland and Osterdal in Hedmark.
On the west coast of Norway cretinism occurs in the area immediately
north of Bergen and south of the Sogn Fjord (Skaar 281 ) . North of the Sogn
Fjord the prevalence in relation to environmental iodine supply has been
studied by Iversen, Lunde & Wi.ilfert. 271 At the isolated village of Veite-
stranden in Sogn 70 % of the 500 inhabitants were found to be goitrous.
Not far distant, the district of Vik in Sogn is goitre-free.
More recently, Devoid & Closs 270 carried out a goitre survey in the
district of Forsand near Stavanger. In this area goitre prevalence and
thyroid size increased with distance from the sea, from 19.8 % in men and
29.9 % in women in the group nearest the sea to 35.9 % in men and 62.8 %
in women in the group farthest up the valley. Noteworthy was the finding
that consumption of ush by the people decreased as distance from the sea
increased.
Denmark
The older literature repeatedly states that Denmark is free from endemic
goitre. More recently, however, it has been shown that certain parts of the
country have localized accumulations of goitre cases, not severe perhaps,
but sufficiently noticeable to warrant medical attention and the need for
preventive action. Thus, in 1933 Dalsgaard-Nielsen 283 discovered a com-
paratively large number of goitres in Bedsted-L0, a small parish in South
Jutland lying between Aabenraa and L0gum Kloster. On more closely
examining 40 unselected goitres in this area he found 284 that 23 were
hyperthyroid, 6 were hypothyroid and 11 did not show any special
characteristics.
The goitre problem in Denmark was subsequently elucidated more
thoroughly in a comprehensive monograph by Rosenquist 288 who investi-
gated the endemic area along the river Gudenaa between Silkeborg and
Randers, particularly the district at Gem and Svostrup. He compared the
prevalence at these places with that in the goitre-free district of Snejbjerg
some 30 miles farther west. The percentage rates were as follows:
Males Females
Snejbjerg (goitre-free) 0.8 5.5
G e m (goitrous) . . 5.7 18.4
Svostrup (goitrous) . 12.2 30.2
In the two goitre districts (Gem and Svostrup) a total of 2433 persons were
examined of whom 363, or 14.9 %, were goitrous. Forty-six, or 12.7 %, of
these 363 goitrous people showed symptoms suggestive of toxic goitre.
Meulengracht 287 and Iversen 285, 286 have shown that thyrotoxicosis
increased noticeably in Denmark during the Second World War. Meulen-
gracht's evidence, derived from records of hospital admissions, shows that
a gradual rise in the number of cases of thyrotoxicosis during the period
1933-41 was followed by a sudden upward jump in 1942. The number of
cases seen in his own clinic rose from 34 in 1941 to 118 in 1942. Meulen-
gracht considered possible statistical fallacies in the returns, but concluded
that both the steady rise between 1933 and 1941 and the abrupt increase
in 1942 were real phenomena, though probably independent. He could
not find any explanation for the rise; the 1942 "epidemic" could not be
ascribed to the emotional disturbances of war, because in the histories of
his patients he could find no abnormal occurrence of mental crises. Further-
more, there was apparently no corresponding increase in thyrotoxicosis
in neighbouring countries involved in the war.
Iversen, 285 , 286 who greatly amplified and extended Meulengracht's
original observations and brought the matter up to 1947, confirms that the
wartime increase in thyrotoxicosis in Denmark was a real one and not
simply the result of better diagnosis. His figures relating to the city of
Copenhagen are given in the tabulation below. They reveal a slow increase
in incidence from 1938 to 1941, a sharp rise beginning in 1942 and reaching
a peak in 1943-44, and a falling-off to 1947, when the rate was practically
the same as in 1939-40.
Year Cases per JOO OOO
o f population
1938 19
1939 23
1940 23
1941 34
1942 77
1943 84
1944 83
1945 52
1946 31
1947 21
The psychological effects of the German occupation are not held responsible
for the sudden change in prevalence because the behaviour of the invaders
during 1941, when the rise in thyrotoxicosis began, was comparatively
mild and there was no further rise in 1944, when conditions became much
more exacting. Moreover, during the same period, the incidence and
severity of toxic goitre tended to decrease in Belgium and the Netherlands,
while in Norway a small increase in incidence during the early stages of the
German occupation was followed by a fall.
Iversen points out that wartime changes in diet may have played some
part and in this connexion puts forward the following interesting theory,
although without proof. Before the war large quantities of soya-bean-oil
meal were imported into Denmark for feeding cattle. These imports were
greatly reduced in 1940 and ceased entirely in 1941 and subsequent years.
Soya bean is w,ell known to contain an anti-thyroid factor which, when
soya is normally used as cattle-feed, might find its way into cow's milk
and thus supply the human population with sufficient anti-thyroid factor
to keep down the incidence of thyrotoxicosis. If this were true, cases of
thyrotoxicosis would tend to increase in number when, as in wartime, the
supply of soya bean with its content of anti-thyroid factor was cut off.
These speculations find some support from what in fact were the very
opposite experiences of Belgium during the war. Here, not only was there
no increase in the absolute number of cases of toxic goitre, but the severity
of existing cases appeared to decline. Side by side with this was an increase
in the incidence of simple goitre. In explanation of these phenomena,
Bastenie, 282 who made the observations, points out that during the war
the Belgian people tended to eat more and more vegetables of the Brassica
genus-cabbage, kale and the like-which contain anti-thyroid substances.
If the increased simple goitre in Belgium was in fact of the "cabbage"
goitre type, then a reduction in severity might be expected' in cases of toxic
goitre on the same diet. The opposite effects might therefore be expected
if anti-thyroid compounds were withdrawn from the diet. Such, it is postu-
lated, was the case in Denmark during the war.
Estonian SSR, Latvian SSR and Lithuanian SSR

There does not appear to be much goitre in the former Baltic States.
Adelheim's data for Estonian schoolchildren are quoted by McClendon 296
and show a goitre rate of less than 0.5 % in the four districts Hapsalu,
Tallinn, Rakwere (Wesenberg) and Paide (Weissenstein). A later survey
by Ucke 297 confirmed that there is little goitre in Estonia.
Goitre occurs in some districts of Latvia. Here, the special morpho-
logical characteristics of the disease have been described by Ilinskii. 289·291
The iodine content of Latvian waters in relation to the distribution of
goitre has been studied by Kupzis. 293 , 294 In general, where the disease is
known to be absent or infrequent, as at Kemeri, Mitau, Silupe, Riga and
the surrounding coastal districts, Liepaja in the west, and Wolmar in the
north, waters contain between 2 µ g and l Sµ g of iodine per litre. In contrast,
iodine contents of 0.1 µg to 2 µ g are found in areas farther inland where
goitre is of common occurrence-namely, Zesvaine, Madona and Priekule.
Theses by Justus 292 and by Lewin, 295 published in 1913 and 1928 res-
pectively, refer to the occurrence of goitre in Konigsberg (Kaliningrad) and
other neighbouring towns in Lithuania and what was formerly East Prussia/
a Now part of Poland
notably at Memel (Klaipeda), Braunsberg (Braniewo ), Lyck (Elk), Allen-

stein (Olsztyn), Neidenburg (Nidzica) and Osterode (Ostroda). Prevalence
was mild, being about 5.78 % in girls and 3.08 % in boys. Modern data on
goitre in this territory are lacking.
Netherlands
The first reliable goitre statistics from the Netherlands were those of
Brand, 300 for whom the war of 1914-18 provided an opportunity to examine
46 975 mobilized servicemen from all parts of the country. He found that
10 % of men from the Rhine-Maas area in the centre of the country had
goitre, whereas only 1.4 , of those from the Province of Groningen in the
north were affected.
Subsequently (1924), the Central Board of Health of the Netherlands
Government set up a special commission to study the goitre problem in
greater detail and to advise on appropriate measures to remedy a situation
which had apparently been getting gradually worse during the previous
25 years. This commission-composed of clinical men, chemists, patho-
logists, bacteriologists and other experts-reported in 1932 on the examina-
tion of 34 OOOchildren and adults in schools and factories. 304
These new statistics for the most part confirmed Brand's distribution
data of 15 years earlier and, as a result, a very detailed goitre map of the
Netherlands has been made. Broadly speaking, the eastern, central and
southern parts of the country are prone to be goitrous, whereas the \Vestern
and northern regions are almost free from the disease.
Immediately to the east of the Zuider Zee a considerable incidence has
been found in such places as Wolvega, Steemvijk, Hoogeveen, Meppel and
Kampen. At the south end of the Zee goitre occurs among the people of
Harderwijk, Hilversum, Bussum, Naarden and Weesp. Towards the eastern
frontier the incidence is liable to be high in Emmen, Koe,,orden, Almelo,
Enschede, Diepenheim, Boekelo, Winterswijk, Aalten and Doetinchem.
Centrally, high figures were found among schoolchildren in the Betuwe
("river" area) at Tiel, Wamel and Leeuwen, and at Hoven, Arnhem,
Ede, Renkum and, particularly, Kuilenburg, Gorinchem, the Krimpen
area and Breda. In the extreme south and south-east of the country the
survey revealed goitre in Roermond, Eindhoven, Roosendaal and Bergen
op Zoom; and on the western seaboard it has been found at Hillegom,
Lisse, Sassenheim, Noordwijk and Warmond.
Places which are goitre-free, or have a negligible prevalence, are Assen
and Groningen in the north, Zutphen in Gelderland, and Gouda and
Barendrecht in the western part of the country. In a recent nutrition survey
of Ijsselmonde, goitre was encountered occasionally by Kaayk. 305
An interesting study of goitre in the south-east corner of Friesland has
been made by Pasma. 306-305 He refers particularly to the municipality of
Ooststellingwerf, where 40 '.; of the children were found to have thyroid
enlargement. In the same area goitre is common at Weststellingwerf and

·among very young children at Wolvega. Pasma observed that the intel-
lectual level of the affected children was much below that of children who
were goitre-free. Conditions in south-east Friesland are in marked contrast
to those in north-west Friesland, which is entirely non-goitrous.
As part of the work of the Goitre Commission, Dr J. F. Reith, of the
State Institute of Public Health at Utrecht, carried out a large number
of analytical studies which prove conclusively that deficiency of iodine in
the drinking-water is the cause of goitre in the Netherlands. 304 , 309 The
inverse relationship between the goitre rate and the iodine content of
drinking-water is clearly seen in the tabulation below, which shows the
percentage of goitre found among schoolchildren in various towns and the
content of iodine in the water. 304
Goitre rate Iodine lndine
in water Goitre rate
in water
(%) µg
( per litre) (%) (µg per litre)
Hoogeveen 66 3.6 Harderwijk 45 2.3
Renk um 58 1.3 Doetinchem 44 2.4
Roosendaal 55 1.5 Kampen 41 0.9
Alemlo 53 3.0 Steenwijk 36 1.1
Gorin chem 52 3.0 Bergen op Zoom 31 1.1
Arnhem 50 1.0 Meppel 27 1.1
Kuilenburg 50 1.6 Zutphen 9 36.3
Ede 48 2.5 Gouda . 6 69.8
Breda 47 1.7 Barendrecht 0 89.2
On the basis of their investigations the Goitre Commission reached

the conclusion that, on an average, the daily intake of iodine from food and
water was deficient by 80 µ,g per head of population. Accordingly they
recommended that drinking-water in goitre regions should be fortified
with potassium iodide so that each individual would receive approximately
80 µ,g of additional iodine per day. The per caput consumption of tap-
water in prepared food and for drinking purposes was estimated to be
1.5 litres daily. It was therefore decided to raise the iodine content of
tap-water by 50 µ,g per litre.
l;'he iodizing installation used by the municipal water departments
consisted of a glazed-stone mixing-vessel in which 100 litres of a 0.5 % or
1 % solution of potassium iodide were prepared. The addition of this stock
solution to the main reservoir was achieved by means of a regulated
dropping-needle, and the raised iodine content was checked by periodical
analyses.
The Netherlands is the only country where goitre prophylaxis by iodized
water has been successfully applied for any length of time on a large scale.
In the hands of the Netherlands authorities the method has yielded results
which compare favourably with those achieved in other countries by iodized
salt. For example, at Kuilenburg a rate of 40 % among children in 1931 had
declined to 18 % by 1937, to 14 % by 1939 and to 4 % by 1941.
Unhappily, plans to set up additional installations to supply iodine-rich

tap-water throughout the country had to be abandoned on account of the
1939-45 war. Indeed, the Germans stopped this form of prophylaxis
entirely and it has never been re-introduced. As an alternative, the public
health authorities advocated that all salt used for making bread be iodized
in those municipalities which had previously applied the iodized-water
method of prophylaxis. Accordingly, a decree came into force in 1942
making it compulsory for bakers in those particular municipalities to use
only iodized salt the so-called" Jobrozo ". Writing in 1952, De Josselin de
Jong 301 states that Jobrozo (which contains 1 part of iodine in 33 OOOparts
of salt) is now used compulsorily for bread-making in 260 communities.
Originally Jobrozo was somewhat more expensive than common salt; but
the Royal Netherlands Salt Industry now produces it at the same cost. The
results of this method of preventing goitre in the Netherlands have recently
been described by Hipsley, 303 ,vho has introduced the method in Australia.
While officially controlled prophylaxis, first with iodized tap-,vater and
later with bread salt, was gradually being applied town by town, a lively
public awareness of the goitre problem became evident, and places not at
once covered by the official measures began to introduce various uncon-
trolled prophylactic procedures of their own. To regularize these independent
activities the Royal Netherlands Salt Industry put on the market an iodized
salt, called " Jozo ", for general use. This contains 1 p a n of potassium
iodide in 200 OOO parts of salt, and bet\:veen 1932 md 1951 its production
rose from 520 OOOkg to 10 million kg.
All the most up-to-date information on endemic goitre in the Nether-
lands, including the results of preventive measures, has been brought
together recently (1959) in a comprehensive volume published by the
Organization for Health Research under the authorship of Pasma, Terpstra,
de Wijn, Kroes, & Langeveld. 30 2 The main conclusions from this remarkable
survey deserve brief mention.
Examination of large numbers of schoolchildren from all over the
country shows that, apart from municipalities where iodine prophylaxis has
brought about a decrease in goitre rates, only a few localities are goitre-
free, namely, Zutphen, Gouda, Amersfoort, 's-Henogenbosch, Barendrecht
and Moordrecht. It is stated that in these places absence of goitre is due
to the fact that there is a sufficiently high iodine content in the tap water,
the level being more than 40 /Lg per litre. The remaining parts of the country
still exhibit goitre in varying degrees of intensity. For instance, low rates
are seen in the province of Zeeland; very high rates in the Gelderse Ach-
terhoek.
Results of the Netherlands survey support the view that iodine deficiency
is the primary cause of endemic goitre in the country. Food is the most
important natural source of iodine; drinking water ranks second, and, if
the iodine content is high, may be the decisiw prophylactic source of the
element. Proximity to the sea is of no practical consequence. In test subjects,

thyroid uptake of radioactive iodine in an endemic area was avid and
rapid. 310, 31 1
Medical examination of children with and without goitre (but com-
parable in regard to age, sex and social class) revealed a better nutritional
state in the goitre-free group; onset of puberty is on the whole a year later
.in goitrous than in non-goitrous children; systolic blood pressure is signifi-
cantly lower in goitrous children; and in the intellectual and emotional
sphere, goitrous children are at a disadvantage compared with their non-
goitrous counterparts.
The Netherlands goitre campaign is a model of what can be done with
determination and efficient management to rid a country of this disease.
Within 20 years the youngest generation-children below 5 years of a g e -
has been freed from the menace of goitre; serious cases are no longer
observed among adults; the prevalence of moderate thyroid enlargement is
decreasing steadily; and no harmful consequences of iodine prophylaxis
have been reported (De Josselin de Jong 301).
This account of goitre in the Netherlands would be incomplete without
mention of the recent investigations of Binnerts, 298· 299 who, building upon
the earlier studies of Brouwer and Wiertz, has clearly shown that as one
passes from severely goitrous areas through mildly goitrous areas to regions
where there is no goitre, there is a corresponding rise in the iodine content
of the cow's milk collected.
Eastern Europe
Poland
Practically the whole of the south of Poland is goitrous. The disease

occurs with high intensity in the Voivodship of Krakow, in Lower Silesia,
and all along the northern slopes of the Carpathian Mountains westward
into Sudetenland. In these parts the goitre rate is always about 10 % and
in some localities-notably in the Myslenice and Nowy Saez districts of
Krakow Voivodship-rises to 40% or even 60% (Hauke; 320 Samelson; 331
Chodzko & Tubiasz; 313 Tubiasz; 332-334 Nowakowski 330). In 1953 Czyzewski
et al. 318 examined 6000 people in Lower Silesia and found pronounced
thyroid enlargement in 17.8 % of 3195 women and in 9.8 % of 2805 men.
Krol & Stylo 324 found 38 % of cases among the 48 774 persons they exa-
mined in the Voivodship of Krakow in 1957.
Goitre is also endemic in central and eastern Poland, in such places as
Poznan, Zielona Gora, Krotoszyn, Leszno, Kalisz, L6dz, Warsaw, Kielce
and Lublin. Here, the prevalence, although significant, is somewhat lower
than in the south, being 13 % in districts around Poznan and 21 % to 28 %
at Krotoszyn (Czyzewski & Falkiewicz 315). The disease is not endemic in
the Voivodship of Bialystok in the north-east of Poland where Karbowski 323
examined 3421 men, women and children during 1953-1957. Nevertheless,

Karbowski advises the application of iodine prophylaxis as a safety
measure.
Surveys are now in progress at Gdansk, Sopot and Gdynia on the Gulf
of Danzig, and at Koszalin somewhat farther to the west, to ascertain
whether goitre is of current public health significance in the northern section
of Poland. Interest will centre on whether the findings confirm those of
Liek 325-329 published bet,veen 1925 and 1929 that goitre does in fact occur
in this area, albeit without great severity. Incidentally, Liek is one of those
who reject the "iodine-lack " theory of causation.
Before the 1939-45 war a National Goitre Committee was established to
collect statistical data and to apply prevention by iodized s a l t - a measure
introduced in the Voivodship of Krakow on 1 January 1935. The results of
this committee's work, available in papers by Tubiasz 334 and Heller, 321
show that an average rate of 17.6 % of goitre among military recruits in
Krakow Voivodship over the five years prior to salt iodization was reduced
to 2 % by 1938, that is, after three years of iodized-salt prophylaxis. This
rapid and marked decrease in the goitre rate occurred with a salt iodized
at a level of 1 in 200 OOO and only in districts where the salt was employed.
It was not observed elsewhere.
Post-war investigations have established that the distribution of goitre
in Poland corresponds in general with that prevailing before the war, but
the intensity of the disease has increased. The endemic is severest in the
south, and individuals who have left goitre-free districts to come to live in
Lower Silesia are known to develop goitre there. It appears, too, that a
hitherto unknown endemic focus of considerable intensity exists in the
region of Poznan. According to Heller, 322 the rise in goitre incidence in
Central Europe (a similar increase has been found in Germany) was to be
expected owing to quantitative and qualitative defects of diet during the war.
He also attributes the rise to changes in fertilizer practice. In former times
Chilean nitrate of soda, which contains a significant proportion of iodine,
was extensively used in Poland; it has now been superseded by synthetic
nitrogen fertilizers containing no iodine. Another contributory factor is
said to be the cessation of kelp-burning for iodine on the coast of Brittany.
Considerable volumes of iodine vapour from this source were carried inland
by the prevailing winds, and Heller estimates that at one time about 14 tons
of atmospheric iodine annually fell in rain on to Central European soils.
The validity of this supposition is fully discussed in the Geochemistry o f
Jodine. 312
The increased post-war severity of the disease has prompted the Ministry
of Health to institute a preventive campaign on a national scale, and
provincial goitre committees have been set up in Krakow, Lublin, Poznan,
Warsaw, Katowice, Rzeszowa and Kieke, with the duty of mapping the
extent of goitre in Poland and organizing the distribution of iodized salt.
FIG. 3. NORTHERN AND EASTERN EUROPE
The red hatching indicates the areas where endemic goitre has been found.
PREY ALEKCE AND GEOGRAPHICAL DISTRIBUTION 73
Iodized salt was re-instituted in the Voivodship of Krakow in 1946 and was
introduced for the first time in that of Wroclaw in 1949.
To make it possible for just comparisons to be made of results from
different districts, the Ministry of Health have recommended the adoption
throughout Poland of a uniform scale for measuring the degrees of goitre.
A modification of the classification of Nowakowski is favoured-namely,
group 1, in which the enlargement is less than half the size of the fist of
the person examined; group 2, visible thyroid enlargement equal to half the
size of the individual's fist; group 3, enlargement equal to the size of the
individual's fist; group 4, enlargement greater than the size of the individual's
fist.
A unique feature of the Polish preventive campaign is the proposal to
transfer for a time all pregnant ,vomen and small children from endemic
valleys to higher localities where goitre is non-existent. This " settlement
operation", as it is called, is based on experience in Switzerland, where as
long ago as 1849 it was found that children transferred in this manner did
not develop goitre to such an extent as those who had not changed their
habitation.
An evaluation of the iodine prophylactic programme in Lower Silesia
has recently been made by Czyzewski et al. 319
USSR (excluding Estonian SSR, Latvian SSR and Lithuanian SSR)

In point of goitre distribution, the vast territories comprising the Union
of Soviet Socialist Republics may conveniently be divided into three sec-
tions-European, Caucasian, and Asiatic.
European section
In the European section eastwards as far as the Ural Mountains, which
form the natural physical boundary of Europe, goitre occurs endemically
in several places. To the north-west numerous cases are found on the eastern
shores of Lake Ladoga and in the area between Lake Ladoga and Lake
Onega, particularly in the valley of the river Oyat and throughout the
district of Olonetz. This focus may be regarded as an extension of the
Finnish endemic.
Byelorussia (White Russia) exhibits goitre in and around Minsk, and,
farther south, in the marshy low-lying country drained by the Pripet and
the Beresina rivers where about 20 % of the schoolchildren are sufferers,
but there is no cretinism. The Ukraine has several goitrous localities,
notably at Chernigov in the north-west and at Sumi, Kharkov and along
the Tim river nearer the centre. South-eastwards from Kharkov there is
goitre in the industrial district of Lisichansk-Rubezhansk.
The higher mountainous country towards \Vestern and south-western
Ukraine bordering on Poland, Czechoslo,akia and Romania is severely
goitrous in many parts. An extension of the Polish endemic is found at Lvov

and in the Region of Volhynia, where the disease is reported to be mainly of
the hyperthyroid and large colloid type, accompanied by considerable dental
caries and severe disturbances of the circulatory and digestive systems.
Farther south, the Carpathian mountains carry the malady from Czecho-
slovakia and Romania into the West-Ukrainian areas of Stanislav Bukovina,
Chernovitskaya, and northern Moldavia. Immediately to the south of
Chernovitskaya there is a zone of high prevalence (56.5 %) in the Vaskovskij
district along the foothills of the Prut-Siret watershed. Here, the drinking
waters contain an average of 0.55 µ,g of iodine per litre, whereas throughout
the Kelmeneckij district in the neighbouring Prut-Dniester watershed to the
east, the local drinking waters contain 2.15 µ,g of iodine per litre (Shvetz 416)
and, correspondingly, no goitre is seen.
Another goitrous region in the European section of the USSR lies to
the north-centre, relatively close to Moscow. The areas affected are to the
north-east of Moscow at Yaroslavl, Kostroma and Ivanovo, and to the
south at Serpukhov, Ryazan, and along the river Oka which drains part of
the Central Russian Uplands.
Proceeding eastwards towards the Ural Mountains one crosses a belt
stretching from Kirov in the north to Saratov in the south. In the northern
part of this belt, goitre is found on the Vyatka river near Kirov and in Mari
Region between Gorki, Chuvash and Kazan. The adjacent province of
Tatar is also goitrous. Farther down the Volga basin goitre occurs in the
regions of Alatyr, Ulvanovsk, Penza, Kuznetsk, Syzra and the lower Volga
town of Saratov. The valley of the river Sok and the neighbouring area of
Kuibyshev (Samara) east of Syzra are also reported to be goitrous.
In the main chain of the Urals goitre is found at various places, but
particularly in the centre, on both the western and eastern slopes. The
valley of the river Sylva and the nearby towns of Perm (Molotov), Debessy,
Kungur, Krasnofimsk and Birsk are the chief seats of the disease on the
western slopes. On the Siberian side, Sverdlovsk and Chelyabinsk are the
principal goitre regions of the central Urals.
Caucasian section
In the Caucasus, centres of goitre and cretinism are found all along the
southern declivities of the mountains. In the north-west, the valley of the
Kuban river, which flows westward through the Territory of Krasnodar to
enter the Black Sea just south of the Sea of Azov, is stated to have a goitre
rate of 40 % among the female population. High rates are also found in the
adjoining areas of Karachaevsk and Kabardino-Balkarsk, especially
around the Elbrus group of mountains.
In Gruzia (Georgia) the valleys of the rivers Ingur, Adzharis-Tskhali
and Rion, which flow near Kutaisi into the eastern end of the Black Sea
north of Batum, are well-known goitre areas, and in the neighbourhood of
PREY ALENCE AND GEOGRAPHICAL DISTRIBUTION 75
Batum itself there is an intense focus in the mountainous districts of

Adzharistan.
In 1938, Gelovani 356 reported what was then a new endemic locality
in Letshkhoom, an upland area of Georgia bordering on the lower part of
Svanetia. Here, 52 % of the people suffer from goitre and there is much
cretinism. The water-supply of Letshkhoom villages is derived from
shallow wells, to which the larger domestic animals also have access, and
which have been proved by chemical analysis to contain little or no iodine.
In central Caucasia there is a goitre focus in the valley of the river
Aragwa in Georgia north of Tiflis. At the east end of the range in the
vicinity of the Caspian Sea there are centres of goitre at Gunibsk and Laksk
in Daghestan, and near Shemakha in the Republic of Azerbaidzhan west of
Baku. Goitre occurs also in the extreme south of the Caucasian region,
particularly at Ordubad where the provinces of Nakhichevan, Armenia and
Azerbaidzhan adjoin. The overall goitre rate at Ordubad in 1959 was 28.8 %
(Alikishibekov 338).
Asiatic section
Eastward beyond the Caspian Sea, over the great Kara Kum desert and
through Turkmen, there lie the Republics of Uzbek, Tadzhik and Kirghiz,
which together encompass one of the most notorious goitre areas of the
world. In Tadzhikistan an inverse relationship has been found between the
prevalence of goitre in certain districts and the amount of iodine present in
local foods and water. Experiments to control goitre by the iodization of
bread have been undertaken in these localities.
The central Asiatic endemic begins at Bukhara and Samarkand and
reaches its greatest intensity in the Region of Ferghana (Kirghiz), especially
in the Chatkal Mountains, around the towns of Tashkent, K o k a n d t and
Andizhan. To the south of this area, abutting on the extreme north of
Pakistan, lies the Pamir plateau, where in some valleys notably that of
the river Wanj which flows into the head-waters of the great river Oxus
(Amu-Darya) the entire population without exception is said to suffer
from goitre. The goitre endemic of Ferghana and the Pamir plateau is
continuous with that extending south-eastwards through Kashmir and the
Himalayas.
Grouped with the Ferghana focus is the endemic found throughout the
mountains of Semirechensk in " The Land of the Seven Rivers " between
Lake Issyk-Kul in the north of Kirghiz and Lake Balkhash in Kazakh
(formerly Turkestan). It was in this part of the ,.vorld that Marco Polo
saw goitres ,vhen on his famous travels from Venice to the court of the
Grand Khan in China about the year 1275. After passing through the high
Pamirs he came to the Chinese provinces of Kashgar and Yarkand at the
a Kokand has been described as·· a city of cretins · i (Brir. ma/. J. 1905, 11 34).
extreme western end of the Takla Makan desert in Sinkiang (Chinese

Turkestan). Writing of the people in Yarkand, Marco Polo 388 says: "They
are in general afflicted with swellings in the legs, and tumours in the throat,
occasioned by the quality of the water they drink." The leg swellings were
due to elephantiasis.
Elsewhere in the Asiatic section there are three major goitre areas. These
lie in the south of central Siberia, one at the head-waters of each of the
three great parallel northward-flowing Siberian rivers-the Ob (or Obi),
the Y enisei, and the Lena.
Proceeding from west to east, the first of these three districts extends
from the Altai Mountains, at the north-west corner of the Mongolian
plateau, northwards to the town of Tomsk. The endemic is especially
severe in the middle and west Altai, that is, in Ojratsk, and covers the area
o f the sources of the rivers Ob, Bija, and Katun in the east Altai district of
Kusnetz.
The second focus lies in the upper basin of the Yenisei and centres
round Tulunsk, a town on the trans-Siberian railroad midway between
Krasnoyarsk and Irkutsk. The river Uda flows northwards through goitrous
regions at this. point. Somewhat to the south-west of Krasnoyarsk the
disease is rife in the Khakassia region where it has been a special problem
among children and adults on the site of the Abakansk railroad construc-
tion. Still farther east one encounters a considerable endemic around Lake
Baikal and the head-waters of the river Lena. Here, in the neighbourhood
of Irkutsk, about half the population are goitre sufferers. In the middle
reaches of the Lena a goitre belt stretches for more than. 600 miles from
Kirensk to Yakutsk.
East of Lake Baikal, in Buryat-Mongol and Chita (formerly Trans-
Baikalia), goitre is found in two more or less circumscribed areas-one in
the district watered by the river Chilok, which flows into the south-east
end of Lake Baikal, and the other on the eastern slopes of the Yablonoi
Mountains, particularly at the town of Nertchinsk and at the confluence
of the Shilka and Argun with the Amur, rivers which form the boundary
between this part of Soviet territory and the. north of Manchuria. Here,
the goitre rate may reach 74 %- Arndt 340 records that goitre is often found
in association with local endemics of osteo-arthritis. Domestic animals are
also affected with goitre in this area.
Finally, at the extreme east of the USSR goitre is found in the Primorsk
Region, that strip of mountainous eastern seaboard territory extending
from the mouth of the river Amur in the north to Vladivostok in the south.
Goitre prevention throughout USSR

Throughout the whole of the Soviet Union an enormous amount of
systematic and painstaking analytical and survey work has been carried
out to establish the causes. of goitre in different parts of the country and to
PREVALENCE AND GEOGRAPHICAL DISTRIBUTIO'\ 77
elucidate whether incidence is related to excesses or deficiencies of mineral

elements in the local soils, \Vaters and foods. These clinical and geochemical
surveys amply support the iodine-deficiency theory of causation, a conclu-
sion with which all investigators, although maybe working in areas widely
separated, are unanimously and uncompromisingly in agreement. As a
consequence, organized preventive measures have been instituted under
government auspices in almost every part of European and Asiatic Russia
where goitre occurs.
One or two salient features of this All-Union effort deserve mention
here:
Several investigators have been preoccupied with the environmental
relationship between high manganese and low iodine. At the Kazan
Medical Institute it has been found that in ordinary foods a high manganese
and a low ascorbic acid content goes hand in hand with a high incidence of
endemic goitre. Similar research in the adjacent Tatar Region has estab-
lished that a high soil content of manganese occasions a reduced content of
iodine in the soil, thereby leading to goitre occurrence (Kamchatnov 366, 367).
Gurevich 358-360 reached the same conclusion from his studies in far-
eastern Primorsk.
As regards absolute iodine content of soils, waters and foods, Shul-
pinov 415 found in Mari Region that dry soil in areas of high endemicity
contained 122.2 f-lg, in areas of moderate endemicity 267.8 f-lg, and in areas
free from goitre 1597 f-lg of iodine per 100 g. The iodine content of
the potato in highly endemic areas was only one-thirtieth of that of
potatoes grown in non-goitrous areas. Savchenko,4° 8, Jo9 ·who has made an
" iodine map " of the Ukraine, found that the prevalence of endemic goitre
was greatest when the iodine content of water did not exceed 1-2 f-lg per
litre, moderate when \Vater contained up to 2-3 ,_,g per litre, and low when
the level reached 3-4 µg per litre.
Results of iodine prophylactic measures are recorded by many observers.
Bergman 345 testifies to their effectiveness in Transcarpathia. A re-survey of
the Sverdlovsk region in the years 1957/59 revealed goitre rates one-fifth to
one-third of those prevailing in 1929/31 when iodine prophylaxis was first
introduced. After five years of systematic treatment with iodized salt
(1952-1956/57) in the Stanislav area, goitre rates fell from 10.9 % to 6.9 % in
the whole population, from 291- to 15 , in expectant and nursing mothers,
and from 17 ; to 11 / among schoolchildren. The beneficial results of
long-term iodine prophylactic programmes, extending over 25-30 years,
have been documented by Nikolaev Joo for Russia as a whole, and by
Mamedov and Orudzhiev 387 for the Caucasian republic of Azerbaidzhan.
In the all-embracing biogeochemical studies carried out in the USSR,
animal goitre has not been forgotten. Few countries can boast a map more
detailed and comprehensive than that prepared by Koval'skij 377 showing
areas in which deficiency or excess of mineral elements in the soil may affect
78 C. F. KELLY & W. W. SNEDDEN
human and animal health. Soils of the non-chernozem zone of the Soviet
Union are poor in copper, cobalt and iodine, a fact that influences the
content of these microelements in fodder plants and therefore leads to
animal diseases due to their deficiency.
The foregoing review of goitre distribution throughout the USSR is
based on information taken from the comprehensive treatise on the subject
by Arndt 340 and from papers by the following authors; localities with which
particular authors are specially concerned are given within brackets.
European section : Aber (Ukraine); 336 Antonov (Stanislav); 339 Bergman
(Transcarpathia); 345 Chekalov (Kostroma and lvanovo); 347 Davidova
(Transcarpathia); 35° Fedinets (Transcarpathia); 353 Florinskii (Yaro-
slavl); 354, 355 Goncharov (Tatar & Mari); 357 Ionisyants (Smolensk); 362
Kamchatnov (Kazan); 365 Kamchatnov (Tatar & Mari); 366• 367 Karpova
(Yaroslavl; 368, 369 Kharitonova (Sverdlovsk); 370, 371 Kutsherenko
(Ukraine); 379, 38° Kutsherenko, Judina & Kutsherenko (Chernigov); 381
Kutsherenko, Judina & Rimak (Volhynia); 382 Landishev (Tim River); 384
Lyapustin (Urals); 385 Mayer (Arctic); 390 Meshchenko (Transcar-
pathia); 393• 394 Plotnikova (Sverdlovsk); 403 Primak (Ukraine); 404 Rodn-
janski (Byelorussia); 405 Rybalkin (north Bukovina); 406 Savchenko
(Ukraine); 408, 409 Schermann (Mari); 410 Shinkerman (Bukovina); 411, 412
Shmagina & Usmanova (Tatar); 414 Shulpinov (Mari); 415 Shvetz (Cherno-
vitskaya); 416 Skatkov (Moscow district); 417-420 Tabakov (Birsk); 423
Tikhonova & Shifman (Lisichansk-Rubezhansk); 424 Tsarikovskaya et
al. (Lisichansk-Rubezhansk); 425 Udod (Stanislav Region). 426
Caucasian section : Alfeev (Karachaevsk); 337 Alikishibekov (Ordu-
bad); 338 Aslanishvili (Svanetia }; 341 Balakhovskaya et al. (Daghestan); 342• 343
Egorov & Orudzhiev (Azerbaidzhan); 352 Ionisyants (Azerbaidzhan); 361
Kalishevskaya (Onskii, Georgia); 364 Kuznetsov (Karachaevsk); 383 Mame-
dov (Azerbaidzhan); 386 Mamedov & Orudzhiev (Azerbaidzhan); 387
Nikolaev (Kabardino-Balkarsk); 398 Nizhibitski (Karachaevsk); 401 Slavin
(Kabardino-Balkarsk); 421 Strunnokov (Karachaevsk); 422 Valedinskaya
(Kabardino-Balkarsk); 427 Zhukovski (Karachaevsk). 428
Asiatic section : Abdulakhatov (Uzbek); 335 Belikhova (Abakansk); 344
Bolotova (Abakansk); 346 Chukanin & Levitin (Andizhan); 349 Gurevich
(Primorsk); 358, 359 Gurevich & Mukhina (Primorsk); 36° Khazan (Tadzhi-
kistan); 372 Khvorov & Ionisyants (Krasnoyarsk); 374 Kolomiitseva (Tadzhi-
kistan); 375 Kruchinina (Uzbek); 378 Masumov (Ferghana); 389 Mirochnik
(Khakassia); 396 Nikolaev (Khakassia); 399 Obliiarov (Uzbek); 402 Shka-
renko (Uzbek). 413
Romania
The most highly goitrous regions of Romania lie along the Carpathian
Mountains running from north to south of the country, and along the
Transylvanian Alps from west to east. Studies by Campeanu 431 and by

Danielopolu and co-workers 432-437 contain a wealth of information, with
numerous distribution maps and illustrations showing what must be
among the saddest and most distressing cases of goitre and cretinism ever
photographed.
Two areas in which Danielopolu and his associates made a detailed
investigation are Bukovina in the north (now part of the Ukraine) and the
District of Sibiu, which lies in the centre of the country on the northern
slopes of the Transylvanian Alps. In Bukovina, the Czeremosz valley, which
traverses the Romanian-Ukrainian frontier, is highly goitrous, as also is
the valley of the Moldavitza in the District of Campalung-Moldavia.
Here, 46 % of the inhabitants examined by Danielopolu had goitre. At
Ispas in the Bukovinian district of Storojinet (now in the Ukraine) 465 cases
were seen in seven small hamlets. Although simple goitre was commonest,
there were many cases of cretinism, myxoedema, deaf-mutism and im-
becility.
Among the communes investigated in the Transylvanian district of
Sibiu were Talmacuil with a goitre rate of 21.5 %, Sibiel with a rate of 50 %,
and Cisnadie with a rate of 25.4 %- At Ighisul-Nou, in the valley of the
Tarnava Mare immediately north of Sibiu, Danielopolu found 31.7 % of
goitre. Zlatna in the District of Alba Iulia to the north-west of Sibiu is also
very goitrous.
Goitre is prevalent in certain parts of Moldavia, on the east side of
Romania. Andronovici 429 examined the schoolchildren of thirteen Mol-
davian towns and found rates of 20.2 % at Falticeni, 24.1 % at Jassy, 24.5%
at Roman, 34.1 % at Piatra Neamt and 13.5 % at Bacau.
In Romania, goitre is notoriously a disease of poverty. The inhabitants
of all the small goitrous villages surveyed by Danielopolu were very poor
and lived under exceedingly primitive housing conditions very often a
whole family in one badly ventilated and ill-lit shack together with their
domestic animals. There is least goitre among the men who pass a large
part of their time in the mountains as shepherds, woodmen and charcoal
burners. Social environment in relation to unfitness in military recruits in
Romania during the years 1941-46 has been the subject of study by Banu
& Dinu, 430 who mention goitre as one of the causes of rejection for service.
Romania now takes her place as one of the countries which has tackled
the goitre problem with vision, determination and system. Prior to the year
1944 the State health authorities had done almost nothing to arrest the
disease. Shortly before that time attempts had been made to introduce
iodized salt a and prophylactic dosage with Lugol's solution into some
communities, but as these lacked official stimulus and supervision little
came of them. Not until 1947 did the Ministry of Health entrust to
a Parhon recommended its use in 1908 (Rum. med. Rer., 1, No. 1. 61).
Dr S. M. Milcu the task of organizing an anti-goitre campaign throughout

the country.
Under Milcu's direction, fresh surveys were undertaken by specially
trained teams of endocrinologists, a goitre map of the country was built-up
piece by piece, and preventive measures were set on foot. To cover all the
clinical forms and degrees of the goitre manifestation in Romania, Milcu
introduced the term "endemic thyreopathic dystrophy", a three-degree
classification into which all cases can be grouped according to severity.
By a wider coverage of the country, and by uniform methods of examination,
Milcu and his colleagues gave precision to earlier assessments of the extent
and seriousness of the endemic. Detailed surveys among schoolchildren
belonging to communities in the Jiul valley to the south west, along the
course of the Arge river from Pite ti through Giie ti to Bucharest, in the
Muscel region towards the centre of the country, and in the districts around
Ploe ti and Sliinic, revealed rates varying from 20 % to 90 %.
Concurrently with these investigations, preventive action with iodized
salt (1 in 50 OOO strength) was instituted. An iodide tablet (1 mg Kl) has
also been used. Seven years of experience with these methods have been
uniformly good. The rate among schoolchildren has been cut by anything
from one-fifth to one-third. Schools in the Muscel region, for example,
showed a rate of 81.8 % in 1950. and by 1954 this had been reduced to
46.5 % as a result of iodine prophylaxis. No more cases of cretinism or
congenital goitre in children below the age of 4-5 years have been reported.
Milcu and Negoescu 441 emphasize also that no accidents or ill-effects due
to mass prophylaxis with iodized salt have been observed.
Full details of all the many-sided aspects of these recent Romanian
studies are available in numerous papers and in several impressive volumes
published under Milcu's editorship. 438-448
Bulgaria
Mass examination of 971 864 schoolchildren in 4 036 communities

throughout Bulgaria showed that thirty-two provinces were affected with
goitre in 1958, twelve severely. The endemic regions are in the mountainous
parts of the country; except for a few isolated foci, coastal areas are goitre-
free (Penchev et al. 459) .
The disease is markedly prevalent along the banks and tributaries of the
west Bulgarian river Struma, which rises in the Vitosha Planina south-west
of Sofia and has a general north to south direction, eventually flowing
through Greek Macedonia and entering the Aegean at the Gulf of Strimon
on the east of Thessalonika. In Greece the spelling of the name changes to
Strofima, and in classical times the river was known as Strymon.
The word " Struma " is often used, especially in German literature, as a
synonym for goitre-the adjectives "scrofulous", "strumous" and
PREVALEJSCE AND GEOGRAPHICAL DISTRIBUTION 81
" goitrous " being nearly interchangeable. Some say that the river was
named after the disease. It seems much more likely that the disease took the
name of the river in whose Yalley it abounds.
Two left-bank tributaries of the Struma, the Rila and the Bistritsa,
flow through exceptionally goitrous country where surveys have been made
by a team under the leadership of Penchev, 455-458 and by Tsvetkov. 462 On
the upper course of the Rila (which joins the Struma midway between Sofia
and the northern border of Greece) 62 , of a total of 3810 people examined
in seven communities had goitres. Newcomers into the area are not long in
contracting the disease, and cretinism and deaf-mutism are of common
occurrence. On the lower course, a rate of 50.4 % was recorded among more
than 5000 people examined in the townships of Stob, Porominovo and
Kocherinovo near the confluence of the Rila and Struma. In these lower
stretches of the river, cretins and deaf-mutes were not evident.
More than 300 families (60 , of all households) were examined for
thyroid enlargement by Tsvetkov 462 in the township of Bistritsa situated
on the river of the same name flowing through the extreme south of Sofia
province into northern Macedonia. Here, 47.3 % of the inhabitants were
found to be suffering from goitre.
The city and district of Plovdiv towards the centre of the country is yet
another goitre area in Bulgaria. Khaidudov, Chervenivanov & Armenkov 452
associate the goitre endemic in this region with low nutritional standards and
poor living conditions.
The goitre rate among adults and schoolchildren in the town of Teteven,
about 50 miles north-east of Sofia, was investigated by Ticholov 461 in 1926
and again in 1947. In the former year about 10 % of the total population
were affected; by 1947 this over-all figure had risen to 20 %, and the rate
among schoolchildren was as high as 80 %. In the village of Ribaritza, a
strong focus of endemic goitre situated about 12 km from Teteven, no less
than 81 % of boys and 89 of girls were found to be goitrous in Ticholov's
1947 investigation. Teteven was originally supplied with water from local
springs and wells; in 1939 the source of supply was changed to water
carried by aqueduct from the neighbouring river Beli-Vit. It has not been
possible to determine the iodine content of both well and river supplies, but
Ticholov assumes that alteration in the chemical quality of the drinking-
water is the cause of the increased incidence of goitre in Teteven.
On the recommendation of Penchev, 459 Khaidudov 452 and others, steps
are now being taken in Bulgaria to apply iodine preventive measures on a
community scale.
Yugoslavia
Endemic goitre is a serious public health problem in Yugoslavia, con-
tributing much to chronic ill-health and lowered output: it adds signifi-
cantly to the cost of State medical care. The general distribution of the
disease has been described by Simitch, 493 by Miholic, 482 by Ramzin, Bucic
& Lukic, 490 and by Matovinovic; 480 detailed surveys of particular areas
have been made by numerous other workers whose findings are noted
below; the occurrence of thyroid enlargement in domestic animals is
d,iscussed by Jovanovic, Pantic & Markovic; 475, 476, 483 and the problem of
goitre in the army has been the concern of Ceramilac. 469
The goitrous area extends continuously for more than 500 miles from
Slovenia in the north-west to the extreme south-western corner of the
country in the neighbourhood of Bitolj (Monastir) and the lakes Presha
and Okrida in Macedonia. The only goitre-free areas lie along the Adriatic
coast and throughout Vojvodina in the north-east. The intensity of the
endemic varies. It is highest on the banks of the river Ibar and in certain
valleys of the Zlatar. Planina in the sandjak of Novi Pazar, i.e., in the south-
western part of Serbia. Slovenia, too, has high rates; and severity is con-
siderable in Croatia, in Bosnia and Herzegovina, and in northern Monte-
negro. Goitre in Yugoslavia is mostly located in high mountain districts
and tablelands, but is also found in river valleys and in the plains.
Slovenia
In the north-west of the country (Slovenia) there is considerable goitre
throughout the head-waters of the rivers Sava and Drava (Danube) between
the towns of Ljubljana and Maribor (Marburg). This centre, which is an
extension of the Klagenfurt-Graz goitre area in southern Austria, has been
specially studied by Arko, 465 who mentions the following places as goitrous:
the mountains of Kozjak, Pohorje and Haloze, and the low-lying area of
the Pannonian plain in the vicinity of Beltinci. Arko very carefully examined
257 children (up to 14 years of age) in the village of Zetale near Rogask
Statina and found goitre in 60 % of them.
Croatia
An investigation of the Croatian villages of Rude and Braslovje, in the
near vicinity of Zagreb, undertaken jointly by the Institute of Hygiene and
the Clinic of Internal Medicine, Zagreb, showed thyroid enlargement in
83.3 % of 856 persons examined. More than 58 % of these cases had severe
goitres of the first degree, and 10 % of the total population of the two villages
were handicapped for hard physical work .on that account. Twenty cretins
were found among the 856 people examined (Ferber et al.; 470 Matovino-
vic 480). Buzina et al. 467 say that in Croatia goitre is most widespread in
the district of Jastrebarsko south-west of Zagreb and in Virovitica situated
due east of the capital almost on the Hungarian border.
Prebeg et al. 486 examined 21 482 Zagreb schoolchildren in 1953/54
prior to the compulsory iodization of salt and found an overall goitre rate
of 46.5 %, the proportion being 42.2 % in boys and 50.9 % in girls. They
PREVALENCE AND GEOGRAPHICAL DJSTRIBUTJON 83
confirmed the well-known finding of many earlier investigators that goitre

develops more readily in rapidly growing children-the tall, heavy, rather
dull pupils at school. The physiological demand for thyroid hormone is
less in smaller, lighter children, among whom thyroid enlargement is con-
sequently less evident.
Extending their studies from the Croatian mainland to the adjacent
Adriatic islands, Ferber & Buzina (quoted by Horvat & Maver 473) noticed
a high incidence (40 {-46 , ) of goitre on the island of Krk, whereas on
other neighbouring islands the disease is very rare or wholly absent. On
closer investigation of this interesting phenomenon, Horvat & Maver 473
reached the conclusion that goitre in Krk is the result of a complex nutri-
tional deficiency involving not only lack of iodine but also deficiency of
vitamin A. Subsequent studies with 131 1 do not, however, entirely support
this suggestion; it seems that a low iodine intake, aggravated no doubt by
factors impairing iodine utilization, is the dominant goitre-producing
agency (Buzina et al.; 468 Horvat et al. m).
Bosnia and Herzegovina

Although endemic goitre in Bosnia and Herzegovina has been a subject
of intermittent study for more than 80 years-indeed, since Austrian replaced
Turkish rule in 1878-exact information did not become available until the
modern surveys of Zarkovic & Radovanovic m conducted under official
auspices. In 1953 the Yugoslav Commission for Medical Scientific Research
sponsored a study in the district of Srebrenica north-east of Sarajevo and
found 75 % of all schoolchildren had manifest goitre. 478, 494 Three years
later (1956), an organized mass examination of 34 343 persons of all age-
groups over six years drawn from 975 settlements spread throughout the
entire Republic of Bosnia and Herzegovina (approximately I % of the total
population) exposed an average goitre rate of 20 % among males and 33 %
among females. The districts of Brcko, Sarajevo, Gorazde, Fojnica and
Trebinje in the eastern section of the country, and Banja Luka in the north,
are hyperendemic regions. Contrary to earlier assumptions, the Sava river
valley in the north was found to be as strongly goitrous as the Drina valley
in the south.
No positive correlation was established between the amount of iodine in
drinking water and the prevalence of goitre in Bosnia and Herzegovina; but
this, as Zarkovic and Radovanovic m say:
. . . cannot be taken as proof that lack of iodine is not the most important single agent
in the epidemiology of goitre. First of all, the analysis of one sample of water-Jet alone
a sample taken at the time of the lowest water-level in sources and wells- cannot be
considered representative of the annual content of iodine and still less of the iodine
content in a decade. Besides, water is not the only source of iodine for the population.
Big differences in the types of food and in their iodine content are characteristic of Bosnia
and Herzegovina, and certain foods might compensate for or aggravate the Jack of iodine
in the water. Finally, the differences in goitre prevalence among people with equal con-
sumption of iodine might be pmduced by a series of other influences, including differing

doses of various goitrogenic factors.
Serbia and Montenegro

Much has been written about the severe south Serbian focus, which
includes the valleys of the Lim, Uvac, and other rivers flowing from the
Zlatar Planina, the towns of,Nova Varos, Prijepolje, and Novi Pazar, and
extends eastwards over the.! river !bar to the Kopaonik and Jastrebac
Mountains in Moravia, with a southwards branch into the Kosovo-Polje
plains and the valley of th river Vardar at Skoplje. Simic et al. 492 found a
rate of 6 % to 12 % in 147 families (758 individuals) in three villages of the
Sumadija region. Gvozdenovic 472 records a morbidity varying from 37.8 %
to 60. 7 % among the people of Mataruge in the Kraljevo district of central
Serbia; and in the village of Gornia Josanica in the Jastrebac mountains,
Kicic & Radmili 478 diagnosed nodular goitre in no less than 366 (57.6 %)
out of 759 persons examined. Olive Lodge 479 in her book Peasant Life in
Yugoslavia writes that 80 % to 85 % of the population of the sandjak suffer
from enlarged thyroids.
The detailed survey made by Schneider & Gauss 491 in the villages arid
valleys surrounding the Zlatar Planina offers good examples of the variations
in prevalence which may occur within a comparatively small area. At
Hisardzik, a small mountain village of 250 people situated on the southern
slope of the deep valley of the river Milosevo, 60 out of 80 persons examined
had pathologically enlarged thyroids. Further up the same valley, at
Karaula, there was no goitre at all; nor could any cases be found at Kacevo,
a settlement close to Hisardzik. Similarly, in the not-far-distant Kosatica
valley the upper reaches are goitre-free while the lower part is distinctly
goitrous. High up on the top of the Zlatar Plateau itself, goitre is com-
pletely unknown, but in the northern: declivities at Nova Varos and lower
down the Bistrica valley " lovely " goitres are seen.
Schneider & Gauss 491 attribute these variations to sharp distinctions in
local geology and topography. Goitre occurs only in valleys, not on pla-
teaux. Valleys in which the slopes are chiefly covered with soft rich soils are
not goitrous; those with steep wall-like sides scantily covered with poor soil
.favour the disease. The incidence is higher where faults and folds predomi-
nate, and at the intersection of strata of differerit ages.
In northern Montenegro goitre is prevalent throughout the upper basin
of the river Lim, particularly in the neighbourhood of Bijelo Polje, and
cretinism is of frequent occurrence (Gusic et al. 471). Macedonia at the
extreme south of Yugoslavia is another region of high prevalence, especially
in mountain areas where chestnut trees abound (Petrov 485).
Jovanovic, Pantic & Markovic 475, 476• 483 describe hypothyroidism occur-
ring among domestic animals in areas where the human population suffers
from goitre. Goats showed most thyroid enlargement but no signs of
dwarfism, sterility or low vitality. In sheep, the thyroid enlargement was not
so pronounced but poor lactation, poor wool production, and a high
mortality rate among lambs were noteworthy. Sterility, low milk yield, short
lactation, too frequent silent heat, and poor condition of young stock are the
symptoms of hypothyroidism reported in cattle. Little abnormality was seen
in pigs. Horses also suffer from goitre, the incidence being higher in primitive
than in important breeds. Affected animals were less able to work, and
stallions had decreased sexual impulse. Foals do not develop normally and
are often stunted.
Owing to the seriousness of the goitre endemic in Yugoslavia, the
Government is giving every support to control programmes, and, in keeping
with recommendations made by the World Health Organization, has
passed a law, effective from 1 July 1954, requiring the iodization of salt at a
level of 10 mg of potassium iodide per kg of salt. Salt-iodization plant has
been installed on a pilot scale and will be increased until all salt distributed
for human consumption is iodized in conformity with this regulation
(Matovinovic; ;so Brozek & Ferber m ).
Albania
In Albania thyroid disease is known at Berat towards the south of the
country. There is no published literature on goitre in Albania; the fore-
going information was communicated privately by C. Evelpidi (1948).
Greece
Reports communicated privately by Evelpidi (1948) of goitre in and
around Poroy, Djuma and Serrai (three towns situated on the edge of the
lowland Grecian slopes where the Struma valley broadens into the plains
of Greek Macedonia) and also farther west at Karadjova in the Yiannitza-
Vodena area, have been confirmed by Hadjidakis. 495 His field enquiry,
part of a State programme to improve Mother & Child Welfare, involving
the clinical examination of almost 12 OOO children and youths, disclosed a
goitre rate of 53 % in an appreciable number of villages in the northern
districts of Greece, especially in Thessalonika, Macedonia, and Epirus.
Although iodine deficiency could not be chemically proved, the fact that in
some instances goitre prevalence diminished following iodine administration
indicated the probable influence of this agency.
Central and Southern Europe

Austria
Goitre has long been a concern of Austrian preventive medicine. Pro-
phylactic admixture of potassium iodide with common rock salt in the
proportion of 1 part of iodide in 10 OOO parts of salt was strongly recom-
mended by Kost! 503 in 1855, more than 100 years ago. With the exception
of a few districts in the Danube valley and in the direction of the Hungarian
plain to the east, practically the whole country is goitrous. From west to
east the most notorious localities are:
(1) The Province of Vorarlberg, which is bounded by the Swiss Alps,
Lake Constance and the Algauer Alps to the south of Bavaria. Here, the
district of Montafon south of Bludenz is specially affected.
(2) The Tirol, especially in the neighbourhood of Telfs and Innsbruck.
(3) The Province of Salzburg, particularly along the river Salzach at
Zell-am-See and Taxenbach. The city of Salzburg itself has a high goitre
rate.
(4) The Province of Kiirnten (Carinthia), especially the area around
Klagenfurt. This includes the valley of the river Drau (Drava) and the
towns of Friesach, Wolfsberg and St. Paul.
(5) The Province of Steiermark (Styria) where the areas around Murau
and Judenburg have a high incidence. The town of Graz on the eastern
edge of the Styrian Mountains and many other places along the valley of
the river Mur are mildly goitrous.
(6) Upper Austria in the vicinity of Vocklabruck, Bad Hall, Steyr, and
Rohrbach north.-west of Linz.
(7) The .extreme east of the country is the least affected. Nevertheless,
many cases are found in Burgenland Province on the borders of Hungary,
and in Vienna, the capital city (Schroetter; 509 Burtscher & Sprenger; 499
Wagner-Jauregg;_ 511• 512 Bauhofer; 497 Kopf; 501 Kutschera-Aichbergen 505).
The prevalence throughout Austria is high. Taking the country as a
whole, 44.2 % of boys and 48.1 % of girls were found to be goitrous in
the 1923-24 survey of 686 OOO schoolchildren organized by Wagner-
Jauregg. 511, 512 The highest regional rates were in Vorarlberg Province,
with percentages o f 58.9 in boys and 63.6 in girls. The lowest rates were
in Burgenland Province, with.15.9 % in boys and 19.5 % in girls. The city
of Vienna showed percentages of 41.1 in boys and 46.2 in girls.
The situation in more recent times is scarcely less acute. A survey of
five groups of Viennese civilians under United States occupation in 1945
revealed non-toxic diffuse goitre in from 21 % to 42 % of those examined,
the rate in children under 14 years being 38 % in boys and 35 % in girls
(Davidson et al. 500). In the Upper Austrian town of Rohrbach, notorious
for its high goitre rate, the percentage with thyroid enlargement was 31
in 1952 compared with 66 in 1946. The drop is due to the adoption of
iodine preventive treatment. At Bad Hall, an Upper Austrian watering-
place well known for the high iodine content of its drinking-water, about
11 % of schoolchildren are affected. In contrast, the rate among children
living outside the town in nearby districts is 35 % or even higher. In Steyr,
for instance, the rate for children is 49 %- The fact that 11 % of Bad Hall
children have goitre in spite of a high iodine intake from water is evidence
that iodine deficiency is not the whole etiological explanation; goitrogens
in food, bad 1iygiene, or other factors may also be involved (Kopf 502).
Studies of the occurrence of endemic goitre among people who have
moved from goitre-free areas into affected areas have been made by
Schreckels. 508 He examined 2220 such people in and around Salzburg and
found that within a year of coming to live in the goitre area 40 % of them
developed thyroid enlargement. The longer the people had been settled
in the area, the higher was the prevalence of goitre among them.
A feature of the goitre endemic in Austria stressed by Kriebernig 504 is
the increase in prevalence which has taken place in post-war years, especially
in the newborn. This happened both after the First World War (Abels 4 9 6 )
and after the Second. Sollgruber 510 gives the following figures: among
4800 newborn infants examined in the ten years 1944-53 in the maternity
ward of Dornbirn hospital in Vorarlberg, the average goitre rate was 7 % ;
in the two years 1952 and 1953 the rate was 11 % and in the first quarter
of 1954, 20 { Sollgruber treats these infants from the third day of life
with large doses of iodine spread over several days. He strongly recommends
the general use of iodized salt and considers it should be the standard salt
on sale everywhere, untreated salt being obtainable only on special prescrip-
tion. Kopf 502 records that, in Vocklabruck, administration of potassium
iodide to pregnant women, preferably from the fourth month, reduced the
goitre rate in the newborn from 47 % to about 5 % in the space of two years.
Hungary
According to Kiss, ·520 there are 500 OOO goitrous people in Hungary.
Endemic cretinism is said to have been known in the country since the
14th and 15th centuries. 5H Broadly speaking, goitre is confined to three
main parts of Hungary the northern frontier, the west-centre and south-
west, and the neighbourhood of Debrecen in the north-east. The Great
Hungarian Plain in the centre and east of the country is goitre-free.
Upper Hungarian localities affected are: Magyar6var, on the river
Leitha in the extreme north-west, ,vhere a percentage prevalence in school-
children of 33.3 has been recorded; Komarom, with a rate of 35 %; and
Tatabanya, with a rate of 59.3 1 among children. Farther east, children
in the northern towns of Vac, Salgotarjan and Miskolc in Upper Hungary
showed rates of 9.3 {, 17.5 , and 14.5 ' respectiYely. In the department
ofN6grad due north of Budapest on the Slovakian border, Kiss 520 examined
13 683 children and found rates of 10 to 301 in the townships of Nograd,
Salgotarjan, Balassagyarmat, Szecseny, Szob and Szirak. In some com-
munities, notably Bujak, Dejtar, Di6sjen6, 6rhalom, Patak and Romhany,
the prevalence reached 50 1 or more. By contrast, the neighbouring S6shar-
tyan community could offer only two cases among 1800 inhabitants. Here,
the local water, known as " Iodaqua ", is regarded as " medicinal " and
contains among other therapeutic ingredients a high proportion of iodine.
Besides being goitre-preventive, " Iodaqua " is reputed to have significantly
beneficial effects on general health, especially in reducing abnormally high
blood pressure. In Budapest and surrounding districts, from 5 % to 12 % of
children are said to be goitrous (Gortvay; 515 Bodnar & Straub; 513
Straub; 528, 530. S6s, Fekete & Molnar 525).
In the west-central part of the country near Lake Balaton, children in
the towns of Siimeg and Tapolca showed rates of 11 % and 10.1 %, re-
spectively; but at Tihany, which lies immediately on the lake shore, there
is no goitre (Straub 528). According to Veli, 537 schoolchildren are con-
siderably affected in the town of Kaposvar, which lies between Lake Balaton
and Pees. In this general area, too, a goitre endemic among the children
of Koml6 has been reported by Varbir6, Szava & Koch. 536 In Pees itself,
thyroid enlargement is commonly seen in newborn infants, among school-
children (who exhibit a rate of 10 % to 13 %) and in older people (Hal & Hor-
vath; 516 Horvath and co-workers 518, 519). The iodine content of food and
water in relation to goitre in Pees was determined in 1933 by Scheffer 522
and again in 1949 by Horvath, N6gradi & Danos. 518 The latter study
showed that one part of the city supply contained 4.5 µg of iodine per
litre and another part 1.5-2.0 µg per litre. Goitre was commoner in that
part of the city supplied exclusively with water of the lower iodine content.
In the extreme east of Hungary, little goitre is seen; but there are excep-
tions-notably in the neighbourhood of Debrecen, where the following
goitre rates have been recorded by Straub & Torok: 533 Hajduhadhaz
(11.7%), Vamospercs (22.6%), Ujhuta (40%-50%), 6huta (50%-60%),
Budahegykozseg (82.2 %) and 6massa (83.3 %). In 1947, Kiss 521 drew
attention to the increasing prevalence of goitre in Nadudvar, in the Debrecen
area.
A feature of the goitre literature of Hungary is the several attempts
that have been made to find out whether the radioactivity of soils and their
fluorine content are factors implicated in the causation of goitre. Straub &
Kovacs 532 conclude from their investigations that goitre will not develop
from the consumption of fluorine-containing waters if the individual has
access to a sufficiency of iodine. If, however, the iodine supply is deficient
or the utilization of iodine in the thyroid is disturbed through excess of
dietary calcium or for some other reason, then the goitrogenic action of
fluorine can manifest itself.
From the results of iodine determinations on more than 700 samples of
water collected from goitrous and goitre-free areas, Szabo, Remenar &
Demeczky 534 established without doubt that endemic goitre in Hungary is
mainly due to iodine deficiency; the degree of hardness of water may also
play a part. Independently of hardness or other factors, complete freedom
PREVALENCE AND GEOGRAPIDCAL DISTRIBUTION 89
from goitre is found where the water contains more than 25 p.,g of iodine
per litre. I f the iodine value is between 13.5 p.,g and 25 p.,g per litre, pro-
tection against the disease depends on the hardness, while for values be-
tween 5 p.,g and 13.5 p.,g per litre freedom from goitre is ascribed, irrespective
of the hardness of the water, to a high content of iodine in the soil. Where
the water contains less than 3 p.,g of iodine per litre, goitre appears whether
the water is hard or not.
Iodized salt (10 mg of K l per 1000 g of salt) was officially introduced
into certain parts of Hungary in 1948, and the results of five years' prophy-
laxis by this means have been summarized by S6s & Szab6. 526 The most
marked improvement has occurred in the west and north of the country,
particularly among children. No very significant reduction in prevalence
has been noticed in the south trans-Danubian region.
Czechoslovakia
Maps prepared by Feix, Rezler & Silink, 539 • 540 on the basis of the
examination of 44 262 men and women and 85 060 children from all districts
of Bohemia and Moravia in 1947-48, show that thyroid enlargement of
every type is prevalent to a considerable degree throughout the whole of
these regions of Czechoslovakia. In some communities the frequency may
be as high as 100 % among women.
Data on the distribution of goitre in army recruits collected by Klima 544
in 1933 reveal a marked focus along the Erzgebirge on the Saxony border
to the west of Bohemia, especially in the neighbourhood of Karlovy Vary
(Karlsbad) and Pilsen. This western belt extends round the northern
Sudetenland frontier, through such places as Usti and Liberec, and links
up with the Silesian goitre districts of south-west Poland.
Determinations of the urinary output of iodine by individuals in 29 west
Bohemian communities situated in the neighbourhood of Liberec, Usti,
Prague, Pilsen and Karlsbad have been made by Vohnout & Pihar. 570 On
the assumption that the minimum iodine requirement is 100 p.,g per head
daily, the results show that people in these regions have an intake of iodine
deficient by 30-80 p.,g per day.
During the years 1949 to 1954, Hostomska et al. 543 treated 1931 Prague
children in age-groups from 3 to 15 years with thyroglobulin plus iodized
salt in strengths of 1 in 100 OOO to 1 in 40 OOO. A considerable decrease in
the size of both medium and small goitres resulted. In the Prague area,
goitre is also reported from the towns of Dobrn;, Roudnice and Susice
(Fleischhans; 541 Silink & Marsikova 560). In Susice and neighbourhood,
all schoolchildren and most workers in the Union of Agricultural Co-
operatives were examined by Horackova & Pokorn5·, 042 ,vho found hyper-
thyroidism to be the most common type of thyroid disturbance even where
cretinism is traditional. The intensity of the endemic in this district has
90 F. C, KELLY & W. W. SNEDDEN
decreased since the removal of people from the most seriously affected
areas; nevertheless, prevalence remains high and presents a grave health
problem, especially among children in upland areas. The systematic use of
iodized salt is strongly urged by the authorities.
With the object of measuring the prophylactic effect of iodized salt
administered over a period of years, Silink, Reisenauer & Chaloupsky 562
recently (1959) evolved a procedure to solve the problem of uniform and
objective mapping of goitre. The value of their method has been demon-
strated in Bohemia and Moravia where, as a result of iodization, the average
mass of the thyroid gland in adult women has been reduced by 12 % in seven
years, namely, from 41 g i n 1948 to 36 g i n 1955. Important recommenda-
tions on the standardization of iodized salt and on the means of removing
influences affecting its prophylactic efficiency have been made by Reisenauer
& Likar 557 and by Silink & Reisenauer. 561
Moravia, the central part of Czechoslovakia, is heavily goitrous, parti-
cularly in the north. Local goitrogenic factors have been investigated by
Silink & Marsikova, 560 who determined thiocyanate values in the blood of
volunteers from Sumperk in northern Moravia and Roudnice in Bohemia,
two districts where goitre is rife. These values are higher in autumn, when
the consumption of fruit and vegetables is greatest, than in the spring, and
there is a direct relationship between the amount of thiocyanate in the
blood and the degree of thyroid. hyperplasia.
This does not mean, however, that thiocyanate itself is the goitrogenic
factor, because the serum thiocyanate values in the goitre subjects from
Sumperk and Roudnice are no higher than those found in subjects who
had been given less than 0.1 g of potassium thiocyanate by mouth for long
periods without the thiocyanate having any goitre-producing effect whatever.
Silink & Marsikova argue, therefore, that the foods consumed by the
inhabitants of these districts contain not only a substance capable of raising
the blood thiocyanate level, but also a specific goitrogen which they have
not been able to identify.
Podoba et al. 556 found a significant difference in the weight and histo-
logical picture of thyroids from rabbits fed raw cabbage alone, and from
those fed mixed vegetables of the Brassica genus, both raw and cooked. The
goitrogenic effect of the cooked mixed vegetables was lower than that of
the raw mixed vegetables and significantly lower than that of raw cabbage.
Vomela 572 has studied the Holesov and Frystat areas of eastern Moravia
in great detail. In the mountains, extreme forms of goitre and cretinism are
common; 80 % to 90 % of the inhabitants are affected in some villages.
Here, the general picture is definitely one of hypothyroidism. On the
Moravian plains, on the other hand, goitre also occurs but is accompanied
by tachycardia, exophthalmos and other symptoms of hyperthyroidism.
Zones of intermediate altitude show goitres of both types, even within one
family.
PREY ALENCE A D GEOGRAPHICAL DISTRIBUTION 91
During his surveys in the district surrounding Ostrava in the extreme

north of Moravia, Dolecek 538 found a relatively large number of goitres
associated with hypertension and other related disturbances. Dolecek is
among those who stress the importance of goitrogenic factors in the local
foods and the need to employ rational prophylaxis.
Farther east, in Slovakia proper, goitre has been the subject of special
study in Banska Bystrica 564 and in the Zitny Ostrov area immediately
south-east of Bratislava where Slovakia abuts on Austria and Hungary
between Vienna and Budapest. This focus is noteworthy inasmuch as the
disease is more prevalent in the lowlands than in the surrounding mountains
(Tomanek; 568 Podoba, Nemeth & Grmelova; 555 Nemeth & Podoba 551).
Following an extensive survey of the Zitny Ostrov area by the Bratislava
Institute of Endocrinology in 1949, iodized salt was introduced in October
1950, first at a level of 1 in 200 OOO and later at a level of 1 in 100 OOO. A
resurvey carried out in 1954 on 17 750 persons of both sexes, ranging in age
from 6 to 20 years, showed that there had been a distinct recession of the
endemic, a decrease in the number of nodular cases, and a striking diminu-
tion in the size of local goitres (Nemeth & Podoba 551).
Finally, in the extreme east of Czechoslovakia there lies Carpathian
Ruthenia-now part of the Ukraine-where, in the vivid description of
Suk, 567 goitre and its consequences (cretinism and myxoedema) may be
seen at their worst. Here, the most wretched centres are the poor villages,
in which, during the unfavourable winter months, the people live an un-
healthy life in dark and cold unventilated huts. They consume large quanti-
ties of cabbage-raw cabbage, pickled cabbage, boiled cabbage and
cabbage water. Indeed, cabbage is the staple diet. The goitrogenic effect of
cabbage is revealed in the data collected by Suk in a number of out-of-the-
way villages in the Carpathian highlands (see Table VI).
I t is seen that the percentage of cases without goitre is much higher in
all villages taken together than it is in the three villages where the con-
sumption of cabbage is excessive.
T A B L E YI. GOITRE PREVALENCE IN CHILDREN AGED 6 TO 14 YEARS IN SOME

VILLAGES IN THE C A R P A T H I A N HIGHLANDS
A l l villages Three villages with

taken together excessive cabbage diet
Results of examination
I
number percentage number percentage
I I
Without goitre
Slight goitre
136
262
25.2
48.61 I 25
151
I 9.1
54.9l
Medium goitre 100 18.5 74.7 67 24.4 90.9
Large goitre 41 7.6 1 32 11.6,
Total examined
·I 539 275
The foregoing is but an outline of the goitre problem in Bohemia,

Moravia and Slovakia. Medical literature of Czechoslovakia in recent
years is rich in research on regional and etiological problems, of which only
bare mention is possible here: Nemeth, 550 and Nemeth & Stukovsky 552
on the retardation of bone development among children in goitre districts;
Silink et al. 563 and Reisenauer, Silink & Rohling 559 on the iodine metabolism
of people in goitrous areas of Bohemia and Moravia; Langer and his
colleagues 547-549 on the role o f calcium and other dietary factors in the
genesis of goitre in Czechoslovakia; Verner 569 on the inferior intelligence
and mental capacity of children in goitrous regions; and Stukovsky et
al. 565, 566 on the parallelism between human and animal goitre in western
Slovakia.
Germany
Proceeding from the south to the north of Germany, it is possible to

distinguish five main goitre zones: one extending from Baden-Baden and
the mountains of Breisgau and the Black Forest eastwards through Wtirt-
temberg and southern Bavaria to the Austrian border; one in the Vogtland
and Erzgebirge on the north-western frontier of Czechoslovakia; one
stretching from the borders of Luxembourg north-eastwards along the
Hunsri.ick and Taunus ridges through Hesse and Lower Franconia into
Thuringia; one comprising Mtinsterland, parts of Westphalia, and the
Bergische Land near Dtisseldorf; and one in Brandenburg, extending from
the region of Cottbus south-eastwards into Polish Silesia.
The first of these zones includes the Kaiserstuhl area, the valley of the
river Kinzig and the towns of Wolfach and Freudenstadt in the Black
Forest, the towns of Hechingen and Geislingen in Wtirttemberg, and a large
number of places along the Austrian frontier between Lake Constance and
Salzburg. Among these southern Bavarian centres are Lindau, the Algauer
Alps, Kempten, Landsberg, Schongau, Weilheim, Garmisch, Wolfrats-
hausen, Tolz, Ebersberg, Miesbach, Traunstein, Pfarrkirchen and Berch-
tesgaden. Goitre is also said to occur in the Bayrischer Wald along the
north bank of the Danube between Regensburg and Passau.
The second important zone lies between Plauen and Dresden. It covers
the Vogtland and the north side of the Erzgebirge and takes in Auerbach,
Freiberg, Chemnitz, Oelsnitz, Schneeberg, Marienberg, Zwonitz and
Anna berg.
In the third distinctive area, incidence is not excessively high but there
are, nevertheless, some well-marked goitre centres. Between Luxembourg
and Koblenz the disease occurs in the Eifel district north of the Moselle
river-notably, at Prum, Bitburg and Wittlich. On the south of the Moselle,
the town of Bernkastel and the neighbouring ridge of the Hunsri.ick are
affected. Across the Rhine to the east of Koblenz there is goitre within a
circle drawn through Siegen, Giessen, Wiesbaden and St. Goarshausen.

This includes the Westerwald and the Taunus country immediately north of
Wiesbaden where Konigstein is a known focus. A traveller proceeding
north-eastward from Siegen to Kassel would find goitre cases at Wittgenstein,
Biedenkopf, Frankenberg, Fritzlar, Rotenburg and Melsungen. In the
Mannheim-Frankfurt area there is goitre on the Odenwald and in the
Spessart country, the town of Heppenheim to the north of Mannheim
deserving special mention. Farther east, one finds the disease on the upper
Tauber river, at Rothenburg in Middle Franconia, along the Steiger Wald,
where Iphofen is a well-known centre, and at Gersfeld in the Rhongebirge
west of Meiningen. In Thuringia, the towns of Weissensee and Schmalkal-
den are said to be affected.
Fourthly, there is an area of slight endemicity in the D u i s b u r g -
Dortmund-Diisseldorf triangle and in the Bergisches Land, a region which
rises in plateau-like terraces from the Rhine near Di.isseldorf. The nature
of thyroid disorder here has been described by Leicher. 610 During their
post-war investigation of the nutritional status· of children in the British
Zone of Germany, Widdowson & McCance 627 found cases of thyroid
enlargement in the municipal orphanages at Duisburg and Wuppertal-
Vohwinkel.
The fifth zone is found in the far east of Germany. It begins at Guben
and Cottbus and extends south-eastwards to join the goitre belts of south-
west Poland and northern Czechoslovakia. Goitrous localities of special
note in this region are Spremberg and Hoyerswerda.
Throughout the past hundred years the geographical distribution of
goitre in Germany has remained fairly constant, but the intensity of the
disease has been subject to marked fluctuation. After the First World War,
German physicians reported an increase in prevalence all over the country,
even in areas normally goitre-free, like uremberg, the Ruhr district and
the North German Plain. By the end of the 1920's this outbreak had
subsided. The same happened after the Second World War. An upward
trend in the frequency of thyroid disease became noticeable around 1942.
Between the end of the war and the close of 1950 this had developed into an
extensive epidemic, much more widespread and severe than that which
occurred after the 1914-18 war. The following figures given by Ligdas 611
are typical of many reports. They relate to schoolchildren in Dresden and
other towns in that area of Saxony.
Goirre rate ! / ;
1948-49 1949-50 1950-51
School beginners . 9.1 11.9 14.4

Fourth-year scholars 8.7 19.1 19.8
" Confirmands " 11.6 19.0 22.6
Trades School 13.0 18.0 23.6
High School . 12.2 16.2 22.8
Trades High School 16.2 20.4 37.7
These post-war goitre waves are due, as is apparent from many reports,
to dietary deficiency during the war period. Proof of this is found in the
fact that certain well-fed groups of people-for example, cooks, interpreters
and occupying troops-escaped the goitre wave. This is also borne out by
Haubold's investigation of schoolchildren in Bavaria, where the goitre rate
rose to 42 %, while only 9 % of children in occupying American families
were affected.
Arguments have been advanced by Haubold 600•603 that the specific
dietary deficiency responsible for the post-war goitre wave is a decreased
intake of vitamin A and carotene. His goitre surveys in the Weilheim
district of Upper Bavaria show that in villages where the vitamin-A and
carotene contents of butter and herbage are exceedingly low, the goitre
rate is more than double that in villages where these dietary factors are
substantially more plentiful. The goitres occurring under circumstances of
vitamin-A deficiency are of the hyperthyroid type, and it has been shown
by Bukatsch, Haubold & Lackner 582 that treatment with vitamin A or
carotene causes regression of the goitre and amelioration of the signs of
hyperthyroidism.
On the other hand, Ligdas 611 maintains that, in spite of the interesting
observations by Haubold, deficiency of iodine in natural form remains the
factor chiefly responsible for the post-war goitre waves. At the beginning
of the Second World War the German people were consuming an average
of 12 kg of sea-fish per head per annum. During the first five years
following the end of the war the people hardly ever saw sea-fish at all,
according to Ligdas. The connexion between agricultural food production
and the occurrence of goitre among schoolchildren in the Berlin area
has been examined in detail by Habermann 596·599 in an excellent series of
papers.
In the years between the two wars, prophylaxis by iodized salt, " Voll-
salz " as it is called in Germany, had been tried in many areas; but owing to
the fear of possible harmful effects (now known to be without foundation)
more propaganda against the use of iodized salt has been advanced in
Germany than in any other country in the world. Gloel, 593 Medical Officer
of Health at Landsberg in Bavaria, reported in 1934 that as a result of the
almost exclusive use of iodized salt a strong, healthy, non-goitrous genera-
. tion was growing up in the goitrous districts of Bavaria, notably at Kempten.
He deplored the fact that in his own district the practice had been abandoned
for fear of iodine poisoning. Where iodized salt had been in general use
since 1924, Gloel did not find a single case of thyroid enlargement among
pupils of a school he inspected in 1930. Four years later, however, owing
to the withdrawal of iodized salt, 75 % of the children in the same school
were suffering from .thyroid enlargement. He also records that provincial
teachers had noticed a corresponding decline in the average intellectual
capacity of children beginning school life.
Today the situation in southern Bavaria is little better than in 1934,

and a strong plea for the re-introduction of iodized salt has recently been
made by Bauer. 576 In co-operation with five medical colleagues he examined
a total of 45 818 schoolchildren in the localities of Miesbach, Chiemgau,
Traunstein, Berchtesgaden, Pfarrkirchen and Donauworth, and was
" shocked " to find goitre rates of 80 % and even more in some places. In
the Donauworth area, for example, 93 % of young people in Egelstetten
had goitre, 61 % in Ellgau, and 77 % in Genderkingen, while Donauworth
itself, with 23 %, was relatively immune.
Hundreds of papers have been written about goitre in Germany.
Entries 573 to 628 in the bibliography at the end of this chapter are selected
as dealing more especially with distribution and prevalence.
Switzerland
Endemic goitre has long been a serious health problem in Switzerland.
Practically all parts of the country are prone to the disease, and in many
localities it is markedly associated with mental deficiency, deaf-mutism and
other disorders. Indeed, the burden of cretinism has been a heavy charge on
public funds. In 1923 the Canton of Bern alone, with a population of little
more than 700 OOO, had to hospitalize 700 cretins incapable of any social life.
Cantons where the incidence has always been high are Aargau, Zurich,
Schaffhausen and Thurgau in the north; Appenzell, St. Gallen and Grau-
bi.inden in the east; Bern, Luzern and Uri in the centre; and Fribourg and
Valais in the south-west. There is less goitre in the north-western cantons,
Basel, Solothurn and Neuchi!tel.
Thanks, however, to the official encouragement given to the general use
of iodized salt the situation has greatly improved in recent years. Goitre
rates have fallen steeply and deaf-and-dumb institutions have been closed or
diverted to other purposes (Wespi 675, 678). Recruitment statistics provide
unmistakable evidence of this downward trend. Table VII (Schaub 665)
T A B L E VII. INCIDENCE OF GOITRE A M O N G A R M Y RECRUITS IN S W I T Z E R L A N D
Number of men , Number o f men exempt Number o f , o · t r e s

Year examined on account o f goitre ' per 1000
190J 26 283 2 451 93.2
1905 26 448 3 093 116.9
1914-18 151105 3 403 22.5
1921 32 838 1 817 55.3
1925 39 681 1 2�9 30.9
1935 29 627 338 11.4
1939-45 228101 340 1.5
1945 31 654 21 0.6
1947 31 366 23 0.7

shows that between the years 1925 and 1947 the number of exemptions from
military service on account of goitre fell from 31 per thousand to less than
1 per thousand .. The recession began with the introduction of iodized salt in
the early 1920's and has been maintained ever since.
The same decline is seen in the goitre statistics relating to young people.
For example, an examination in 1937 of schoolchildren in the Canton of
Valais-a region particularly affected-gave the results shown in Table VIII
(Bayard 629).
TABLE VIII. INCIDENCE OF GOITRE AMONG SCHOOLCHILDREN IN THE CANTON
OF VALAIS
Normal Palpable Enlarged Pronounced

Period thyroids I thyroids neck I goitres
I (%) (%)
I (%) (%)
1920 (Before introduction of iodized salt) 28.8 54.3 14.9 2.0

I
1934 (Ten years after introduction of

iodized salt in 1924) 70.5 27.3 2.1 0.15
At three towns in the valley of the Broye, a singularly goitrous area of

the Canton of Vaud, where 20 % to 40 % of conscripts were usually rejected,
Messerli 653 has shown that between 1921 and 1951 thyroid enlargement in
children has very greatly decreased. The statistics are as follows; they
should be considered in the light of the fact that since 1924 100 % of all salt
consumed by the people throughout the Canton of Vaud has been iodized.
Locality Goitre rate ( %)
1921 1937 1951
Avenches 78.9 24.1 7.1
Payerne. 78.0 22.4 4.0
Moudon 73.5 18.3 4.9
Similar results have been obtained from many different parts of Switzer-
land, and all responsible investigators agree that the descending curve of
incidence can be correlated with the period over which supplementary
iodine has been introduced into the diet of the population'. The sale of salt
is not a federal but a cantonal matter, in accordance with the salt laws of
individual cantons. Accordingly, the introduction of iodized salt has differed
markedly from canton to canton, both in point of time and in regard to the
quantity sold. Goitre statistics coincide precisely with these facts. Thus,
the reduction in the number of conscripts rejected on account of goitre
begins much earlier in those cantons which introduced prophylaxis in the
years 1922, 1923 or 1924 than in those which did not introduce it until
1929 or 1930. Furthermore, as is evident from the statistics shown in
PREVALE!\CE AND GEOGRAPHICAL DISTRIBUTION 97
TABLE IX. RELATION BETWEEN CONSUMPTION OF IODIZED SALT

AND REJECTION OF ARMY RECRUITS ON ACCOUNT OF GOITRE
I . Average consumption of iodized

salt per canton, expressed as
Average number of rejections
on account of goitre, per 1000
Cantons* a percentage of total salt consumed recruits called up
1910-22 I 1923-32
i I 1933-42 I 1943-47 1910-22
I 1923-32 I 1933-42 I 1943-47
1 to 9 Nil** 75.3 96.5 96.0 36.3 16.7 1.8 0.3

10 to 17 Nil 30.0 68.1 86.8 I
'
30.1 21.2 6.0 0.7
18 to 25 Nil 8.5 25.1 53.5 35.2 22.2 8.7 1.5
:
.
* 1 to 9: Nidwalden, Vaud, Zug, Schaffhausen, Schwyz, Obwalden, Valais, Neuchatel, and
Appenzell Ausser-Rhoden
10 to 17: Ticino, Glarus, Uri, Appenzell Inner-Rhoden, St-Gallen, Geneva, Graubunden,
and Thurgau
18 to 25: Zurich, Bern, Luzern, Fribourg. Solothurn, Basel-Stadt, Basel-Land, and Aargau
* * The single exception is the Canton oi Appenzell Ausser-Rhoden, where iodized salt was
introduced in 1922.
Table IX (Schaub 665), the magnitude of the reduction is directly parallel

to the absolute amount of iodized salt consumed.
In his assessment of the results of goitre prophylaxis in Switzerland
published by the World Health Organization in 1953, Nicod 657 remarks
that the only canton which has almost entirely resisted the use of iodized
salt, that of Aargau, is the one which still rejects the largest number of young
people on account of goitre. Kicod's later review 658 (1957) of the progress
of goitre prevention by iodized salt in Switzerland re-emphasizes emphati-
cally its effectiveness and safety.
The dental caries problem in Switzerland has prompted Wespi and his
colleague Eggenberger 676· 677, 680 to recommend the manufacture and
distribution of a dual-purpose salt enriched with 200 mg of sodium fluoride
and 10 mg of potassium iodide per kilogram of salt.
The literature on Swiss goitre is extensive; in the bibliography at the
end of this chapter, only a few of the more important epidemiological
studies are cited. 629-682
Italy, Sicily and Sardinia

The many descriptions of goitre and cretinism to be found in the classics
and in Italian literature of the Middle Ages show that thyroid disease has
been a problem in Italy from earliest times. Indeed, its seriousness and
persistence into the nineteenth century prompted one of the first and most
competent goitre surveys ever made under goYernment auspices. This was
the Commission of nineteen members appointed in 1845 by King Carlo
Alberto of Sardinia to inwstigate the extent, nature and causes of the
disease throughout his Kingdom, ,vhich in those days comprised the pro-
vinces of Savoy, Nice, Piedmont, Genoa and the island of Sardinia. 771
7
Modern reviews of the goitre problem in Italy have been undertaken

by Ciocchi 705-707 and by Costa and his school, 710 -717 both of whom refer
particularly to the outbreaks of acute goitre that occurred in Piedmont
during the war years of 1940-1945. According to Costa & Mortara, 712
endemic goitre, widespread in the last century and in the first decade of the
present, subsequently began decreasing in the north of Italy while increasing
somewhat in central and southern parts of the country. About 20 years
ago, however, the phenomenon of epidemic goitre made its appearance in
the north; this has given rise to much research to determine its cause and
its relationship to the endemic type. In Costa's view, the endemic noxa in
Italy cannot be identified with goitrogenic factors or iodine deficiency in
local foods and waters; no substantial differences have been shown between
endemic and non-endemic areas.
Cerletti 702 is convinced that even today five million people in Italy
(i.e., 10 % of the population) are affected by thyroid disease. The literature
of Italian goitre, of which we cite 100 papers, 683-782 is certainly the most
extensive of any country in the world.
Geographically, the endemic occurs to a varying degree throughout the
whole of the Alpine region in the north of the country, in a semi-circular
belt extending from the Ligurian Alps through Piedmont, Lombardia and
Trentino to Venezia in the east. The disease is found not only in the upland
valleys, but also in the plains north and south of the river Po, although to
a much smaller extent.
In the Region of Piedmont, intensively studied by Cerruti 704 and by
Mortara, 748 the places particularly affected are, first, the towns of Cuneo
and Saluzzo, where outbreaks of acute goitre occurred among troops
in 1940-41 (Anglesio 686). Children from various schools in the districts of
Cuneo, Saluzzo and Alessandria were recently (1957) examined by Mortara
& Martinetti 751 who found that the disease still affects the rising generation
in these places. Farther north are the district of Aosta and the valley of the
Dora Baltea at the foot of Mont Blanc, long a noted centre. It has been
surveyed fully by Trikurakis 776-778 and by Raggi & Marocco, 767, 768 and
was the focus of an outbreak described in 1948 by Vogliazzo & Forni. 781
Nearby, is the Canavese region, the chief centre of which is lvrea where
acute forms of goitre in adults have been noted by Maggiorotti. 740
In this same general area goitre is seen at Vercelli and in the valleys of
the Sesia and Ticino rivers. Also affected are the Province of Varese
between Lakes Maggiore and Como; the town of Como itself; the valley
of the river Adda and the mountains of Valtellina and Sondrio in the
extreme north; the alpine hinterland of Bergamo and Brescia, including
Breno and the valley of the Chiese; the valleys of the Peio, Sole and Rabbi
west of the Trento-Bolzano axis; the Region of Trentino-Alto Adige (which
includes the Dolomites); Valsugana; the neighbourhood of Belluno; the
Carnie Alps and the district around Udine in Venezia-Giulia. Authorities
who have written especially about these regions are Pighini, 759 Muggia, 754•756
Fiorio, 732 Cancellara, 699 Paccagnella, 758 and Turri. 780 Their investigations
indicate that in the area between the Alps and the river Po thyroid enlarge-
ment is found in 20 {-30 % of schoolchildren. In high mountain districts
these figures may rise to 50 %-60 % and in certain communities may reach
even 70 %-80 %- Indeed, rates of 100 % are not unknown (Ambrosi 684).
In the great north-central plains thyroid disease is much less severe,
but acute episodes do arise from time to time as, for instance, that recently
described by Denes & Andreotti 725 at Carmignano di Brenta, a municipality
in the grape and cereal-growing country 9 miles north-east of Vicenza in
Padua Province. Here, signs of thyroid enlargement were first noticed in
1947, attained their greatest sewrity by 1950, and then disappeared.
Apart from the main Alpine belt and the sporadic outbreaks in the
northern plains, goitre also occurs in the Ligurian Apennines immediately
north of Genoa (Bagnasco 657). A large number of places in the Etruscan
Apennines due south of Modena are also affected. For instance, Mucci 752
records rates of between 10 , and 60 % among boys and girls at Montese,
Magreta, Guiglia, Mirandola and Riolunato. The etiology of acute goitre
in the valleys of the Secchia and Dolo rivers has been investigated by
Pighini & Gualdi; 760 and Businco 696 has described at length all the cir-
cumstances surrounding a goitre focus of unusual severity in the district
of Sestola near Monte Cimone. Somewhat further south is the Province
of Pistoia, where an epidemic of goitre in young people occurred in the war
years 1941 to 1946 (Bizzarri 6 9 3 ) . All sorts of theories have been advanced
to account for this outbreak-nitrites and sulfur compounds in the water-
supply, emotional factors due to war stress, and so o n - b u t it seems that
food deficiency during the period of emergency is the most likely cause.
In Tuscany, also, epidemic goitre has been noted by assi & Calamari 757
in the region of Montespenoli, an upland village about 16 miles south-west
of Florence. Clinical examination of the children led to the conclusion that
an infection acting on a population in a state of nutritional deficiency and
border-line thyroid adequacy was the cause. The most recent accounts
of goitre in the PrO\"ince of Florence are those by 1fagherini & Zecchi 741
and Magherini et al. 712 They examined 1756 children aged 6 to 14 years
in the communes of Londa, San Godenza, Vicchio di Mugello, Pontassieve
and Rignano sull 'Arno, and found goitre rates n r y i n g from 36 - in Londa
to 70 % in Rignano. Goitre was evident in 69 out of 97 mentally subnormal
and in 77 out of 134 mentally normal children.
Due east of Florence towards the Adriatic coast, a centre of severe
endemic goitre lying in the upper valley of the river Conca on the eastern
slopes of Monte Carpegna has been minutely described by D'Alo. 719 The
affected area, which is horseshoe-shaped, is bounded by the Faggiola and
San Paolo on the east, by Monteboaggine and the Carpegna massif on the
south, and by Monte Palazzuolo and Costagrande on the west. The most
important inhabited centre in the locality is Montecerignone. Extreme

poverty, malnutrition, wretched living conditions, and unhygienic ill-lit and
badly ventilated houses are the unhappy lot of the people in this area.
Goitre is endemic in Umbria and throughout the Marches in central
Italy, especially along the river Tenna in the Montegallo area and in other
parts of the province of Ascoli Piceno (Scoccianti; 772 Balice; 688, 689 Pit-
zurra; 761 Pitzurra & Modolo; 764 Tarozzi 774).
In the west, the disease is known in the Latium uplands in the Viterbo
area (but not in Viterbo itself) to the north of Rome (Cerletti 702) and at
Giulianello in the parish of Cori to the south of Rome. This latter focus
has been carefully studied by Di Porto & Antoniotti, 727 who point out that
the district is extremely volcanic and suggest that the prevalence of goitre
may be due to an excess of silica in the local foods and waters, a theory in
agreement with that of Trikurakis. 778
Very high goitre rates (40 %-80 %) are reported by D 'Amora 720 from
villages in the Sorrento peninsula. At Lauro, a village in the uplands about
30 miles east of Naples, 9 % of boys and girls between the ages of 5 and
14 years were found by Sainsbury 769 to have goitre. The main formation
in the area is limestone and the water is deep spring with the low iodine
content of 2.1-2.2 µ,g per litre. The dietary standards are poor and the
consumption of fish negligible. On the opposite side of the country, goitre
centres are found both on the sea-shore and in the hills of the Gargano
peninsula (Cerletti 702). In Lucania thyroid enlargement is noticeable at
several places, particularly in Potenza Province (Ambrosi; 683 Calbi; 697
Pitzurra & Ponzio; 765 Barbieri; 691 Pitzurra, Modolo & Mori 763). Throat
measurement of elementary schoolchildren at Palazzo San Gervasio, a
town lying between Canosa and Potenza, has enabled Cancellara 698 to
calculate an index of thyroid enlargement which he finds useful for determin-
ing the incidence of thyroid disease in a given section of the population.
In the extreme south of Italy, a little-known area of endemic goitre has
been described by Criscenti. 718 This includes the districts of Savuci, Taverna
and Maranise, in the Province of Catanzaro, where the people live very
largely on chestnuts and rye, and where the soils are derived from granitic
rocks and archaean crystalline schists. At Taverna 93 % of schoolchildren
were found to be sufferers; at Savuci the rate was 77 %.
Foci of endemic goitre and cretinism in Sicily have been described by
Coppola 708 who refers especially to Nicosia in the Province of Enna as
a noted centre. A prevalence of 29 % among schoolchildren in the munici-
pality ofBarcellona Pozzo di Gotto on the north-east seaboard was observed
by Spadaro & Alfano 773 in 1955. Dental fl.uorosis was noticeable in a high
percentage of the goitre carriers. A re-survey of the area by Previtera,
Molino & Pagano 766 in 1958 revealed lower rates, due it is believed to
improved water supply. In 1957, Tempestini 775 inspected 500 inhabitants
of the village of Motta Camastra (Province of Messina); of these, 42 % of
PREVALE'<CE AND GEOGRAPHICAL DISTRIBUTION 101
adults and 49 la of children showed thyroid enlargement, and 58 % of adults

and 41 % of children, dental fluorosis. No direct relationship between the
two conditions could be established; the greatest severity of fluorosis was
seen in people with no thyroid abnormality.
In Sardinia the prevalence of goitre among schoolchildren has been
studied in the Province of Cagliari by Corda 709 and by Desogus. 726 In
the middle-west of the country, goitre is endemic in the town of Santu-
lussurgiu and its surroundings, but cretinism is unknovm (Ferraris et al. 728) .
At Sondrio and in the Valtellina goitre prophylaxis by iodized salt
(1 : 50 OOO) had, by 1938, been in vogue for about fourteen years with good
results (Lutrario; 738 Ambrosi; 684 Cerruti 704). In that time the number of
cases showing obvious enlargement fell from 57 % to 1.4 %- Besides the
general decrease in thyroid size there was a lowering of the infant-mortality
rate and improved mental alertness among children. Iodine preventive
measures have also been applied in the Valle d'Aosta by a committee set
up by the public health authorities of the Region. Iodized chocolates, each
containing 10 mg of potassium iodide, were distributed to schoolchildren
at the rate of two per week, and in some schools open wide-mouthed bottles
of tincture of iodine were exposed. Good results were obtained from the
chocolate tablets, but no benefit followed the exposure of iodine tincture.
Malta
D. C. Wilson (personal communication, 1955) says she has seen goitre

in Maltese people who come from the north and west of the island where
the water-supply is derived from wells. It is of interest that waters obtained
from waterworks in and around the centre of the island have a high iodine
content, ranging from 21 µg to 40 µg per litre. Unfortunately, no compa-
rative analytical figures are aYailable for well waters from the north.
Spain
There is a great deal of goitre in Spain. Almost all mountainous districts

are affected, some to a serious degree. Particulars of the distribution are
derived from four principal sources: (1) the 1927 report of the Commission
of Inquiry on Goitre, set up by the Spanish Government in 1921 under the
direction of Maraii6n; 791, ; n (2) the long and important series of investiga-
tions (1947-56) conducted under the leadership of Ortiz de Landazuri of
the Faculty of Medicine, Granada, and the Department for Goitre Pro-
phylaxis, Board of Health; ,ss, 795-808, 813-815 (3) the reports 786, 810 of the
well-known Barcelona endocrinologist Cai'iadell, in collaboration with the
Swiss investigators Eugster & Dieterle: and (4) the accounts of goitre in
the Province of Sevilla by Rivero Fontan and co-,vorkers. 784, 811 The
history of goitre in Spain has been written by Greenwald 787 who sheds
interesting light on reasons for the comparative rarity of the disease among
Jews.
From data acquired by provincial health inspectors, Ortiz de Landazuri
and his colleagues have prepared a map showing, by a system of crosses,
the comparative intensity of the endemic in those provinces in which the
disease chiefly occurs. 788 , 803 The indications are as follows (provinces
not mentioned are those for which no data are given on the map):
Northern Provinces
Lugo ++ Navarra ++++
Oviedo ++++ Huesca -:-+
Santander ++ Lerida +
Vizcaya ++ Barcelona ++
Pontevedra + Zaragoza +
Leon +++ Tarragona +
Zamora +-
Central Provinces
Avila ++ Guadalajara +++
Madrid + Teruel +++
Caceres ++++ Albacete +
Cuenca ++ Castellon +
Badajoz ++ Valencia +++
Southern Provinces
Sevilla ++ Jaen ++
Cordoba + Granada ++++
Cadiz +- Almeria +-
Malaga ++
In the north, a belt of very considerable intensity extends from Cataloma
along the Pyrenees through the Cordillera Cantabrica and the Asturias to
Galicia in the west. Tracing this in greater detail, we find goitre especially
in the north-west of Gerona Province, where the regions of Ribas de Fresser
and Camprod6n provide many cases. In the neighbouring Province of
Barcelona there is much goitre in the Montseny area, in the Llusanes
valley and in the country to the north of Berga. Conditions here are
described by Eugster & Dieterle 786 as exceedingly reminiscent of those
in the foothills of the Swiss Alps; indeed, the people call the district
"pequena Suiza" (little Switzerland). Incidence is highest in the deep
intersecting valleys of the region, whereas the high tablelands are mostly free
from the disease. Piulachs & Caiiadell 810 have prepared a detailed goitre
map of this area, and representative photographs of the Montseny goitres
have been published by Draper Alfaras. 785
Moving westwards through Lerida Province, we find considerable goitre
in the Valle d'Aran. In Huesca, the northern valleys of the river Cinca
and its tributaries are well known to be goitrous. From thence the endemic
extends through the Provinces of Navarra and Vizcaya into Santander,
PREVALE"'<CE AND GEOGRAPHICAL DISTRIBUTION 103
whence it spreads over the Asturias, Oviedo, Leon, and into the valleys of
Galicia. In the extreme north-western section the endemic is less severe
than in the high valleys of the Pyrenees between Spain and France where,
in addition to simple goitre, there is a good deal of cretinism and deaf-
nrntism. Cretinism is also a strong feature in the Asturias-an area which,
according to Marafion, 792 has been studied in great detail by Goyanes and
Ceniga. Here, numerous cases of goitre and cretinism occur near the sea
as well as at higher levels.
In central Spain goitre is found along the Sierra Gredos lying to the
south of Avila Province west of Madrid. In this area the valleys of the
head-waters of the rivers Tormes and Alberche are particularly affected,
as also is the valley of the Tietar where the endemic has been studied in
some detail by Martin Uizaro. 791 West of this towards the Portuguese
border, goitre is exceedingly prevalent in the Sierra de Gata. Here, indeed,
we find one of the most notorious goitre centres in the world-the region
of Las Hurtles, a section of the Sierra de Gata covering the extreme northern
tip of the Province of Caceres.
Las Hurtles constitutes an incomparable field for the study of goitre.
It is the most important focus in all Spain. The area, mapped by Perez-
Vitoria, 809 is composed of three long narrow valleys of unbelievably rough
and inhospitable country. The geological formation is exclusively of slate
and has a sparse and unproductive vegetation. The prernlence of goitre
exceeds 25 % and large numbers of the goitrous population are also cretinoid.
Cases of idiotism, deaf-mutism, infantilism and dwarfism are many, and
not a single man from the district has been found fit for military service,
either because of Io-w stature or marked feeble-mindedness. The whole
region is one of tragic aspect and has given rise to numerous legends-often
exaggerated no d o u b t - i n the records of ancient and modern travellers and
national writers (Legendre; 790 Marafion 791). Other goitre areas in central
Spain lie in the east towards the Mediterranean; they include the Province of
Castellon de la Plana, 783 particularly the mountains of the Alto _\faestrazgo,
and a large part of the Province of Valencia.
Southern Spain's most goitrous proYince is Granada, where the region
of Las Alpujarras on the southward slopes of the Sierra Nernda is highly
affected and has been studied in detail by the school of Ortiz de Landa-
zuri. 788, 795 -sos, 813-81·' Elsewhere in the south goitre is found in the north
part of Sevilla in the neighbourhood of Constantina between the Guadal-
quivir and the Sierra Ivforena. Cases are also encountered in the Sierra de
Algodonales between the ProYinces of Sevilla and Cadiz, and in the Serrania
de Ronda on the ,vest border of _\falaga Province. 75; · " " 3 , 811
The outcome of a great deal of experimental work in the University
of Granada has convinced Ortiz de Landazuri and his colleagues that
iodine deficiency is the main cause of goitre in the Granada area. This
assumption is based on the extremely low iodine content of the drinking-
waters from affected districts 796 and is confirmed by the fact that in the
space of 16 months there was an over-all decrease in the goitre rate, from
60 % to 33 %, as a result of administering iodized salt (1: 50 OOO) in an
area of extreme endemicity. 788
Most recent results (1959) of mass prophylaxis with iodized salt in
Spain are those of Ibanez Gonzalez et al. 789 whose data refer to the. Alpujarras
region of Granada. Applied to a population of 100 OOOsince February 1954
the general use of iodized salt has resulted in a progressive decrease in the
goitre rate from 55 % in 1953 to 33 % in 1955 and 13 % in 1958. Neither
administrative inconvenience nor any harmful secondary effects were
encountered.
Portugal
The distribution of goitre in Portugal is best seen on the map published
in 1950 following the national inquiry on endemic goitre instituted by the
Director-General of Health. 816 Although nowhere exceptionally severe, the
disease is endemic or of frequent occurrence in the following districts:
Northern Portugal. Vinhais, Terras de Bouro, Mondim de Basto, Ama-
rante, Penafiel, Baiao, Castro Daire, and Satao. Cretinism is seen in
Vinhais and Amarante.
Central Portugal. To the east, the goitre belt of western Spain (Sierra
de Gata) extends into the districts of Sabugal, Belmonte, Penamacor,
Fundao, Castelo Branco, Oleiros, Proern;a-a-Nova, Ma9ao, and Crato.
On lower ground to the west, nearer the sea, goitre occurs in Miranda do
Corvo, Anciao, and Castanheira de Pera.
Incidence is highest in the region of Castelo Branco; here goitres begin
to develop in children of five or six years of age, whereas the great majority
of cases in other parts of Portugal occur between puberty and the age of 50.
South Portugal. Goitre is seen in the neighbourhood of Montemor-o-
Novo east of Lisbon, and there is a belt of mild incidence in the extreme
south, covering the districts of Odemira, Ourique, Almodovar, Loule and
Tavira.
In common with other countries the disease occurs much more frequently
in females than in males; it often appears in various members of the same
family; but in only four sufferers was it found to be associated with deaf-
mutism. Goitre is known by several different words in Portugal. Bacio is
the medical term, but ordinarily it is called papeira or papo; other familiar
names are garganta, !oho and papada. Organic debility, emotional dis-
turbances, prolonged anxiety, and peculiar qualities of soil and water are
some of the factors to which goitre is attributed. There is a popular notion
in Ourique that the disease is caused by drinking water that has passed
over the roots of a fig-tree.
Western Europe
Belgium
It seems to be generally agreed that goitre is not an outstanding problem
in Belgium today, although there are earlier reports of its endemic occurrence
in some of the high-lying southern districts towards the Ardennes and
Luxembourg. The comparative absence of goitre goes hand in hand with
Clinquart's 828 observation that drinking-waters in Belgium contain more
iodine than those in Switzerland.
During the 1939-45 war, however, Brull 819 first drew attention to a
changing incidence of thyroid disease in Belgium. He found that the basic
metabolic rate of all goitre cases seen at his clinic in Liege showed a steady
decline from an average figure of _'.__21.9 · in 1939 to +6.6 % in 1942. This
was confirmed by Bastenie 818 ,vho, in comparing the number and severity
of cases of thyroid disease observed at the St. Pierre Hospital, Brussels,
in the years before and during the German occupation, found that whereas
the incidence and severity of hyperthyroidism did not increase and may
probably have decreased, there was a significant increase in the incidence
of simple goitre at all ages but particularly in the age-group 15-25 years.
The observed changes in incidence and severity are thought to be related
to the quantity and quality of the diet, especially the wartime increase in
the consumption of cabbage and related vegetables which contain sub-
stances of the thiourea group. In this connexion it has been pointed out
that if the increase in simple goitre in Belgium during the ,var ,vas in fact
comparable to t h e " cabbage " or "rape-seed" goitre of animal experiments,
a reduction in severity might be expected in cases of toxic goitre on the same
diet. Such patients would, in effect, be treating themselves on the most
modern lines. If this is the correct explanation it leaves open the possibility
that there was an actual increase in thyrotoxicosis in Belgium during the
war, which was masked because the population was being simultaneously
dosed with thiourea compounds taken in the diet.
The latest study of the distribution and frequency of goitre in Belgium
is that by Brull & Dewart 826 who examined 54 OOOarmy recruits. Of these,
only 1.3 % showed thyroid enlargement at enlistment; and most of the
cases were simple hypertrophy without either toxic or hypothyroid
symptoms. Frequency increased from the coast to the east and south of
the country, i.e., towards the higher areas of La Fagne, the Ardennes, and
Luxembourg.
England and Wales
In his Treatise on English Bronclzocele, Inglis 866 says that at one time
goitre was as common in the Yorkshire dales as in GeneYa or any of the
Alpine valleys. Children could be seen at play with pieces of black velvet
tied around their n e c k s - a superstition to ward off the goitre evil or charm
it away.
FIG. 4 . WESTERN AND SOUTHERN EUROPE
Other records a in the early medical history of English counties show

that goitre and cretinism were prevalent in Norfolk, in the Manchester area,
in Monmouthshire, in Cornwall and elsewhere. There was a strong endemic
centre in Weardale in the west of Durham, and cretins were notorious at
Chiselborough in Somerset. A local predilection for oatmeal cakes was
believed to be responsible for goitre in Matlock. And to this day the
synonym " Derbyshire neck " brands that county as goitrous-albeit
unfairly, for goitre has always been equally severe, if not more so, in
Oxfordshire, Gloucestershire, Somerset and Dorset.
The first connected account of the geographical distribution of goitre
in England is that by Berry, 836 who found thyroid enlargement moderately
prevalent in the south-east of England, particularly in the Wealden area
of Sussex and on the high ground around Horsham and towards Haslemere
in Surrey. To the west and south-west the disease was conspicuous in
Gloucestershire and in east and south Somerset. There was a distinct seat
of occurrence in the Warwickshire villages south of Leamington. Farther
east, a centre existed in Bedfordshire and there was evidence of goitre in
Buckinghamshire and Hertfordshire. In the midlands a considerable
number of goitrous people were noticed in Staffordshire, Lancashire and
Derbyshire. From thence Berry traced the goitre belt northwards through
Yorkshire to the junction of west Durham, Northumberland and Cumber-
land where there ,vas a well-known endemic focus at the lead-mine district
of Alston and the adjoining area of \Veardale.
A comprehensive all-England examination of 375 OOO schoolchildren
undertaken by the medical department of the Board of Education in 1924 839
not only confirmed the goitrous areas delineated by Berry a quarter of a
century earlier, but disclosed a trend of goitre incidence sufficiently dis-
quieting to prompt the first official recommendation that " prophylactic
administration of iodine to girls in some endemic areas of England and
Wales might be desirable ". 883 The over-all goitre rate reYealed by the 1924
survey among schoolchildren of 12 years of age was 5.26 ; in boys and
13.33 % in girls in areas of high prevalence, and 1.49 ' in boys and 4.41 %
in girls in the areas of low prevalence. But some places-notably, in
Devon, Somerset, Oxfordshire, Northumberland and D u r h a m - h a d goitre
rates of 10 % to 20 ' among boys and more than 30 / among girls.
The prophylactic administration of iodine recommended by the 1924
survey was neYer giwn general effect; but during the inter-war years some
attempt was made to introduce iodized chocolate and sweets in a few
affected localities. These measures, howeYer, depended too much on the
unaided efforts and enthusiasm of indi,idual public health officials and
consequently lacked the continuity which support from a central authority
alone can ensure.
a See reference S32, 834, 835, 837, 838, 8 4 \ 845, .s.r:·. 551. S.53, s::6, :557, 859, 860, 862-865, 868, 872. 873,
875-880, 882, 888-890, and 893 in the bibliography.
Without doubt the prevalence of goitre in England has considerably

diminished over the past hundred years in consequence of rising standards
of public hygiene, better food and improved water-supplies; but the disease
has never been entirely extinguished and has always continued to disturb
the minds of research groups and organizations anxious to improve the
physique and health of the people. In the year 1936, in the County of
Somerset, goitre rates of 36 % were still the rul.e among schoolgirls living
in the neighbourhood of Taunton, Yeovil and Wells; 894 and in 1940 urgent
attention was being drawn in the medical press to the high incidence of
goitre persisting throughout South Wales. 844
The war of 1939-45 brought the subject into a new prominence because
of reports that thyroid enlargement was increasing in areas cut off from
supplies of sea-fish. It was also noticed that the condition was unusually
common among young women drafted into factories for war work. The
Medical Research Council of Great Britain thereupon appointed a com-
mittee to consider these observations and to carry out special surveys of
certain sections of the population in several counties of England and in two
in Scotland. Among the committee's findings were: established goitre
in 50% of adult women at Hook Norton, Oxfordshire; thyroid enlargement
in 43 % of girls at Sherborne in Dorset; in 26 % of boys and girls at Oke-
hampton in Devonshire; and in 21 % of girls at St. Albans, Hertfordshire.
By contrast, only 2 % of children showed thyroid enlargement at Maldon in
Essex where the drinking-water is rich in iodine. 871
In short, the areas in which official surveys have located evidence of
iodine deficiency in England are the same today as they were 50 or 100 years
ago. At the time of their investigation (1944) the Goitre Subcommittee of
the Medical Research Council estimated that in England and Wales there
were some 500 OOO cases of thyroid enlargement in persons of ages 5 to
20 years inclusive. 867 There is no reason to suppose that this figure is any
less today, 12 years later; indeed, the following comparatively recent reports
suggest the very opposite. Lisney, 861 County Medical Officer of Health,
Dorset, refers to a surprising increase in thyroid enlargement coupled with
increased lassitude and anaemia among women seen at the Dorchester
ante-natal clinic in 1949 compared with previous years. Similarly, Simp-
.son 881 reports thyroid enlargement linked with real ill-health, lassitude and
catarrh among expectant mothers attending her ante-natal clinics in the
Isle of Wight during 1951. Cooke 841 also describes a symptom-complex
among women in West Hartlepool which responds to thyroid medication and
is believed to be analogous to, if not identical with, the Roberton syndrome
commonly met with in Christchurch, New Zealand. This involves lassitude,
coldness, and hair changes following pregnancy, and is regarded as a
condition of hypothyroidism associated with endemic goitre. Hoey 851
reports a high incidence of goitre in the Bedwellty area of Monmouthshire,
particularly in Aberbargoed and New Tredegar. He recommends the
PREVALDiCE A D GEOGRAPHICAL DISTRIBUTION 109
compulsory use of iodized salt and suggests that it would possibly be

helpful to make thyroid disease notifiable. The prevalence of goitre in two
contrasted South Wales communities (Rhondda Fach and the Vale of
Glamorgan) has been studied by Cochrane & Miall,sJo with the assistance of
W. R. Trotter.
Schools of north Oxfordshire in which the Medical Research Council
team 871 recorded high goitre rates in 1944-48 were re-examined in 1958 by
the same clinical methods and classification. The area in question lies on a
belt of limestone and marl extending through the county from Witney to
Banbury. Hughes, Rodgers & Wilson, s5J, 855 who undertook the second
survey, found that the previous rate of 26.9 % in girls had significantly
increased to 40.4 %. No significant change was found in the rate for boys;
this remained at 14.8 %-
The iodine level in milk from farms in north Oxfordshire was compared
with that of milk from farms in Wales and Essex; no significant difference
was found. It is suggestive, however, that the water drunk by cows in
non-goitrous Essex contained from 18-117 ug of iodine per litre whereas in
Oxfordshire and Wales, both of goitrous tendency, the corresponding
values were 1.7-5.3 µg per litre and 2.2-2.9 µg per litre, respectively.
In 1944 850 and again in 1948 871 the Goitre Subcommittee of the Medical
Research Council urged the general adoption of iodized salt throughout
the United Kingdom as a means of preventing goitre. The level recom-
mended is 1 part of potassium iodide in 100 OOO parts of all salt, or 1 part
in 40 OOO parts if only packeted table salt is to be iodized. In 1950 the
Government of the day seemed disposed to fulfil this recommendation; but
no action followed. All that has been sanctioned and carried into effect
is the addition of potassium iodide to the vitamin tablets issued by the
Ministry of Health to expectant and nursing mothers.
Scotland
The survey by the Medical Research Council m mentioned in the

section on England and Wales confirmed the well-known fact that the
content of iodine in drinking-water is a determining factor in the distribution
of endemic goitre. Even more important, however, was the finding that an
iodine level which in a soft water may be adequate to prevent goitre may
be insufficient where the water is hard. This explains why in Scotland,
where the waters are mainly soft, goitre appears at a lower level of iodine
intake and is much less prevalent than in England, where the ,vaters are
mainly hard.
Although goitre is not a common disease in Scotland there are never-
theless some areas where it is prone to occur, namely, in the Southern
Uplands and in parts of Inverness-shire. At one time the affected region
in the south extended over the greater part of Roxburghshire, the west of
Berwickshire, the upper parts of Selkirk and Peebles, the northern districts
of Lanarkshire, the eastern side of Ayrshire, the whole of Dumfriesshire
and Kirkcudbrightshire, and the eastern parishes of Wigtownshire. 900 Today,
goitre has largely disappeared from these counties with the exception
perhaps of Dumfriesshire, where the valleys of the rivers Esk, Annan and
Nith remain distinctly suspect areas. The rates of thyroid enlargement
found among boys and girls in the 1948 survey of the Medical Research
Council were: 19% at Kirkconnel in upper Nithsdale,a 20% at Langholm,
23 % in the Burgh of Lockerbie, and 17 % in the Burgh of Dumfries.
In Inverness-shire a considerable amount of thyroid enlargement has
been found among schoolchildren at Fort William, at Kingussie, in the
Burgh of Inverness itself, and in Glen Urquhart, where the rates were
particularly high, 35% in boys and 47% in girls. 871
Elsewhere in Scotland goitre is of little account nowadays, but to
complete the record it should be mentioned that in earlier times there were
goitre centres in Perthshire, 896• 898• 899 in the Isle of Arran, 896 around
Wishaw, 903 in the valleys of the western tributaries of the Clyde, especially
in the coalmining district ofLarkhall, 898 and in and near Fauldhouse mid-
way between Edinburgh and Glasgow on the east side of the Forth-Clyde
watershed. 901 Goitre is also said to have occurred at one time on the east
coast of Fifeshire. 898
A fairly recent study has been made by Keddie 895 of the distribution of
congenital deaf-mutism in Scotland. He states that 928 congenital deaf-
mutes attended schools for the deaf in Scotland during the 20 years 1924-44,
but the records of the districts from which these children came reveal
nothing to suggest that deaf-mutism is invariably confined to the goitre
areas.
Northern Ireland
During the course of routine medical examination of people from
Northern Ireland applying for visas to enter the USA in 1929-30, Olesen &
Neal 906 found a surprising amount of simple goitre among individuals
coming from all parts of the six counties of Ulster.
In all, they examined 4648 males and 3992 females ranging in age from
a few weeks to more than 80 years. The rate of indisputable thyroid enlarge-
ment among the males was 11.8 % and among the females 27.4 %. In both
sexes the greatest amount of goitre was found between the ages of 15 and
24 years, the percentage being highest (33.1) in girls of 15 to 19 years.
More recent investigations have been made by Erskine, 904, 905 who
determined the goitre rate in children attending public elementary schools
in the south of County Antrim. Here, the goitre areas are typical rural
districts with some small towns and villages situated on the main roads and
a Long ago Mitchell 90 gave the disease the local name of " Nithsdale neck ".
PREYALEKCE A"'ID GEOGRAPHICAL DISTRIBUTION 111
near the sea coast. They extend from Waterfoot near Cushendall in the
north, to Derryclone in the extreme south of the County and are bounded
on the north by the Atlantic Ocean and the North Channel, on the east by
Belfast Lough, on the south by the city of Belfast and the river Laggan, on
the west by Lough Neagh, and on the north-west by the Ballymena region
of the County. The type of country varies considerably. On the north-east
is a coastline of steep escarpments rising from the sea; inland a great
plateau slopes down to a low-lying area on the west covered by flat bog or
deposits of glacial clays and gravels.
Compared with other countries, the average goitre rate in Northern
Ireland is not high. In every 1000 children examined, Erskine found 39 cases,
of which 26 were in girls and 13 in boys. She saw more thyroid enlargement
in rural than in urban schools and seldom found a case among sea-coast
communities. Although the over-all rate averaged only 3.9 %, there were
some individual schools on the west plateau and in the valleys sloping
towards Lough Neagh ,-vhere the rate reached anything from 9 % to 25 %,
Faulty diet, iodine deficiency, bad hygiene and poor housing are the
causes of goitre in County Antrim, according to Erskine. Focal and general
infections are commoner in goitrous than in normal children; and the
adverse effect which the condition has on the health of women during
pregnancy and at childbirth is particularly noticeable.
Ireland
The general impressions of those competent to judge are that goitre is
obviously much commoner in Ireland than in England. The area of highest
endemicity is the South Riding of County Tipperary, but the disease is
also known in County Dublin, County \Vicklow, County Meath, and in
Kilkenny 910 (also I. Brady and T. Stallard-personal communications,
1955). Cases have been recorded in an orphanage in Sligo (M. K i r b y -
personal communication, 1950) and there is a slight incidence in Counties
Leix and Mayo. Goitre is said to be unknown in Galway and Kerry. 911
The high prevalence in South Tipperary has been the subject of study
by the Medical Research Council of Ireland over a period of years, and the
results of their investigations are to be found in papers by O'Shea, 911
Naughten, 908 and O'Donovan. 910 Data (see Table X) were accumulated
from clinical examination of schoolchildren and chemical determination
of the iodine content of the local dietary, soils and waters, not only in
South Tipperary but, for comparison, in the non-goitrous sea-coast village
of Spiddal in Galway, and in Port Laoighise ( faryborough) and Clare-
morris, two localities of intermediate goitre incidence.
These data show clearly how goitre is most prenlent where there is
least iodine in the locally produced foods-milk, soda-bread and potatoes.
The outstandingly high iodine content of soil and water in the coastal
TABLE X. RELATION BETWEEN OCCURRENCE OF GOITRE IN SCHOOLCHILDREN

A N D IODINE CONTENT OF SOILS, FOODS, A N D W A T E R
Iodine content (µg per 100 g) of

I Goitre in I
Place County children
I soils soda-
waters milk I potatoes
<%> I I I I bread
Cloran Tipperary 65 3 721 1.9 1.0 1.6 0.5

Kilsheelan " 70 3 809 0.9 0.9 0.9 0.6
Tipperary town " 65 3 071 0.5 1.5 4.7 0.6
Maryborough Leix 40 3 010 1.7 3.5 12.6 11.7
Claremorris Mayo 10 5 050 0.4 3.6 10.7 7.0
Spiddal Galway 0 14 390 20.1 55.6 18.3 5.6
district of Spiddal corresponds with high iodine in the local foods, and
entire absence· of goitre.
There is no law compelling people to use iodized salt in Ireland, but the
public health authorities encourage its use throughout the whole country
and particularly in the areas where goitre is known to be prevalent.
France
The geographical distribution of goitre in France is the same today
as it has been throughout the past century, although during that time the
intensity of the disease has much decreased (Mayet; 941-944 Rochaix 948).
The principal zones are: an eastern belt extending along the entire
German-Swiss-Italian frontier from northern Alsace to the Alpes-Maritimes
on the Mediterranean coast; a south-central zone covering the Auvergne
and Massif Central; and a strong but smaller belt along the Pyrenees and
Spanish frontier. Isolated from these three main areas are foci in the
Departments of Aisne and Orne in the north-west. Excluding the two
last-named, the districts of greatest incidence may be conveniently listed
thus:
North-eastern Zone
Moselle Bas-Rhin
Vosges Haut-Rhin
Haute-Saone Doubs
South-eastern Zone
Jura Haute-Savoie
Ain Savoie
I sere Hautes-Alpes
Drome Basses-Alpes
Vaucluse Alpes-Maritimes
PREVALENCE A1'D GEOGRAPIDCAL DISTRIBUTION 113
South-Central Zone
Puy-de-Dome Saone-et-Loire
Correze Loire
Cant al Rhone
Lot Haute-Loire
Aveyron Ardeche
Lozere Gard
Pyrenees Zone
Landes Haute-Garonne
Basses-Pyrenees Ariege
Hautes-Pyrenees Pyrenees-orientales
In the eastern zone the heaviest intensity lies in Savoy, where the Taren-
taise and Maurienne ranges are intersected by many goitrous valleys.
Berard & Dunet 918 regard water as the essential etiological agency in this
area and they point to the existence o f " conscripts' springs ", ,vhere recruits
used to go to drink the water in order to develop neck swelling and so escape
military service. They recall, too, the boarding-school at St. Jean-de-
Maurienne where the pupils developed goitres during term but lost them
when on holiday out of this area, only to develop them again on returning
to school. " Holiday goitre " also develops rapidly in individuals from other
parts of the country who choose to spend their vacation in these goitrogenic
districts. To the south, goitre persists in the valleys of the Maritime Alps,
more particularly along the rivers Vesubie and Bevera (Marot 939).
North of the Savoy mountains the endemic stream follows a course
along the Jura and Vosges whence it swings to the north-west over the
Moselle country and through the Ardennes into the northern Paris plain.
In Alsace the high ground on either side of the Rhine is affected; but the
valley between, especially in the neighbourhood of Strasbourg, is goitre-
free (Rhein 947).
Of the south-central area covering the Auvergne mountains and extend-
ing eastward to the Cevennes and wemvard to the plain of Aquitaine, there
is little to be said except that compared with former times the intensity of
the endemic here has greatly decreased in recent years (Berard & Dunet 9 1 8 ) .
A series of fairly recent papers by Faugere, Vichnevsky, Laroche, Tremo-
lieres and Derache define the present goitre position in the Departments
of Correze and Lot, which lie in this general area." 27 · 937• 9as. 951, 9·52 In both
these departments goitre rates of 40 , to 50 , are to be found among
schoolchildren of ages between 7 and 18 years.
In the Pyrenees, also, goitre is on the wane according to Rochaix. 948
It has not, however, completely disappeared and what seem to be almost
permanent foci still exist in the canton of Luz-Saint-Sauveur, in the valley
of the Adour south of Bagneres-de-Bigorre, and in the valleys of the Neste
and the Aure (Gleizes & Boy; no, 931 Marot 9 3 9 ) .
Since the intensity of goitre is automatically diminishing with improved
conditions of sanitation, and especially of water-supply and nutrition,
preventive measures as practised in other countries have never been con-

sidered necessary by public health authorities in France.
Records of goitre among domestic animals are occasionally met with
in French veterinary literature. As long ago as 1862 Baillarger 916, 917
described occurrences among mules, horses and dogs in the mo mtainous
eastern regions of the country. More recently (1940), Jacob 933 writes of
thyroid disease of hyperthyroid type in foals born in the Breton coastal
region north of Brest.
Goitre is not considered to be endemic in Corsica; nevertheless, cases
are by no means infrequent in upland villages (Marot 939).
PART II-AFRICA, ASIA AND OCEANIA
Africa
Isidor Greenwald, 956 the well-known goitre historian, has accumulated
what he regards as compelling evidence that goitre, now endemic throughout
most of Africa, was unknown in ancient Egypt or in Roman North Africa
and, indeed, did not originate anywhere on the African continent until
the nineteenth or even the twentieth century.
Nevertheless, there are several early accounts of its existence. Johannes
Leo 965 (c. 1494-1552), usually known as Leo Africanus, an ItaJian of noble
Moorish stock and long ranked as the best authority on Mohammedan
Africa, records in his Descrittione dell' Affrica having seen goitre during
his travels (1513-15) through Morocco and the Sahara. This account has
been supplemented by a number of later observations which confirm that
in North Africa goitre has long been endemic on the slopes and in the
valleys of the Atlas Mountains, in Spanish Morocco, and in the Kabylia
Mountains in Algeria.
When making his way from the Gambia to the upper waters of the
Niger in 1795-96, Mungo Park 980 saw goitre among the native peoples
in the Bambuk country and at Segu-Sikoro in the direction of Timbuktu.
The first European to reach Timbuktu from Tripoli, A. G. Laing, 986 also
mentions goitre in the narrative of his West African journeys (1822) when
endeavouring to reach the source of the Niger through the interior of
Sierra Leone.
The histological and other characteristics of goitres found among
North African immigrants in the Lyons region of France are described in
detail by Guinet & Berger. 957
Algeria
Some of the goitrous localities in eastern Algeria are mapped in a short
paper by Sergent 960 published in 1912. He refers to the c.alcareous nature
of the terrain and mentions the regional names given to the disease-
PREVALENCE A1'.l) GEOGRAPIDCAL DISTRIBUTION 115
namely, Handjoura (Arabic); Hazzouza at Thaourirth-naith-gana; Aghbal

at El-Kseur; Arkoum at Tizi-Ouzou; and Akerkour at Lafrye'.te.
The fullest and most recent studies are those in 1955 by Vergoz, Boulard
& Bernard, 9 62 and in 1959 by Vergoz & Sicard. 963 They have mapped the
endemic area and found it much more extensive than that traced by Sergent
in 1912. It seems that the most seriously affected area is the Department
of Constantine on the eastern side of the country where the disease is found
throughout practically the whole of Little Kabylia from the interior to
the sea coast. Goitre centres particularly noticeable in this zone are Collo,
Philippeville, El Milia, Taher, Djidjelli, Akbou, La Soummam, Bougie,
Guergour, Takitount and Oued Amizour.
The goitre belt continues westwards into Grand Kabylia in the Depart-
ment of Algiers where comparatively high rates are seen at Tigzirt, Tizi-
Ouzou, Michelet, Boghni, Dra-el- izan, Palestro, Menerville, le Fondouk,
Rovigo, and Souma. This section of the endemic terminates at Blida, just
south of Algiers. The city of Algiers itself is immune. Farther to the west
there are one or two places on the coast, notably Gouraya and Montenotte,
where the prevalence, although lower than in Kabylia, is still disquietingly
high.
Oran, to the west of the country, is the least goitrous of the three main
northern divisions of Algeria. The only place where the disease has been
noted up to the present is the neighbourhood of Nedroma, which lies near
the Moroccan border just south of Nemours.
The inquiry by Vergoz, Boulard & Bernard took account of about
40 OOO persons-schoolchildren, military recruits, hospital patients and
o t h e r s - o f whom 4500 had goitres. This over-all rate of approximately
10 % rose markedly in certain groups and in certain places. Thus, at
Takitount in the Department of Constantine, 189 children out of 200
(94.5 %) were found to be goitrous; at Souma 65 and at Cap Aokas
61 % of children were victims. Women were more intensely affected than
men; in an area of high endemicity the figures were 71 % for women and
23 % for men. Cretinism appears to be rare in Algeria, and among the
40 OOO people examined there was not a single case of deaf-mutism.
Vergoz and his colleagues make a strong plea for the introduction of
iodized salt in Algeria. They do this from general economic and humani-
tarian considerations rather than because they think the goitre scourge in
Algeria is exceptionally severe: in fact, goitre is much less intense there
than in many other countries. They remind us that although goitre may
not kill and although its lighter incidences may not seriously affect the
behaviour of the subjects (mildly goitrous children are able to pursue
their studies and adults are able to marry and have children) it is never-
theless a degenerative social malady from which greater evils may develop
and involve unnecessary charges on the medical services of the state.
The charge against public funds for goitre operations in Algeria has been
FIG. 5. AFRICA
PREVALDfCE AND GEOGRAPHICAL DISTRIBUTION 117
estimated by Vergoz & Sicard. 963 Hospitalization and surgical treatment

of a single case costs 180 OOO French francs. The hospital of Mustapha
alone deals with 150 goitre operations annually, thereby incurring a total
expense of 27 million francs. Similar costs apply in many other Algerian
hospitals operating in the endemic zone. These facts should be faced and
preventive measures applied.
The iodine contents of drinking-waters from a non-goitrous locality
and from two widely separated goitrous localities in Algeria are compared
by Vergoz, Boulard & Bernard. 962 The figures have an obvious significance:
µg o f iodine per lirre
Algiers (no goitre) 2.0
Souma (goitrous) 0.7
Cap Aokas (goitrous) 0.2
These authors also state that salt supplied for domestic consumption
in Algeria, of whatever origin, has a very low iodine content.
Morocco
In former Spanish Morocco goitre is called "Hans/a" by the local
people, and endemic centres are to be found scattered here and there along
the Rif mountain chain. Two of these have been studied in some d e t a i l -
the kabila of Beni Jaled by Manuel Amaro 966 and the kabila of Berri
Ahamed by Alonso Romeo. 96 ±
The kabi!a of Beni Jaled consists of 72 hamlets with a total of 14 200
inhabitants. The district lies in the mountains almost at the centre of the
country and through it runs the main highroad connecting the towns of
Melilla in the east and Tetuan in the west. Goitre occurs in only four of
the 72 hamlets in the kabi!a-namely, Achedad, Ifartan, Takasbut and
Taska. Out of a total of 300 persons in these four centres taken together,
Manuel Amaro found 18 cases of simple goitre, 2 cretins, 2 deaf-mutes,
and 1 case of Graves' disease. In each village the affected persons were
near relatives all deriving their supplies of drinking-water from the same
springs. Large quantities of turnips are eaten by these people; indeed,
turnips constitute a staple food. Manuel Amaro believes this to be a causal
factor but thinks also that the district is poor in iodine owing to its altitude
and the mountain barriers which shelter it from the sea. The prevailing
wind is from the desert south.
Beni Ahamed, the second district in which a goitre sun ey has been
made, adjoins Beni Jaled on the west. .\faximum intensity in the zone
occurs in the townships of Dar Gaba, Tafsa, Bazet and Kelala. Alonso
Romeo 9 sc1 made a careful clinical examination of 91 cases drawn from
19 townships, and among these he diagnosed hypothyroidism, hyper-
thyroidism and one case of cretinism.
The endemic area covering the centre of former Spanish Morocco
extends southwards into the north of former French Morocco, where,
according to Alonso Romeo, the kabila of Beni Zerual is greatly affected.

However, there do not appear to be any precise accounts of the nature and
distribution of goitre in former French Morocco. During their investiga-
tion of endemic fluorosis in the phosphate-mining community at Khouribya,
which lies inland about 60 miles south-east of Casablanca in the direction
of the Atlas Mountains, Murray & Wilson 967 found no evidence or record
of goitre in this area. The mean iodine content of four samples of water
from the supplies used by the Khouribya settlement was 10 µ,g per litre, a
relatively high amount which would probably account for the absence of
thyroid disease in this area of endemic fluorosis.
Madeira and Canary Islands

With regard to the islands lying off the north-west African mainland,
goitre is said to be rare on Madeira 8 but rather prevalent on Santa Cruz
de la Palma, one of the most westerly islands of the Canary group.
Hernandez Feliciano 968• 969 examined 274 cases (13 men and 261 women,
the great majority of whom were in middle adult life) from 14 localities
and found that the dominant clinical characteristic was one of hyper-
thyroidism. A map giving the distribution of the 274 cases shows that
the disease is not localized but may be found all round the island at widely
separated places:
Santa Cruz 86 Tazacorte 30
Brefia Alta 8 Tijarafe 2
Brefia Baja 4 Puntagorda 5
Mazo 32 Garafia 8
Fuencaliente 1 Bari oven to 2
El Paso 13 Puntallana 7
Los Llanos 54 San Andres 22
Later, he extended his survey to 1104 schoolchildren among whom
he found goitre rates of 46.3 % in 575 girls and 35.5 % in 529 boys. 969
La Palma is a mountainous island of underlying basaltic structure
covered by a thick cap of porous volcanic rock and profusely encrusted
with lava, tuff, and banks of sand. The iodine content of the drinking-
water, derived chiefly from springs, is exceedingly low; values for samples
drawn from nine different localities ranged from 0.11 µ,g to 0.87 µ,g per
litre, with an average of 0.27 µ,g per litre. Hernandez Feliciano stresses
the need for prophylaxis by means of iodized salt.
His study is impressive refutation of the common belief that coastal
areas and sea-girt islands are goitre-free.
French West Africa a

Of all national goitre surveys none has been bolder in conception,
vaster in area, more exacting for the surveyors, and in its results more satisfy-
a At the time when the survey described under this heading was conducted, French West Africa was
sti1J a poBtical entity.
PREVALE CE AD GEOGRAPHICAL DISTRIBUTION 119
ing for its promoters and for the reviewer than that conducted by the
medical officers of the Government Public Health Service in French West
Africa under the impetus and direction of Dr Leon Pales. 971-977
The former Federation of French West Africa embraced the following
eight separate territories: Mauritania, French Sudan, Upper Volta, Niger,
Senegal, French Guinea, Ivory Coast and Dahomey; it covered an area
of more than 1 800 OOO square miles (4 600 OOO km 2) , nearly nine times
that of continental France, and had a population of about 16 OOOOOO.
During the year 1948 the medical administration examined 3 162 039
people, of whom 153 591 were found to be goitrous, that is, 4.86 %- At
that time Pales 971, 971 concluded from these statistics that there were pro-
bably not less than 700 OOO sufferers from goitre in all French \Vest Africa.
A further investigation was made in 1950 to fill gaps left in the 1948
inquiry and to complete as far as possible the detailed map of distribution.
The number of Africans examined has now risen to 4 449 040, of whom
371 205, or 8.3 ; , \Vere found to be suffering from endemic goitre. If this
new knowledge be accepted as the basis of a general estimate, it will be
seen that rather more than 1 300 OOO people are afflicted with goitre in
this area and that Pales' earlier figure of 700 OOO was an underestimate. 976
Excellent maps prepared by Pales & Tassin de Saint Pereuse on a scale
of 1: 2 OOOOOO and printed in five colour gradations from yellow to dark-
brown show the distribution and varying intensity of the endemic in French
West Africa and also the names of the tribal races occupying the affected
locations. 972, 975, 976 Looking across the map from west to east and south-
east, the following areas stand out as the most goitrous:
Senegal
Rates of 14 1 to 40 · are common in the cantons in low-lying east
Casamance on the banks of the Songrougrou and Casamance rivers just
south of the Gambia. High rates are also found around Dialakoto on the
upper waters of the Gambia river.
Guinea
There are centres of high prevalence (from 12 ;,; to 30 ;;) throughout
the Fouta Djallon mountain region, which covers practically the whole of
the central part of the territory. Farther east, rates of 20 1 , 40 ; and 50 %
occur in some of the cantons around the town of Siguiri. To the south of
Guinea, where it borders on Liberia and the Ivory Coast, the endemic is
severe around Macenta, Beyla and N'Zerekore.
French Sudan and [Jpper ·valra
The goitre area at Siguiri continues eastwards without interruption
through the southern part of French Sudan and into the territory of Upper
Volta. Among strongly affected areas are those adjoining the towns of
Bougouni, Segou and Koutiala in the Sudan, and an extensive reg10n
encircling the town of Dedougou north of Bobo Dioulasso in Upper Volta.

The most northerly focus in this general area, and indeed one of the most
severe in all French West Africa, lies near Bandiagara about 200 miles due
south of Timbuktu. Here, eight communities register rates of 40 % to 73 %.
Ivory Coast
The principal goitre centre in this territory lies in the mountainous region
of Man. It forms part of the Beyla and N'Zerekore belt in southern Guinea
and shows rates of anything from 10 % to more than 40 %. Another prom-
inent focus lies to the east-centre of the country immediately north of
Katiola 200 miles from the sea, where rates of 31 % and 42 % have been
recorded in the cantons of Fondebougou and Kembigue, respectively.
Dahomey
This narrow strip of territory in the south-east is not so seriously affected
as some of the other territories that made up the Federation. Nevertheless,
there are centres of goitre in the north around Natitiagou and Kandi, and
also on the right bank of the Niger opposite the Canton of Gaya.
Viewing former French West Africa as a whole, there would appear to be
more goitre in mountainous regions than on the plains. But prevalence has
not necessarily any connexion with altitude; thoroughly investigated villages,
in which a very high prbportion of the inhabitants were examined, have
shown rates of 30 %, 40 %, 50 % or even more, whether situated in moun-
tainous country or on the plains, in savanna or in the forest. Two facts,
however, may be regarded as axiomatic: goitre is extremely rare on the
Atlantic sea-coast and is likewise extremely rare in the regions of the Sahara.
Indeed, in this part of Africa goitre is practically non-existent north of
the 14th parallel, a line which constitutes an almost rigid east-west barrier
between the goitrous and non-goitrous zones. The territories of both Mauri-
tania and Niger lie north of this parallel; almost no goitre is found in either.
An arresting explanation is advanced by Pales 971, 974 for this remarkable
phenomenon of disease-geography. For the most part, the highly endemic
zones are sited upon soil foundations of granito-gneiss-a fact confirmed
by Wilson in her later survey of Sierra Leone. 988 Pales, however, does not
pay so much regard to this immutable geological consideration as to the
fact that in the area covered by his survey, the greater part of which lies to
the south of the 14th parallel, the goitrous terrain is precisely the area in
which the native peoples are dependent for their supplies of cooking and
seasoning salt on " pot-ash " derived from the incineration of local plant
foods, and are by reason of economic and transportation difficulties pre-
cluded from access to natural sodium chloride derived from sea-water by
solar evaporation at coastal centres or from the rich salt-producing areas in
the south Sahara. 971, 974
There is little need, Pales says, to suppose a one-time sea in the Sahara
to explain the possible presence in the Sahara salts of sufficient iodine to
confer goitre immunity on the peoples inhabiting that particular zone or

any zone to which Sahara-produced mineral salt becomes available in the
natural course of trade. The fact is, however, that the Sahara salt trade-
routes have never penetrated much below the 14th parallel. 973 Peoples
long established south of that line have for the most part been dependent
on vegetable salts that are rich in potassium but may contain little iodine, or
indeed, as Pales postulates, may possess a subtle goitrogenic agent as yet
unidentified. Inquiries to settle these unanswered questions are proceeding.
In the territories of former French West Africa goitre is about twice as
prevalent in women as in men; it is more frequent in adults than in children.
According to Denoix, 970 whose investigations apply principally to the Upper
Volta, the age of greatest frequency extends from 10 to 30 years, with a
maximum tO\vards the 15th year, that is to say, about the period of puberty.
The largest goitres are seen in old women. It cannot be stated with cer-
tainty whether diffuse parenchymatous goitres or nodular goitres are the
more prevalent, but it is probable that the diffuse type is the commoner.
Cases of hyperthyroidism are exceptional, and in the statistics cancer of the
thyroid is very rarely noted.
Goitrogenic cruciferous plants, more particularly the genus Brassica
(cabbages, turnips, kale, etc.), do not figure in the native dietary. Indeed,
the soils of this region of Africa are of a type far from being favoured by
the Cruciferae. Consequently, these are few in number and variety, and,
oddly enough, the ones that do occur are found mostly in zones free from
goitre.
Prophylactic trials with iodized salt are in active progress and have
already given highly promising results, especially at Macenta in Guinea
just north of the Liberian border. 977 Pales hopes that these first demonstra-
tions of the efficacy of iodine as a goitre preventive are but the prelude to the
systematic iodization and distribution of commercial marine salt extracted
in the salt works of the Sine Saloum at Koalack, in Senegal, where the
present annual production amounts to 50 OOO tons and could be increased
without any difficulty. Various grades of salt marketed in jute bags from
the Koalack factory, and fortified with iodide and iodate at t\vo different
levels, have been subjected to storage and transportation tests. 979 Coarse
salt fortified with iodate is the most satisfactory, inasmuch as iodate does
not migrate to the sides and bottom of the bag. Even so, the problem of
iodine loss has not yet been finally solved; more than half the iodate in
coarse salt disappears within 3 months of storage under inland climatic
conditions.
Besides spreading over extensive tracts of country in former French West
Africa, the goitre belt in this part of Africa also extends into the territories
of Gambia, Sierra Leone, Ghana (formerly the Gold Coast) and Nigeria;
it continues southwards through Cameroun into the hilly districts of
northern Angola. A map showing the distribution of endemic goitre in
relation to the geological occurrence of pre-Cambrian rocks throughout the

whole of West Africa is given by Wilson et al. 988
Gambia
Writers on goitre in this part of the world are wont to say that the
explorer Mungo Park 980 saw goitrous people in Gambia when making his
way to the upper waters of the Niger in 1795-96. He mentions having seen
cases in the Bambuk country and in the neighbourhood of Segu; but these
places lie hundreds of miles beyond Gambia to the east, and it is not certain
that Park saw goitre actually in Gambia itself.
That the disease does occur there, however, has been recorded by
Todd 999 and more recently by M. P. Hutchinson (personal communication
.to D. C. Wilson, 988 1952). The affected area lies in the upper river district
to the east where the pre-Cambrian granite formations begin, and is
obviously linked up with the Senegal endemic in the same region. It would
not be surprising, either, if goitre were found in the centre of the country
in the neighbourhood of Georgetown because, in Senegal, both north
and south of the Gambia river at this point, goitre is known to occur (see
page 119).
Sierra Leone
" Ballansama is a man of the middle size, of a jolly appearance, both
in person and expression, though a little disfigured by a large wen on his
throat, which appears a disease very common to the Koorankos." That
is how Laing 986 described the King of Northern Koranko whom he met
in 1822 when travelling through the interior of Sierra Leone to explore
the sources of the Niger. The Koranko country is goitrous today. In fact,
Sierra Leone provides an excellent example of how, in spite of energetic
studies at widely separated intervals of time and strong recommendations
for iodine prophylaxis on more than one occasion, only desultory efforts to
remedy the situation have as yet been made and goitre still persists.
During December 1923 and the early part of 1924, Blacklock 981, 982
and his wife made a strenuous three-month tour into the hilly regions of
the east and north through the tribal country of the Kono and Koranko,
where they found goitrous people in considerable numbers. Their findings
were fully discussed at a meeting of the Royal Society of Tropical Medicine
in 1925, when Blacklock. concluded his address with these words: " I am
particularly anxious to ascertain what is the experience of members of this
Society in regard to the administration of iodine to populations, because
if the risks are indeed negligible, it is our duty to take steps to deal with
the problem of goitre in our tropical possessions as soon as possible."
Almost exactly thirty years later, Wilson 988 traversed more or less the
same route, found high percentages of goitre where Blacklock found them,
showed that the affected areas coincide with the distribution of granitic
rocks of pre-Cambrian geological age, and correlated the prevalence of the
malady with low iodine content of drinking-water. In her paper to the
same Society, she makes the following comments: " There is thus a belt
of endemic goitre from Senegal to Angola which deserves the attention of
administrators and clinicians in order that appropriate remedial measures
may be instituted. The time [in Sierra Leone] is very favourable for the
introduction of iodized salt which is the easiest method of dealing with
goitre prophylaxis."
Both Blacklock's observations and those by Wilson a generation later
show that goitre is absent in the low-lying western parts of Sierra Leone
towards the coast; these goitre-free areas are situated on comparatively
modern geological formations overlying earlier rocks. In the upland eastern
section of the country the endemic affects the Mende, Kissi and Kono
peoples dwelling in the Kenema, Kailahun and Kono districts of the
South-Eastern Province. Among Kono men and women a rate of 56 %
was noted by Wilson; the thyroid gland was frequently much enlarged,
multinodular and cystic, and obvious goitre was sometimes present in
young children, but no case of congenital goitre was seen. Farther north,
the disease occurs among the Koranko living at the base of the Loma
Mountains and in the Koinadugu district of the Northern Province where
a rate of 71 % has been recorded by Mcintyre 987 in Bendugu village.
On a route from the south to the north of the goitre areas a traveller
would pass through the following places of high incidence Jiama, Paya,
Kaiyima and Yaiya in the Kono country, and Saywaia, Kruto, Banda-
karafaia, Kimadugu, Bendugu, Kaballa and Dankiwalli in the Koranko
country. These villages all lie at the head-waters of the Sewa, Bagwe and
Rokel rivers on the watershed between Sierra Leone and the sources of
the Niger in Guinea.
As already mentioned, the areas of endemic goitre in Sierra Leone are
associated with pre-Cambrian granite rocks which have become altered
by intensive weathering under tropical conditions. It would appear that
the chief factor influencing goitre distribution is that these rocks have
gradually been deprived of iodine by leaching and that, in consequence,
the waters issuing therefrom have an exceedingly low iodine content.
Wilson and her colleagues 988 give the following figures:
Goi:re rme Iodine content
o f water
(.ug- per litre)
Highlands (to the east):
Koinadugu (Koranko) 42.9-71.0 <1.0
Kono . . . . . . . 55.9 <1.0
Kenema and Kailahun . 19.0-2-U <1.0
Lowlands (to the west):
Kambia-Port Loko area no gc,itre 1.0-2.8
Moyamba-Bo area . . . r.o gc,itre 4.3
Goitre was found to be endemic where the waters contained less than
1.0 µg of iodine per litre, but was not recorded where the iodine content
was 2.4 µg per litre or above. Sea-fish, the other important source of
dietary iodine, is obtainable by most people near the coast but is rarely
eaten in the more distant inland areas where goitre occurs. Another factor
which, according to Wilson, may contribute to the causation of goitre in
Sierra Leone concerns the intake of vitamin A from red-palm oil. It will
be recalled that Haubold 603 found a high prevalence of goitre in mountain
villages in Bavaria associated with a low intake of vitamin A and carotene.
In Sierra Leone the intake of fats is generally speaking adequate and that
of vitamin A from red-palm oil is high. But the availability of red-palm
oil depends on oil-palm density, which in the goitre areas of Kono and the
adjacent Koinadugu country is not nearly so high as elsewhere, and supplies
suffice only for a short season. It is possible that this seasonal scarcity may
help to precipitate goitre in places where the iodine content of the diet is
already precariously balanced on the borderline between sufficiency and
insufficiency.
Ghana
In the extreme north of the Northern Territories of Ghana goitre has
been noted by F. C. Rodger (personal communication to D. C. Wilson, 988
1953) on the banks of the Red Volta and also for 50 miles along the Sissili
river, a northern tributary of the Volta. He describes the goitres as " colloid-
looking" and, in one place, as being associated with fluorosis. In this
same general area goitre has also been observed by B. B. Waddy (personal
communication to D. C. Wilson, 988 1954) near the junction of the Red
and White Volta rivers and in the Navrongo and Bawku districts close to
the boundary between Ghana and the Republic of the Upper Volta (form-
erly the Upper Volta Territory of French West Africa).
Nigeria and British Cameroons

When journeying through Nigeria in the early yyars of this century,
Tonkin 994 came across goitre in Gitata, a small pagan village perched
high on a rocky ridge, almost exactly in the centre of the country immediately
north of Keffi on the trade route between Loko on the river Benue and
Zaria some 200 miles northwards. Tonkin estimated that 20 % of the village
inhabitants were affected, some with very large goitres. He saw no sign
of the disease in the valleys on either side of Gitata.
Several later and more or less casual observations have been made
from time to time-notably by Denfield, 990 who has vividly portrayed the
goitres seen in the Bauchi Plateau in a series of remarkable photographs-
but it was not until 1951-53 that Wilson and her colleagues 989, 995-997
correlated the various scattered pieces of information, added to them, and
presented a picture of the Nigerian endemic as a whole.
Broadly speaking, the geological layout of Nigeria consists of three

upland areas of pre-Cambrian granite-one in the north, one in the south-
west, and one in the south-east-separated from each other by belts of
marine sediment lying roughly in the form of a letter Y across and down
the middle of the country. These belts follow the great valleys of the rivers
Niger and Benue, the one flowing from the north-west and the other from
the north-east along the converging arms of the Y to meet at Lokoja and
thence sweep southwards to the sea as one.
The goitrous areas invariably lie on the granites of the pre-Cambrian
complex, or in districts dependent on waters derived from these rocks.
Goitre is absent on the marine sediments of the Niger-Benue river basins.
The central plateau in the cup of the Y, an area studied by Wilson more
intensively than any other, is of special interest inasmuch as basaltic and
lava flows of Tertiary and Recent Age cover part of the granite. Here,
families living or farming on the basalt are free from signs of goitre; they
obtain much larger yields of crops. For example, the Vom section of
the Berom tribe live on granite but farm on basalt and are mostly non-
goitrous; but another section of the Beroms, not far away at Forum, live
and farm on granite and have many goitrous women among them. Simi-
larly, on the escarpment between Pankshin and Shendam to\'rnrds the south
of Plateau Province, and in the adjoining parts of Bauchi Province, goitre
is common among tribes using w·aters that drain off the granite formations
of the Naragota, Shere, Jarowa and Jere hills.
Wilson lists the goitre districts of Nigeria as follows:
.\'orthem Region
North-west and south of Sokoto East of Niger
North of Niger South and east of Zaria
East of Katsina West and south-east of Bauchi
West of Kano North and east of Benue
South of Bornu Many parts of Plateau Province
North-east of Ilorin East and west of Kabba
Western Region
North of Oyo North and west of Ondo
Eastern Region and British Cameroons
North of Ogoja Bamenda District and south of Yola
Western part of Mamfe Division
All these areas of endemic goitre lie on granites of the pre-Cambrian

basement complex, or are associated with waters which drain off these
rocks. The only exception, as explained above, is on the central plateau,
where an obvious difference in prevalence and degree of thyroid enlargement
(much less, if any at all) was found amongst aboriginal peoples living in
granite districts overlain by basaltic lava flows of more recent origin.
The prevalence in relation to the iodine content of the water-supplies
in these districts of differing geology is brought out in Table XI (Wilson 997).
TABLE XI. RELATION BETWEEN PREVALENCE OF GOITRE AND IODINE CONTENT

OF WATER-SUPPLY IN SOME PLACES IN NIGERIA
Place Source of water

Number of
subjects
Percentage
with
IIodine content
of water
I I examined I
goitre (µg per litre)
Zagun Older granite of

pre-Cambrian basement 162 46 0.6
complex 0.7
I I
Miango Basaltic lava flows of 150 Nil 5.0
I
Tertiary and Recent Age
I I I
Vom Pre-Cambrian granite, but -1
people farming mainly on 250 3 0.6
basalt
I
Abakaliki From deep water shaft.
I Marine sediments. Niger 301 Nil 92 *
river basin
* On lead-zinc mine; probably exceptional
The exact incidence of goitre throughout Nigeria is unknown. Among

Rukabi families in Zagun village, .Wilson found an average rate of 46 %,
the distribution being 32 % in adult men, 72 % in adult women, 23 % in
boys and 25 % in girls under 16 years of age. Hyperthyroidism is rare, but
cretinism and deaf-mutism are frequently seen. In Nigeria livestock are
moved about over wide areas, and the only recorded occurrence of goitre
among animals concerns a herd of pigs belonging to a bacon factory situated
in a district where human goitre is prevalent; the condition cleared up
following the administration of an iodine supplement.
There is no evidence that goitrogenic factors other than iodine-deficient
waters are operative in Nigeria. The endemic is not confined to regions
where vegetable ashes are used as salt, as is the case in former French West
Africa (see Pales 971, 973, 974). Local sources of salt are insufficient for the
country's needs; accordingly, imported salt is sold in Nigerian markets. The
question of making iodized salt the only type imported into Nigeria is being
considered by the Federal Medical Department. 993 Already, regulations pro-
hibiting the use of non-iodized salt have been made by Tiv, Nasarawa,
Zaria, Idoma, Igala, Donga and Takum Native Authorities in the Northern
Region. Iodized salt means salt to which has been added potassium iodide
in a proportion of not less than one part in fifty thousand.
Cameroun and French Equatorial Africa a
Two highly interesting zones of endemic goitre have been the subject of
study by doctors of the French Colonial Service-one in the Lom-Kadei
a At the time when the studies described here were conducted, Cameroun had not become an independent
republic and French Equatorial Africa stiJ( existed as a political entity.
TABLE XI. RELATION BETWEEN PREVALENCE OF GOITRE AND IODINE CONTENT

OF WATER-SUPPLY IN SOME PLACES IN NIGERIA
Place Source of water

Number of
subjects
Percentage
with
IIodine content
of water
I I examined I
goitre (µg per litre)
Zagun Older granite of

pre-Cambrian basement 162 46 0.6
complex 0.7
I I
Miango Basaltic lava flows of 150 Nil 5.0
I
Tertiary and Recent Age
I I I
Vom Pre-Cambrian granite, but -1
people farming mainly on 250 3 0.6
basalt
I
Abakaliki From deep water shaft.
I Marine sediments. Niger 301 Nil 92 *
river basin
* On lead-zinc mine; probably exceptional
The exact incidence of goitre throughout Nigeria is unknown. Among

Rukabi families in Zagun village, .Wilson found an average rate of 46 %,
the distribution being 32 % in adult men, 72 % in adult women, 23 % in
boys and 25 % in girls under 16 years of age. Hyperthyroidism is rare, but
cretinism and deaf-mutism are frequently seen. In Nigeria livestock are
moved about over wide areas, and the only recorded occurrence of goitre
among animals concerns a herd of pigs belonging to a bacon factory situated
in a district where human goitre is prevalent; the condition cleared up
following the administration of an iodine supplement.
There is no evidence that goitrogenic factors other than iodine-deficient
waters are operative in Nigeria. The endemic is not confined to regions
where vegetable ashes are used as salt, as is the case in former French West
Africa (see Pales 971, 973, 974). Local sources of salt are insufficient for the
country's needs; accordingly, imported salt is sold in Nigerian markets. The
question of making iodized salt the only type imported into Nigeria is being
considered by the Federal Medical Department. 993 Already, regulations pro-
hibiting the use of non-iodized salt have been made by Tiv, Nasarawa,
Zaria, Idoma, Igala, Donga and Takum Native Authorities in the Northern
Region. Iodized salt means salt to which has been added potassium iodide
in a proportion of not less than one part in fifty thousand.
Cameroun and French Equatorial Africa a
Two highly interesting zones of endemic goitre have been the subject of
study by doctors of the French Colonial Service-one in the Lom-Kadei
a At the time when the studies described here were conducted, Cameroun had not become an independent
republic and French Equatorial Africa stiJ( existed as a political entity.
area to the east of Cameroun (formerly French Cameroon) and the other at
Koumra, which lies between the rivers Chari and Logone-Pende about
60 miles west of Fort Archambault.
Cameroun
There is goitre in the Barnum country in the west of Cameroun and also
in the mountainous region occupied by the Wandala tribe in the north; but
the most seriously affected area lies between the rivers Lorn and Kadei in
the east of the country. This was surveyed in detail by Masseyeff 1001, 1002
in 1953.
The area is formed entirely of primary granitic material of pre-Cambrian
age, with the exception of the semi-metamorphic series of schists and quart-
zites in the valley of the Lorn. The south is a region of forest, very dense
in some places, and the north is to a great extent covered by a savanna of
Jmperata cylindrica. The soil is poor and the area is sparsely populated
with a total of about 100 OOO inhabitants in a density of the order of 1.85
persons to the square kilometre. This section of Cameroun is crossed by
two great intercolonial travel routes, one running from west to east through
Bertoua and Batouri, and the other from Bertoua to the north through
Betare-Oya and Garoua-Boulaye. It is in these places and in other villages
and settlements along the two thoroughfares that goitre occurs.
Masseyeff investigated five localities: the villages of Garoua-Boulaye
and Betare-Oya in the savanna region of the north; certain villages, also
in the savanna, situated on or near the north-south route from Betare-
Oya to Bertoua; the villages of Yanda, Kanda and Mbeth in the forest
region immediately to the west of Bertoua; the western environs of Batouri
where the villages of Bakombo and Ndimbo lie in open forest near the
savanna; and some forest villages situated in clearings in the region of
Ngelebok. A total of 4397 men, women and children were examined; the
results are shown in Table XII.
These figures show that the disease is extremely prevalent, especially
in women. It appears, too, that it is most severe at the boundary between
savanna and forest and tends to avoid true savanna and deep forest. All
the very dense goitre zones are on granite soils; the endemic diminishes in
areas where the soils are derived from gneiss, schists and other metamorphic
rocks.
Nodular goitres are much less common than diffuse goitres, some of
which are, of enormous size, " greater in volume than the heads of the in-
dividuals bearing them ". Consequently, deaths due to tracheal compression
are frequent. Hyperthyroidism is rarely, if ever, seen. Those who know
the country well say that the people are particularly lethargic and indolent
wherever goitre is most in evidence. Every small village has one or two
goitrous cretins. These pathetic creatures live an alm::ist purely veg;;tative
TABLE XII. PREVALENCE OF GOITRE IN SOME LOCALITIES OF CAMEROUN
Males Females
Locality
examined with goitre examined with goitre
I I
Savanna region (north)
Garoua-Boulaye and
Betare-Oya 451 29.9 135 50.4
On route from Betare-Oya to

Bertoua 501 59.3 408 76.0
Forest region (south)

Environs of Bertoua (to west) 745 54.9 933 72.9
Environs of Batouri (to west) 341 51.9 273 82.4
Region of Ngelebok 382 37.7 228 50.0
Total 2420 48.0 1977 70.7

I I
existence, insensible of their surroundings and unable to do more than eat

and sleep. In this region, too, goitre is of common occurrence among goats,
and hunters report having killed goitrous rabbits.
Masseyeff could prove no definite relationship between the occurrence
of goitre and the consumption of any particular food such as groundnuts
or maize, although it seemed to him that the zones in which maize is grown
and consumed coincide very well with those of high goitre rates. The young
shoots of the alimentary herb " sissongho " (Pennisetum purpureum) are
much appreciated by both man and beast in this district and it would be
interesting to inquire by laboratory experiment whether this food has any
goitrogenic properties.
At one time salt made from incinerated vegetable material was extensively
used, but it has long been abandoned in favour of imported salt. The
prevalence of goitre has not thereby diminished; consequently, the hypo-
thesis advanced by Pales 971, 973, 974 that vegetable salt contains a goitrogenic
principle does not appear to Masseyeff to be applicable in Cameroun. He
advocates the introduction of iodized salt, with potassium iodate as the
iodizing agent.
Koumra
On a journey from Algiers across the Sahara and down through French
Equatorial Africa by way ofTamanrasset, Agades, Zinder and Fort Lamy
as far as Bengui on the border ,of the Belgian Congo, Dupont 1000 saw goitres
in many places; but nowhere were they so numerous or so massive as in the
neighbourhood of Koumra, which lies at the centre of a subdivision of the
Region of Mayen-Chari between the rivers Chari and Logone-Pende not
far west of Fort Archambault.
PREY ALENCE AND GEOGRAPHICAL DISTRIBUTIOC"l 129
Here, in the heart of the country of the S a r a s - a beautiful, well-built,

easy-going, brave and devoted people-goitre (called locally " Kaa" or
" Kanreu ") has long been notorious. Bouilliez, director of trypano-
somiasis investigations at Fort Archambault, described and mapped the
endemic area in 1916, noting that about 80 % of the population were
affected. 999 His successor, Muraz, 1003-1005 confirmed Bouilliez's observations
in 1922, added to them, and published his most recent comments on the
goitres of this area in 1943.
Dupont found it exceedingly difficult to establish the exact over-all
percentage prevalence of goitre among the Koumra people, but could fix
it definitely at 75 % among men presenting themselves for medical examina-
tion prior to military service. Since, as elsewhere, goitre in Koumra is
found more frequently in women than in men and also occurs in children
of quite tender age, Dupont concluded that practically the entire Koumra
population suffers from the disease. This is in marked contrast to the
estimated rate of 2.5 % in the Region of Moyen-Chari as a whole, and less
than 1 % in the Region of Ombella-M'Poko, about 300 miles farther south,
where a general survey of 51 villages in the Bangui area was carried out by
Nimier at Dupont's request.
Although the Koumra goitres are seen more often in women than in
men, Dupont found goitre more prevalent in boys than in girls. The goitres
in females do not make their first appearance at the time of puberty; they
are either earlier or later. During pregnancy the swelling markedly increases
in volume but diminishes after the accouchement. Some goitres reach an
enormous size. The average neck circumference of a well-built non-goitrous
adult Sara is 14-15 inches (36-38 cm) in a man and rather less in a woman.
In goitred people Dupont found circumferences of nearly 23 inches (58 cm)
in a woman of 20, and 22.5 inches (57 cm) in a man of 25 years of age.
Goitrous children had neck circumferences of 14.5-16.5 inches (37-42 cm)
and an infant of 18 months with thyroid enlargement had a neck measure-
ment of 11 inches (28 cm).
Cases of goitre in children under 5 or 6 years of ag are exceptional;
most frequently the goitre becomes manifest about the age of 20 years and
in some instances its development may be very slow, extending over 20,
30 or even 35 years. These slowly evolving tumours are a common cause of
sudden death due to asphyxia; the unfortunate sufferer, apparently in good
health on falling asleep, will without warning be seized by suffocation during
the night and die rapidly. The other usual complications of goitre-hyper-
thyroidism, myxoedema, cancer of the thyroid-are rare in Koumra.
Bouilliez considered that the origin of goitre in Koumra lay in the
parasitic infection very prevalent in that area. 999 :Muraz 1003-1005 also held
the same view, but obsen-ed a definite ethnical predisposition inasmuch as
the people of the Baguirmian-Hausa colony, who had at that time been
living alongside the Sara people for 20 years and had been using the same
drinking-water from deep wells, did not present a single case of thyroid
enlargement; they were entirely free from the disease. Dupont, 1000 on the
other hand, regards causation as wholly a matter of water-supply. He was
struck by the fact that there is very little goitre in towns or villages situated
directly on the banks of rivers in the neighbourhood of Koumra. There is
none at Goundere on the river Mandoul only a few miles away. There is
practically none at Fort Archambault on the river Chari; all the goitrous
persons seen there came from the region of Koumra.
The drinking-water of Koumra is obtained solely from a group of
11 deep wells. One of them, no longer yielding much water but once the
main source of the community, has a depth of more than 120 feet (38 m);
another, now supplying most of the people, is 92 feet (28 m) deep. Dupont
inclines to the theory that goitre is infectious in origin; rivers are pure and
undefiled, being sterilized by the intense tropical sun, whereas waters from
deep wells, being deprived of the sun's beneficent action, retain all sorts of
impurities caused by the infiltration of infected products cast out by the
inhabitants, even into the wells, in spite of notices that this is prohibited.
Muraz 1004, 1005 first proposed prophylaxis by iodized salt in 1926, but the
scheme broke down through lack of co-operation. Dupont, 1000 writing
15 years later, believes that, for the time being at any rate, the goitre problem
in this part of the world can only be attacked by surgery or by the individual
administration of tincture of iodine or potassium iodide. The general
iodization of the sun-dried salt which comes in slab form into this area,
especially from Lake Chad, is, he thinks, impracticable. Worthy of mention
in this context-simply to emphasize local ignorance and futility in these
matters-is the native remedy of tying a piece of twine or a thong of antelope
skin tightly around the goitre in the hope of limiting its growth. A similar
Nigerian custom is described by Denfield. 990
The most recent (1958) goitre rates in former French Equatorial Africa,
as recorded by Bascoulergue, 998 are shown in Table XIII.
TABLE XIII. GOITRE RATES IN FRENCH EQUATORIAL AFRICA. 1958
Number
Territories examined Goitrous %
Chad (13 districts) 578 081 78 096 13.4
Oubangui-Chari (39 districts) 978 328 48 550 4.9

Moyen-Congo (29 districts) 408 266 2 305 0.5
Gabon (9 districts) 200 028 873 0.4
Total
I 2 164 703 129 824

In the territory of Moyen-Congo (now Republic of the Congo) the

district of Dongou had the highest rate with 10 % ; in Gabon the highest rate
was 7 % in north Koula-Moutou; and in the province (now Republic) of
Chad the highest rates were found at Koumra, Moissala and Kyabe with
36.4 %, 25.9 % and 12.7 %, respectively. Comparatively high rates were
found in the province of Oubangui-Chari (now the Central African
Republic) particularly at Bozoum (20.3 %), Bakouma (16.5 %) and at
Bangassou (12.7%).
Angola
The West African goitre belt, which, as already shown, begins in Senegal
and extends southwards along the pre-Cambrian foundations of the Gambia
through Sierra Leone, the Ivory Coast, Ghana, Dahomey, Nigeria and
Cameroon, eventually reaches Angola, where the disease has been noted
near the diamond mines in the north-eastern parts of the country by A.
Warwick (personal communication to D. C. Wilson, 988 1954).
Goitre is also found in the elevated plains of Benguela which rise east-
wards towards Huambo in the west-centre of Angola. Here, Leitch 1006
mentions especially one hilly district which is named " Goitre Mountain "
owing to the fact that practically all its inhabitants are affected.
Just outside the extreme south-east border of Angola runs the narrow
Caprivi Strip connecting South-West Africa with Rhodesia and separating
Angola from Bechuanaland. B. T. Squires (personal communication, 1955)
reports a high prevalence in the strip and has seen cretinism there. Since
goitre knows no political boundaries it may be taken for granted that the
endemic spills over into Angola at this point (see also page 144, Steyn
et a1.1os5).
Egypt
More than thirty years ago Dolbey & Omar 1007 drew attention to the
fact that up and down the valley of the ile simple parenchymatous or
colloid goitre is extremely common among the fellaheen-the farmers or
field labourers of Egypt-who make up about 80 · of the total population.
At that time hyperthyroidism was scarcely ever seen among the feliaheen,
but there were increasing and disquieting signs of it among the cosmopolitan
inhabitants of the tO\vns and among Egyptians of wealth and leisure who,
from considerations of taste or of employment, lived in the larger cities
and had adopted European habits and diet.
Recent research by Ghalioungui 1008 has entirely confirmed the frequency
of thyroid disease in Egypt. In a series of 892 patients seeking treatment for
endocrine disorders of various kinds he found 643 " thyroid cases " (72 %)
and of these more than half ,vere hyperthyroid. In Ghalioungui's view the
general prevalence of thyroid disease in Egypt must be higher than these
figures indicate because most people suffering from simple uncomplicated

goitre do not come for consultation; only those who experience toxic
symptoms present themselves.
Goitre is said by Dolbey & Omar 1007 to have been known to the ancient
Egyptians and to have been depicted on their monuments, reliefs and
drawings; but Ghalioungui can find no confirmatory evidence of this in the
works of archaeologists and authors who have studied ancient Egyptian
civilization from a medical standpoint. 1011 The picture of Cleopatra in
Ruffer's Studies in the Palaeopathology o fEgypt (1921) cannot be considered
a portrait, and the slight bulge in the neck region is possibly an exaggeration
due to the high-relief technique practised by Egyptian carvers of that epoch.
Nor, in a fairly wide experience of old Egyptian monuments and their
reproductions does Ghalioungui remember having seen a cretin, a hypo-
thyroid, myxoedematous, or goitrous person represented. However, there
is no reason to believe, he says, that goitre did not exist among ancient
Egyptians, since the conditions of soil, food and water that prevailed forty
centuries ago must have been very much the same as those existing today.
First to mention the endemic as distinct from the sporadic occurrence of
goitre in Egypt was Ibrahim, 1012 who found it in the villages of the Dakhla
Oasis, which lies 200 miles west of Luxor and 350 miles south of Alexandria.
The village with the highest goitre rate was El Qalamun, where 18 % of the
men had goitre and 3 children out of 35 examined were definite cretins.
Other villages were less seriously affected, but there was a rate of 6 % among
adult males at Mut and cases were also seen at El Gedida, and at El Kharga
in The Great Oasis to the east of Dakhla. It was not possible to examine any
women.
Further and more up-to-date information about the goitre endemic in
the Dakhla Oasis is available in two surveys made by Ghalioungui, the
first in 1951 and the second in 1955. 1009 · 1011 The results of the second survey
are summarized in Table XIV:
TABLE XIV. PREVALENCE OF GOITRE IN THE DAKHLA OASIS, 1955
Mut El Qalamun El Rashda El Gedida El Moushia

Age-group I I
A
I
B
I c I A
I
B
I c Al B
I c I A
I
B
I c IA I B
I c
Under 10 years 34 Nil Nil 73 18 25% 9J 14 15% 45 17 38% 65 9 14%
10-15 . 6 2 33% 15 8 53% 23 11 48% 7 4 57% 1 Nil Nil
15-20 . 7 5 71% 1 Nil Nil - - - - - - 1 Nil Nil
Above 20 . 20 2 10% 38 10 26% 17 1 6% 86 39 45% 13 1 8%
Tota •. 67 9113% 127 36 28% 130 26 20% 138 60 81 10
I
112%
143%
I I
A = number of people examined; B = number with goitre; C = percentage with goitre
Goitre is common in all parts of the oasis. The highest over-all rate
(43 %) is seen in El Gedida and the two lowest in Mut (13 %) and El Moushia
(12 %). The condition most frequently occurs between the ages of 10 and
15 years, and the age-group that seems to suffer least is that over 20 years;
this may be partly accounted for, however, by the fact that the young men
regularly migrate to the Nile Valley towns when they come of age. The
general level of intelligence, initiative and activity is very low; defectives
were found in greatest number in El Gedida, the village with the highest
goitre rate. Obvious cretinism and myxoedema are rare.
Regarding the cause, Ibrahim 1012 says that, so far as the Dakhla Oasis
is concerned, contaminated drinking-water is out of the question; the
water comes from artesian wells at a great depth and is comparatively pure.
However, it contains large amounts of calcium and magnesium sulfate and
Ibrahim regards this as the chief causative factor. Ghalioungui 1011 also
agrees that in the oasis polluted water can be excluded from consideration.
On the basis of iodine analyses he holds that the cause of the Dakhla
endemic is, quite simply, the lack of sufficient iodine in the soil, water, local
salt, and agricultural products. This situation is aggravated by hard water;
the varying calcium, magnesium, manganese and chlorine content of the
different wells probably accounts for the different rates at different parts of
the oasis. Fish are unknown and are regarded as legendary animals.
Goitrogenic foods, such as cabbage, do not form part of the diet of the
oasis dwellers.
In the Nile Valley, on the other hand, polluted water is without doubt
the primary goitre-producing agency, in the opinion of Dalbey & Omar. 1007
People living in villages situated immediately on the banks of the Nile
drink the river water; it is comparatively clean and these riparian villagers
do not develop goitre as a rule. Thyroid enlargement occurs almost ex-
clusively among people living in villages away from the Nile where the wells
and irrigation channels are incredibly polluted. Similarly, Dalbey & Omar
found no goitre among the cedouin Arabs who drink from remote desert
wells yielding ,vater which is purity itself compared with that from the
grossly polluted pools, ,vells and canals in the villages of the fellaheen.
Sudan
At least five centres of endemic goitre have been located in the Sudan:
(I) on the Nile around Ed Darner in the orthern Province: (2) at Halfayet
el Melouk, a small village about 20 miles north of Khartoum; (3) in the
Upper Nile Province among the Neur and Shilluk tribes south-west of
Malakal; (4) in the mountains of Darfur Province to the extreme west of
the country; and (5) in a narrow strip of territory inhabited by the Azande
in the south-west.
The first and fourth of these endemic areas are of comparatively minor
importance. The second and third have recently (1956) been studied in
some detail by Ghalioungui et al. 1010, 1013 They examined a total of 809
people, ranging in age from infancy to more than 60 years, and found that
402 of them, or 49.6 %, had definitely enlarged thyroid glands. Sixty-five of
these subjects (16 goitrous) were seen at Halfayet el Melouk; the remainder
were located either in Malakai itself or in villages situated along the Bahr
el Zaraf (Giraffe river), Bahr el Jebel (White Nile), and Bahr el Ghazal
(Gazelle river) to the west and south-west of Malakai. The particulars are
shown in Table XV.
TABLE XV. PREVALENCE OF GOITRE IN TWO ENDEMIC AREAS IN THE SUDAN, 1956
Number Number Iodine content

Village of people Percentage
of goitrous of water
I examined people with goitre (µg per litre)
I I I
Halfayet el Melouk 65 16 24 -
Malakai 86 30 34 -
Bantiu 242 149 62 -
Leer 79 27 34 5.7
Fangak 102 34 33 2.4
-
Wankai
, 181
45
116 64
55 0.7
Tarnob 25
Miscellaneous 9 5 55 -
Total . . . .
I
809
I 402
I 49.6
The highest rate (64 %) was seen in adolescents between 10 and 19 years
of age, but there was also a 60 % rate among children below 5 years. Water
from three localities was examined for iodine content; samples from Tarnob,
where the goitre rate is high, had a very low content.
The fifth endemic area in the Sudan covers a tract of country approxi-
mately 200 miles long and 60 miles wide, lying roughly on a SE-NW axis
just where the Sudan borders on the Central African Republic (former
French Equatorial Africa) and the Belgian Congo. It includes such places
as Yambio, Naandi and Tambura, and is a region that presents features of
unusual interest to the student of goitre. These have been fully described by
Woodman. 1014 Throughout the area are found the sources and head-waters
of innumerable small streams flowing northward towards the Nile. The soil
is predominantly ironstone laterite with acid clay catenas. Limestone is
conspicuous by its absence. Sun-eroded areas are liable to become sandy
and to have much of the nutritive content of the thin soil layer leached out
and carried away by percolating water. Nevertheless, this narrow strip is
PREVALE CE AND GEOGRAPHICAL DISTRIBUTION 135
known as the " green-belt" because it contains the most fertile soil of the
region.
The most striking, and most puzzling, characteristic of the endemic is
the apparently strict territorial limits within which it is confined. On the
east the disease virtually disappears at longitude 29 ° ; proceeding 60 miles
to the north where rainfall is slightly less, where the streams increase in
size but diminish in number, and where the soil gets poorer, goitre becomes
less and less common and soon disappears; the western margin of the
endemic ends abruptly on the borders of the Central African Republic where
the streams run south-westward from the divide to join the M'Bomou
river and eventually the Congo; the same applies to the south, where the
streams run towards the Uele and the Congo.
Restriction of the endemic to this relatively small strip of 200 miles
by 60 miles is hard to explain on ecological grounds. As Woodman 1014
points out, the same kind of terrain, the same tribe and the same conditions
of diet exist to the east of longitude 29 ° , where the endemic stops, as pertain
in the heart of the endemic area. Similarly, why is it that only occasional
goitres are seen immediately south and west of the watershed where the
laterite soils are identical with those of the endemic strip ?
On an average about 3 % of the population have goitre and nearly 85 %
of cases are in women. The condition is commonest between the ages of
13 and 35 years, although there are many cases in girls of ten years and
younger; in one instance an infant in arms and a child of three and a half
were affected. Parenchymatous colloid goitre is the usual type but adenoma-
tous goitres are also seen. Hard nodular thyroids are occasionally met
with in patients bet\veen 40 and 60 years and are usually becoming malig-
nant. Many of the goitres seen in young women involute to comparative
normality but a large proportion attain a weight of 4-6 ounces (110-170 g);
sometimes tumours of 16-20 ounces (450-570 g) are seen. The almost
complete absence of true Graves' disease is a feature; in fact, the type of
goitre seen in this area is described by Woodman as the least toxic of all
known varieties. Cretinism and myxoedema are non-existent.
A presumption that within the endemic area the soils and waters lack
sufficient iodine to prevent goitre cannot, in \Voodman's view, readily
account for all aspects of the endemic in this district. Altitude, climate,
soil (as far as it has been investigated by chemists), flora, tribal inhabitants,
diet, and incidence of parasitic infection and other diseases continue to be
the same outside the affected strip; yet there is no goitre. Can it be, he asks,
that the virgin streams, after flowing for 50-60 miles through a leached and
sandy terrain, begin to derive iodine from rotting vegetation or other source?
Chemical determinations of iodine can alone answer this, and it would
seem of the greatest importance to have these carried out on samples of
water and soil from both inside and outside the goitrous area before indulg-
ing in further speculation.
Woodman concludes: " I t is hoped to make iodized salt available in all

the shops of the endemic area. It would be ideal if this could be the only
salt on sale."
Ethiopia and Eritrea

The high plateau of Ethiopia figures prominently as a focus of endemic
goitre in north-east Africa. In 1904 Singer 1020 made a journey from Khar-
toum up the White Nile and along the Sobat and Baro rivers into Ethiopia,
whence he ascended the plateau and traversed the whole country from west
to east as far as Djibouti in French Somaliland.
People with goitre were met with throughout the entire plateau, more
commonly on the west side than on the east, but none was seen at the point
of entry into Ethiopia, namely, in the flat country below the plateau where
the Sobat and Baro debouch from Ethiopia into the Sudan. This confirms
the observations of Balfour (see Blacklock 9 8 2 ) , who saw no goitre when
travelling on the Pibor river, a tributary of the Sobat, in 1903.
Singer's cases were usually enormous goitres of the parenchymatous
type, but adenomatous and other forms were encountered, and Graves'
disease was far from rare. Indeed, the fact that he more or less accidentally
came across six cases of typical Graves' disease-four in one f a m i l y - in a
brief journey through the country gave the impression that many more
would be found on systematic inquiry. Singer's description of the enlarged
blood-vessels coursing and throbbing over the surface of an enormous tri-
lobed growth pulling at the neck of an exhausted man of 27, seen at Gore
in the west of the country, is especially vivid.
Other earlier writers on goitre in Ethiopia include Merab, 1018 who saw
much of the disease at Tegoulet, Ankober and Djimema. He mentions
that a local method of treatment practised by the Gallas is to catch a live
porcupine and apply it to the goitre in the manner of a leech; its sharp-
pointed teeth puncture the gland in many places, drawing off great quanti-
ties of blood and a considerable amount of colloid fluid. In contrast to
Singer's observations, Merab regards exophthalmic goitre as exceedingly
rare in Ethiopia.
The most recent accounts of the Ethiopian plateau endemic are by Ange-
lini & Scaffidi, 1015 by Gasperini 1016 and by Grassi Bertazzi. 1017 Angelini &
Scaffidi became acquainted with the disease during service in the Italo-
Abyssinian campaign of 1936, when they were struck by the number of
goitrous women who came for treatment to their field hospital at Enda
Atzala Chercos.
Enda Chercos, or Christ's House, lies in the Atzala valley, one of many
goitrous localities found throughout the region of Enda Meconni in
southern Tigrai. The Enda Meconni endemic extends along the Alagi
mountain range from the plains of Mai Mescic in the north to the depression
of Mai Ceu in the south. Beyond this area to the south, Angelini & Scaffidi
saw goitre in the Provinces of Wollo and Shoa where it was particularly
evident at Debra Birhan and Ankober in the orbit of Addis Ababa. They
also refer to its prevalence in W ollega and Gojjam Provinces in the west
of the country.
The high plateau of Scioa, on which the goitrous foci of Debra Sina,
Debra Birhan, Ankober and Sciano are sited, has been closely studied by
Grassi Bertazzi. 1017 He stresses the poor rye-flour diet, lack of vitamins,
and adverse geochemical factors as contributory to goitre in this area.
Angelini & Scaffidi 1015 emphasize that it is almost solely the female sex
that is affected; they saw scarcely any goitre among men and regard the
predominance of cases in women as an indication of the mildness of the
endemic, arguing that in regions where the disease is exceedingly severe the
two sexes are affected almost to the same extent and, in addition, cretinism
and deaf-mutism are always very pronounced. They did not come across
any cretins or deaf-mutes.
On being asked their opinion as to the cause of the disease and the
reasons for its widespread occurrence among women, some of the Atzala
valley people insisted on the particular importance of family mourning,
which, in women, determines the cut of the hair; very often the commence-
ment of a goitre is attributed to the shaving of the head at the time of the
death of this or that relative. Others blamed the drinking-water, so often
fouled by the decaying bodies of land animals and birds. Mention was also
made of a stream in the vicinity of Mai Mescic north of the Alagi range
which bears the name Mai Gurguri (i.e., goitre water) because those who
habitually drink from it invariably contract goitre.
Initial attempts by Angelini & Scaffidi to introduce iodine preventive
measures were succeeded some years later by the more precise and systematic
efforts of Gasperini. 101 6 He was especially concerned with goitre along the
Eritrean border, \vhere the chief endemic centres are a few small villages
in the districts of Makale and Uagh, and in the neighbourhood of Adigrat.
Supplies of salt for this region are obtained in blocks from Massawa and
other places on the Red Sea coastal area of Dancalia.
Gasperini describes in detail the method by which this salt from the
Eritrean salars was iodized and explains how he overcame certain difficulties
connected with the process and with the subsequent distribution of the salt.
British Somaliland
Reporting in 1936 to the Economic Advisory Council's Committee on
Nutrition in the Colonial Empire, the medical authorities in British Somali-
land mentioned that they found some clinical evidence pointing to a possible
deficiency of iodine in the diet of the Somalis: but it would appear that
this cannot be very serious because the report specially stresses the distinctive
stature and physique of the nomad Somalis and the absence of any wide-
spread nutritional disorders. 1021
Uganda
Goitre does not appear to be a pressing problem in Uganda. Never-
theless, nearly every Baganda child examined by Dean 1022 at a primary
school in Kampala was found to have an enlarged thyroid. According to
:Oean no one has yet seen a Baganda cretin.
In his paper on goitre in the Belgian Congo, van Campenhout 1025 refers
to occurrences of the disease on the spurs of the Ruwenzori Mountains and
in the basin of the Semliki river between Lake Albert and Lake Edward.
As the Ruwenzori range and the river Semliki form part of the western
boundary of Uganda, this endemic area deserves mention here.
Tanganyika
There is little information about goitre in Tanganyika, but Trolli
mentions its occurrence " in the mountainous regions ". 1026 Since the context
in which he was writing concerned the Belgian Congo and, in particular,
the uplands around Lake Kivu and in the Ruanda-Urundi territory, it is
possible that he was referring to the mountains of north-west Tanganyika
immediately adjoining this area.
More recently, C. D. Williams (personal communication, 1954) has
recorded the presence of goitre specifically in the southern highlands.
Belgian Congo and Ruanda-Urundi

Four distinct and well-documented regions of endemic goitre exist in
the Belgian Congo. These cover: (1) an upland area in the north and
north-east; (2) the high mountain barrier separating the Belgian Congo
from Uganda and Tanganyika in the east; (3) the mountainous parts of
Katanga Province in the south and south-east; and (4) a smaller area in
the far west situated just south-east of Leopoldville. No goitre is reported
from the vast low-lying parts of the Congo river basin in the centre of the
country. De Smet's 1032 impression is that a prevalence of between 1 % and
2 % occurs all over the country, rising to 80 % in endemic areas of the north.
North and north-east
The first of these endemic regions extends throughout practically the
whole of the area bounded by the Ubangi-Uele rivers in the north and the
most northern stretch of the main Congo river. It thus occupies a strip
of territory about 600 miles in length, from Bangui and Zongo in the west
to Niapu and Panga in the east, and about 150 miles in depth from north
to south. Although the entire area is continuous so far as goitre occurrence
is corrcerned, it may conveniently be considered in three main sections-
west, centre, and east-by reason of the fact that the published literature
on the subject naturally divides itself in this tripartite way;
The western section, described more especially by Schotte,1o3s, 1039

Daloze,1026 van Campenhout,1025 Baudart,1023 and De Smet,1032 covers the
area watered by the rivers Ebola, Dua and Mongala. It includes the districts
of Banzyville and Yakoma on the river Ubangi, and its most heavily affected
focus is Abumombazi, which is situated at the headwaters of the Ebola.
The central section, referred to particularly by Rodhain, 1037 Trolli, 1026
van Campenhout, 1025 and De Smet, 1032 covers the area watered by the rivers
Uele, Likati, Rubi and Itimbiri. It includes the districts of Bondo on the
river Uele, and Aketi and Buta on the river Rubi.
The most easterly section of the endemic has been studied intensively
by De Smet 1030, 1031 but has also been visited by Rodhain.1037 It covers the
region watered by the rivers Lulu and Aruwimi, especially the triangle in
the neighbourhood of Yangambi formed by the Aruwimi and the right
bank of the upper Congo with apex at Basoko. Eastward extensions of
this goitrous area are found as far as Niapu near the source of the Rubi
and at Panga on the river lturi north-east of Stanleyville.
According to natives of this northern Congo area goitre is of fairly
recent origin there, and is said to date back only to about 1895. Van
Campenhout,1025 who spent much time in the Ebola-Likati area south and
west of Bondo during the years 1894-97, was never particularly struck by the
existence of the disease at that time; and Rodhain, 1037 who had lived in the
Ubangi region since about 1900, only mentions his first cases in 1912-15.
Following these early observations, reports of goitre occurrences mount up
rapidly and the survey-map of the Ebola-Dua-Likati area made by van
Campenhout in 1934 shows goitre rates of 20 %, 30 %, 50 % and 60 %-
Confirmatory data were given by Baudart 1023 in 1939, thus:
Number of Number Percentage
people examined goitrous goi1rous
North of the Ebola 4226 1649 39.02
South of the Ebola 4682 2442 52.16
Banks of the Uele 5661 345 6.09
In the Ebola region Baudart observed goitre quite frequently among
infants at birth; but it is of course more prevalent in adults, especially
women. To the east of this northern zone De Smet 1030 noticed an increasing
prevalence (from about 1.5 to 80 ; ) as he moved from Yangambi on the
right bank of the upper Congo northwards towards the Aruwimi river.
On the left (south) bank of the Congo at this point the people are reported
to be less afflicted by the disorder. The explanation given is that centuries
of rain have washed out all iodine from the soils on the northern bank
whereas the alluvial soil of the south bank is being constantly reinforced
with minerals from the river. Among dwellers immediately on the river
banks on either side, where much fish is consumed, there is no goitre. Toxic
goitre occurs in this area; and cases of goitrous fibroma in women are not
uncommonly accompanied by sterility, a condition considered to be asso-
ciated with hypersecretion of the sex hormone, folliculin (see also Velghe 1042).
East Congo and Ruanda-Urundi

Goitre centres have been found in various parts of the north-east and
east of the Belgian Congo, particularly on the spurs of the Ruwenzori
Mountains between Lakes Albert and Edward (van Campenhout 1025),
around Lake Kivu and in the Territory of Ruanda-Urundi at the head of
Lake Tanganyika (Demaeyer & Vanderborght 1029), and in the districts of
Lokandu and Kasongo (Kadaner 1035 and Velghe 1042) which lie on the river
Lualaba, respectively 200 and 350 miles south of Stanleyville.
Ruanda, with a population of approximately two million, was made the
subject of special study by Demaeyer & Vanderborght, 1029 who examined a
total of 22 801 people of the Bahutu and Batutsi tribes-about a thousand
from each of 22 different places. The goitre rate varied from 1.83 % to
28.37 % according to locality; it was higher among women than among men
and most goitres were of the parenchymatous type. Nodular goitre was not
observed in individuals under the age of 30, and no cretinism, deaf-mutism
or Graves' disease was seen.
The higher rates were usually found in places with a high rainfall and
situated on lava and basaltic rocks rich in magnesium, calcium and potas-
sium. Dry regions. on schists and quartzites had a low incidence. The
data for the 22 localities studied bring out this relationship (see Table XVI).
TABLE XVI. PERCENTAGE PREVALENCE OF GOITRE IN RELATION TO RAINFALL AND

NATURE OF ROCKS
Rainfall Schists Granite-Gneiss Lavas

(mm) and quartzites
I and micaschists
I and basalts
Below 800 4.66 - -

800-900 2.04, 2.09, 2.92 1.83, 3.68 -
1000-1100 3.74 4.04 -
1100-1200 7.30, 14.73 17.62 -
1200-1300 11.19 17.57, 23.25 14.60, 25.24
1300-1400 6.25, 12.40 19.31 23.00
1500-1600 - 22.00 -
1700-1800 - 28.37 -
It will at once be seen that in a general way the percentages of goitre

increase from top to bottom .and from left to right of the table, that is,
they increase with the degree of rainfall and, for the same level of rainfall,
with the proportion of potassium, magnesium and calcium salts in the rocks.
In Ruanda, " vegetable " salt used to be eaten but has been completely
replaced by ordinary salt and cannot therefore be associated with the
PREVALE:t-;CE AND GEOGRAPHICAL DISTRIBUTION 141
presence of goitre. Among the different vegetables eaten by the Bahutu and
Batutsi only one has any relationship with the Brassica genus; this is "isogo "
(Erucastrum arabicum ), but as it is in almost general use both in areas of high
and in those of low incidence, it does not seem that it can be incriminated as
goitrogenic.
The goitres mentioned by Kadaner 1035 at Lokandu in the Maniema
region occur predominantly in women and are not regarded as very serious;
those seen by Velghe 1042 among the Matapa at Kasongo were also mostly
in women, but apparently in this district sterility and goitre go hand in hand.
Lack of iodine in the soil and water is not considered to be primarily
responsible for the frequency of goitre here, since the disease is much less
prevalent in neighbouring communities living in an identical environment.
It is believed that the sterility among women is due to a conditioned defi-
ciency of iodine produced by an excessive secretion of the sex hormone,
folliculin, acting as a goitrogenic agent. Men are less affected with thyroid
trouble because their testosterone secretion is generally normal in amount
(see also De Smet 1030).
South and south-east

The southern endemic covers the greater part of the highlands of Katanga
Province. With its centre at Sampwe in the Kundelungu Mountains, where
prevalence is highest, it extends to Mwanza in the north, almost to Elisabeth-
ville in the south, as far east as Pweto on Lake Jvlweru, and westward
through Bukama, Kalule, Kamina and the Lomami country to the river
Lulua and the Dilolo area on the borders of Angola (Schotte; 103s, 1039
Trolli ;1026 van Campenhout ;1025 Calonne 1021).
The Sampwe district, examined closely by Calonne, 102-1 is situated in the
valley of the river Lufira, a tributary of the Lualaba. It is surrounded by
mountain masses yielding a multitude of small streams near to which are
established native settlements consisting chiefly of the Basela and Balomotwa
tribes. These people live a hard and frugal life, as a general rule sowing
only one crop on an impoverished soil, possessing fe,v if any livestock,
and all obtaining their drinking-water from the same mountain sources.
The disease is seen only at lower levels along the margins of the rivers
feeding the Lufira, not on the high plateaux. The over-all rate of established
goitre among 1118 natiws examined by Calonne was 24.5 { If 71 cases of
diffuse hypertrophy seen in young people about the age of puberty are
included in addition, the over-all rate increases to 30.8 %- 1'Ien were less
affected than women: out of 395 males of all ages there were 34 ,vith goitre
(8.6 %) compared with 240 cases among 723 females examined (33.2 %).
Certain districts were intensely affected, with rates among women of 50 % ;
nevertheless, as is not unusual in goitre country, some villages situated in the
very heart of the affected area were, inexplicably, entirely free from the
disease.
Toxic goitres develop in about 25 % of cases, and an interesting obser-

vation is that clinical signs of hyperthyroidism, especially in girls, are quickly
brought on by any unusual physical exertion-running a race, for example.
Congenital goitrous defects-idiocy, deaf-mutism and cretinism-are very
frequent in the Sampwe area.
Western Belgian Congo
Medical census of the population of the Province of Kasai towards the
west-centre of the Belgian Congo, and of the Lower Congo District in the
extreme west, reveals only isolated occurrences of goitre (Trolli 1026). There
is, however, a mildly endemic centre in the Foreami cercle of Popokabaka,
an area occupied by the Bayaka tribe about 150 miles south-east of Leopold-
ville. It covers the region watered by the rivers Kwango, Twana and Wamba,
and it extends to the Mosamba country east of the Wamba. Himpe &
Pierquin, 1033 Vande Voorde, 1040 and Delaunoy & Claeys 1028 are the author-
ities on this endemic.
The staple diet of the natives is " m o n w a " (cassava) and is the same
for all regions of the cercle. The yam is in fairly widespread use, and to a
lesser extent rice and maize. By way of condiments there are gourds,
peanuts, grasshoppers, caterpillars, a few cooked vegetables and pimento.
The survey by Himpe & Pierquin 1033 relates to a total of 36 316 persons in
the administrative sectors of Ngowa, Munene and Kabula among whom
they found only 303 goitres. The prevalence is therefore slight, being on an
average 0.83 % and nowhere higher than 4.25 %- Goitre runs very distinctly
in families, starting at an early age and developing slowly to maturity in
adult life. In regard to size, the 303 enlargements varied considerably and
are classified thus:
Pigeon's egg 78 Fist size 71
Hen's egg 90 Baby's head 16
Duck's egg 45 Football . . 3
There are few complications; goitre does not apparently influence
fertility, and hyperthyroidism if it occurs at all is not acute.
Finally, so far as the goitre geography of the Belgian Congo is concerned,
Perin 1036 has noted that the disease is frequent in the Kimvula area of the
Lower Congo to the west of Popokabaka. Here, the people are of poor
physique, anaemia is common, and there is marked lumbar curvature and a
high proportion of pelvic malformations in women, leading to difficulties
at childbirth.
The Rhodesias
The Districts of Serenje and Mkushi in the Central Province of Northern
Rhodesia are areas of endemic goitre. The region, occupied for the most part
by the Lala, a Bantu tribe, consists of a wooded highland plateau and a
PREYALE.,..,-CE A D GEOGRAPHICAL DISTRIBUTION 143
valley area. The majority of the Lala dwell in the highlands; the rest live in
the lowland valleys through which run the Lukusashi, Luangwa and Lun-
semfwa rivers, which receive the streams and tributaries arising on the
Zambesi side of the Congo-Zambesi watershed.
Beet 1041 made an exhaustive nutritional survey of 660 Lala children
at 17 schools in both plateau and valley areas. He found 38 % of children
with enlarged thyroids. The rate was higher in girls but the difference was
not marked. To the north-east of Serenje and Mkushi, but in the same
general area, lies Chitambo, where D. Mackay (personal communication,
1946) has reported the prevalence of goitre.
There is very little published information about goitre in Southern
Rhodesia but, according to W. R. Carr (personal communication, 1954),
the disease is endemic in many parts. This is confirmed by the decision
of the Government (1954) to consider the iodization of all crude salt,
of which about 10 OOO tons are consumed annually in Southern Rhodesia.
As this supply comes from a number of different local sources, the iodiza-
tion of all consignments presents an administrative problem. Enrichment
of crude salt with potassium iodate is carried out in Salisbury, but its
distribution can be extended only by improved health education. Refined
salt is now more popular in the Rhodesian market, and on this account
proposals have been made to import, or to produce locally, packeted
iodized table salt. 1045
Iodine deficiency among domestic animals in Southern Rhodesia has
been pin-pointed by Affleck 1043 in the Karoi area, on farms along the south
bank of the river Hunyani near Sinoia, and at Raffingora where also the
native population is goitrous. In this same area to the north of Salisbury,
Affleck has seen enlarged thyroids and skeletal deformities among foals in the
Umvukwe Range. Here, interference with iodine utilization due to the
high cyanogen content of wilted lucerne is believed to be a contributory
factor. After a particularly wet season in 1958, a sudden increase in the
number of cases of stillbirth and weakness at birth among goat kids was
reported at Victory Block between Raffingora and the Umvukwes; the
animals were born ,vith very large thyroids and were frequently hairless.
Union of South Africa and neighbouring territories
Following the general north-south pattern of this world survey, it

is convenient to treat the southern section of the African continent as a
whole. Accordingly, the Union of South Africa is considered together with
its neighbouring territories, more or less in the following order: the Caprivi
Strip, South-West Africa, Bechuanaland, Swaziland, and Basutoland.
The main centres, features, and causes of endemic goitre in this vast area
are fully documented and described by Steyn and his colleagues in the 1955
report of the South African Goitre Research Committee. 1065 Among others
144 C. F. KELLY & W. W. SNEDDEN
who have made notable contributions to knowledge of goitre in South

Africa are: Frack 10 51 (Transvaal); Blom, 104 6 Buttner 1047 and Schur Brown 1061
(Langkloof Valley); Dormer 1 049 (Natal); Le Riche 10 54 (Johannesburg);
Kark & Le Riche 10 52 (Orange Free State and Natal); and Steyn's collabor-
ators, Malherbe & Osburn. 10 5s- 10 s1
Eastern Caprivi Strip

As mentioned on page 131, goitre is prevalent in the narrow strip of
territory running between the south of Angola and the north of Bechuana-
land to connect South-West Africa with the Rhodesias. The Caprivi Strip
is some 200 miles long and 20-30 miles wide, with a total area of approxi-
mately 4500 square miles (about 11 500 km 2) and a population of about
15 OOO. The country is flat and very sandy, except in the most low-lying
areas which grow luxuriant crops. During the rainy season large tracts
are inundated. The nutritional state of the people appears satisfactory but
their standard of hygiene is low, and, owing to the marshy nature of much
of the country, malaria is rife.
In 1942, Annecke (see Steyn et al. 10 65 ) made a goitre survey of the
Eastern Caprivi Strip and reported that " anything above 70 per cent of
men, women and children show a simple enlargement which in older age
may become nodular (probably adenomatous) ". He found the disease
predominantly in females and suggested a relationship between its occur-
rence and the distribution of the manketti- or mungongo-nut tree. It was
subsequently proved, however, that the manketti nut has no goitrogenic
properties. B. T. Squires (personal communication, 1955) visited the south-
eastern portion of the Eastern Caprivi Strip in 1949 and reported a 50 %
goitre rate there; enlarged thyroid glands in breast-fed babies were no
exception. In this area manketti-nut trees are extremely rare.
The more recent observations by the South African Goitre Research
Committee (Steyn et al. 1065 ) confirm the high prevalence in the Eastern
Caprivi Strip, even among breast-fed infants and toddlers. The mean
goitre rate throughout the area is 50 %, but at Linyanti village it rises to
70 %. From the results of their investigations the Committee conclude
that the major cause of the endemic is a primary iodine deficiency in soil,
water and food, aggravated no doubt by the contamination of drinking-
water and general unhygienic conditions.
Western Caprivi Strip and South-West Africa

A goitre survey of the western portion of the Caprivi Strip, which for
administrative purposes falls under the jurisdiction of South-West Africa,
has been made on behalf of the South African Goitre Research Committee
by Kuschke. 1065 He found that the endemic of the eastern strip extends
westward and affects the tribes inhabiting the western end of the strip and
the adjoining areas of South-West Africa and Bechuanaland. Among the
Barakwengo, the goitre rate was almost 70 % ; among the Okavango,

62.6%,
Of all the enlarged thyroids examined by Kuschke only a few were
nodular and one definitely in an early carcinomatous stage. He attributes
the disease to iodine deficiency in the food, water and soil of the area and
recommends that iodized salt be supplied not only throughout the whole
of the Caprivi Strip but also to the tribes of the neighbouring Okavango
Native Territory.
For the rest of South-West Africa there are no definite facts, but Steyn
et al. 1065 suggest that as the subterranean waters in the southern semi-arid
regions of the country contain :fluorine, there is every likelihood that :fluo-
rine-induced goitre occurs there just as it does in the adjoining areas of
north-western Cape Province, also known to be :fluorine-rich.
Bechuanaland Protectorate
Goitre is seen in Bechuanaland only in the far north, where the country
marches the whole length of the Caprivi Strip. As already mentioned,
there is a high pre\'alence in this area, especially along the Linyanti river
to the east and along the Okavango river in the extreme north-west of the
Protectorate. Elsewhere in the country only occasional cases of goitre are
met with (B. T. Squires-personal communication, 1955).
Union o f South Afi'ica, Swaziland and Basutoland

Taking the Union, Swaziland and Basutoland as a whole, goitre is found
in the following five main areas :
1. Transvaal. A narrow belt stretching for 300 miles across Transvaal
from Zeerust in the west through Witwatersrand as far as Xelspruit in the
east. Places affected in this endemic area (from west to east) are: Zeerust,
Groot Marico, Kuilfontein, Koster, Rustenburg, Brits, Bronkhorstspruits
(just east of Pretoria), Belfast, Machadodorp, Waterval Boven, Elandshoek
Valley, Nelspruit and Barberton.
2. Swaziland. From the "Nelspruit and Barberton area of eastern
Transvaal the goitre belt curves southward and occupies practically the
whole of Swaziland.
3. Basutoland and the Drakensberg range. The entire Drakensberg
area, including Basutoland, is potentially goitrous. On the northern slopes
of the range the disease occurs at Witzieshoek in the Orange Free State.
On the eastern side it is found along Bushman's river and also in the Est-
court and Helpmakaar areas of Natal. Somewhat farther south on the
eastern Drakensberg there are occurrences at Impendhle, Polela and
Underberg. Goitre has also been noted in and around Blikana and Herschel
which lie at the foot of the \Vitteberg range in Cape ProYince just beyond
the southern border of Basutoland. Qumbu on the south-eastern edge of
10
the Drakensberg is another goitre centre falling within this geographical

group.
Exact information on the degree of prevalence of goitre in Basutoland
was practically non-existent until the report of a survey conducted in 1957-58
by Mufioz & Anderson 1059 recently became available. Seven of the nine
districts of the country were covered by the survey which involved the
examination of 13 284 individuals of both sexes, of all ages, and from
lowlands, foothills and mountains. An average prevalence of endemic
goitre (mainly diffuse) of 41 %, with a range of from 30 % to 50 % according
to district, was exposed. The problem is thus a serious one, and the authors
recommend the use of salt iodized at a level of I part of potassium iodate
in 10 000-20 OOOparts of salt.
4. Southern Cape Province. In the south-east of Cape Province goitre
occurs in the Winterberg area and in places along the river Kei, which rises
in these mountains. Fort Beaufort, to the south of the Winterberg, is a
goitre centre.
In the extreme south of the Province the whole of the region from
Prince Albert and the Groot Zwartberg eastward to,Humansdorp and Port
Elizabeth is a well-known goitre area. It includes (from west to east)
Schoemanshoek; the Outeniquas Mountains and the neighbourhood of
George and Knysna; Uniondale, Krakeelrivier, the Hoeree valley, Klein-
rivier, Joubertina, and other places in the Kouga Mountains and Langkloof-
Kouga river valleys.
In the south-west of Cape Province goitre has been noted at Villiersdorp,
Greyton and Caledon to the south-east of Cape Town; and also at Ceres
and Prince Alfred's Hamlet in the Hexrivierberg region to the north-east
of Cape Town.
5. North-western Cape Province. Goitre occurs throughout the entire
area from the coast at Port N olloth eastwards for 300 miles to Kenhardt.
This belt includes: Springbok, Nababeep and Ookiep; Poffadder; and
Kakamas and Upington on the Orange river. Another 200-300 miles to
the north and east of Kenhardt, the disease is found at such places as
Kuruman and Vryburg.
• Chemical analysis of water in these regions led Steyn et al. 1065 to conclude
that endemic goitre in the north-western Cape Province is chiefly due to the
general presence of goitrogenic quantities of fluorine and calcium in the
drinking-water and not to an inherent primary iodine deficiency. There
are, of course, exceptions. Areas exist in the north and north-western parts
of Cape Province where goitre is due, in a measure at least, to an absolute
iodine deficiency; this is the case, for example, at Upington and Kuruman.
And there is the fact, as yet unexplained, that the prevalence among scholars
at Port Nolloth and Vryburg is fairly high in spite of a very satisfactory
concentration of iodine and a minimal amount of fluorine in the municipal
water-supplies.
PREVALENCE Al\TI GEOGRAPHICAL DISTRIBUTION 147
The prevalence of goitre throughout the Union and neighbouring

territories of South Africa varies considerably. Malherbe found that
26.6 % of children at Kuilfontein School (Oberholzerskloof) in the south-
western Transvaal were affected, but at one place in the Nelspruit-Bar-
berton area on the east side of the Transvaal no less than 290 Bantu women
out of 300 examined had goitre. In Swaziland the rates among school-
children are generally high, varying from 4 % at Goedgegun European
School to 71 at Imbuluzi Native Mission School 11 miles north of
Mbabane.
Among Natal schoolchildren the incidence is apparently considerably
lower than in the Transvaal. Strydom (see Steyn et al. 1065) carried out a
thyroid survey at 14 European, 9 Coloured and 6 Native Schools in Natal
and found rates ranging from zero in the European Schools to 4 % in
the Native Schools.
Thirty-three years ago (1927) about 65 % of the inhabitants in the
Krakeel, Hoeree and Klein river valleys (Langkloof-Kouga region) showed
simple thyroid enlargement. More recent statistics from this area are 23 %
of slightly enlarged glands in Coloured children at a school in Knysna, and
rates varying from 3 lo in primary and secondary schools at Joubertina to
22 % at Opkoms School. Rates of 7 % to 25 % are recorded by the South
African Goitre R.esearch Committee among children in the endemic fluorosis
areas of north-western Cape Province.
During the course of their investigations the Goitre Research Committee
encountered many cases of simple goitre which were intermittently toxic.
By far the highest prevalence of thyrotoxicosis, including exophthalmic
goitre, was seen in north-western Cape Province. Steyn and his colleagues
believe that the fairly general use of large amounts of iodine in the form of
Lugol's solution for the treatment of simple goitre is in some measure
responsible for the high prevalence of thyrotoxicosis here. This raises
once more the eYergreen 'problem of Jod-Basedow or iodine-induced hyper-
thyroidism.
On the question of causation, all the information collected in the course
of the exhaustive analytical inwstigations conducted by the South African
Goitre Research Committee has amply confirmed the view that iodine
deficiency is the primary cause of endemic goitre in the Union and neigh-
bouring countries. Contributory factors in certain areas already mentioned
are excessive quantities of fluorine in the drinking-water. Soils, waters
and vegetation extremely rich in available calcium are also incriminated
in some localities as, for instance, the Langkloof Valley region. It has also
been suggested by Buttner 1047 that the occurrence of the element tellurium
in the Knysna area may be a contributory etiological factor, but there is
no confirmation of this.
The Goitre Research Committee, headed by Steyn, strongly recommend
the non-compulsory introduction of iodized salt in all the endemic goitre
areas where the disease is due to a primary iodine deficiency, i.e., in every
goitre area throughout the Union except in those parts of the north-western
Cape Province where goitre is fluorine-induced. 1065
Thyroid disease is surprisingly uncommon among farm animals in the
endemic goitre areas of South Africa, but occasional cases are seen. When
investigating stock diseases all over the Union and in South-West Africa,
the Eastern Caprivi Strip and Swaziland, Steyn & Sunkel 1063 only twice
saw evidence of iodine deficiency in animals. The first was in a small area
in the Orange Free State where merino ewes gave birth to a high percentage
of lambs with enlarged thyroids and a number of stillborn lambs. The
second occasion was an outbreak of goitre among newborn Afrikander
calves on a farm situated on the south bank of the Black Kei river in the
Cathcart district of Cape Province. The only other recorded occurrence
of goitre in Afrikander calves is that cited by Matthew & Thomas 1058 on a
farm in the eastern Cape Province. According to a recent report (1956)
there is no iodine deficiency among animals in the Highveld region around
Potchefstroom west and south-west of Johannesburg. 1050
Seychelles and Madagascar

Minor occurrences of goitre have been noted in urban and rural areas
of the Seychelles by M. Dick (personal communication, 1952), and in the
mountainous interior of Madagascar by Cloitre 1069 and by Nimier (see
Dupont 1000).
Cases seen in Madagascar are mostly of sporadic and unrelated occur-
rence among Betsileo and Hovas women who come from such districts
on the high plateaux as Ambositra, Ambohimahasoa, Fianarantsoa and
Alakamisy-Itenina. The disease is unknown among the Tanalas, Baras
and other peoples of the eastern coast region and extreme south of the island.
Nimier (see Dupont 1000) found no more than 50 goitres in 60000 inhabi-
tants of the Ambositra district, and Cloitre 1069 emphasizes that there are
no grounds for regarding the disease as seriously endemic in Madagascar.
Of 32 cases seen by him, 31 were in women over 25 and mostly between
35 and 50 years of age. Visible thyroid swelling in adolescent girls was not
uncommon.
Asia
The headquarters of goitre and cretinism on the continent of Asia are
the northern and southern slopes of the Himalaya Mountains. This classic
endemic focus extends eastwards almost without interruption through
Burma into China and neighbouring countries. The adjacent endemic
areas of southern Asiatic Russia have already been noted (see pp. 75-76).
In the western regions of Asia goitre occurs endemically only here and
there; a few places in Turkey are mildly goitrous, and there are centres
in Lebanon and in Iran.
FIG. 6. ASIA
The red hatching indicates rhe areas where endemic goitre has been found
With the exception of Lebanon, the countries along the Levantine

coast-Syria, Israel and J o r d a n - a r e apparently goitre-free, as also are
Iraq and Arabia, although it is said that goitre has been seen on the Yemen-
Aden border.
Turkey
Speaking generally, goitre is .not a serious problem in Turkey. Never-

theless, the fact emerged during discussions at the Tenth National Medical
Congress, held at Ankara in 1948, that one or two areas may be regarded
as endemic. 1074 One of these covers the northern bulge of Turkey where
steep valleys from the spurs of the Kastamonu-Ilkaz mountains slope
sharply to the southern shores of the Black Sea. Goitre maps of this general
area of northern Anatolia have been made by Eser 1071 and by S. N. Yoru-
koglu (personal communication, 1958). These show black spots at Ada-
pazari, Duzce and Bolu; the environs of Bartin, Zonguldak, Kastamonu,
Ta kopru, and Gerze; and on the peninsula at Sinop. Somewhat farther
east, goitre has been found in the district of Amasya, and at Rize, a town on
the extreme south-east coast of the Black Sea.
Another endemic region lies to the west nd s.outh-west of the country;
here the principal centres are Afyon, Aydin arid the neighbourhood of the
Menderes Chai river south-east of Smyrna, and Isparta, which is recog-
nized as an area of pronounced goitre. The Isparta focus has been studied
especially by Eser & Velicangil 1072, 1073 who found rates of 35 % among
boys of 12 to 16 years of age, and of 56 % among women between 16 and 60,
with the maximum frequency at 16 to 19 years. In the southern bulge of the
Turkish mainland opposite Cyprus, goitre is found in the Bozkir and
Ermenek Districts of Konya Province and in the Taurus Mountains. In the
eastern part of Turkey there are centres of the disease at Erzincan
and Erzurum relatively near the endemic areas of Armenia and the
Caucasus.
According to Saka, 1075 the city of Istanbul and the country surrounding
the Sea of Marmara, as well as the regions westward into Thrace, are
practically goitre-free, although cases of thyrotoxic disease appear to be
frequent. Saka examined the thyroids of 71 persons from all parts of Turkey
who had died from a wide variety of diseases. He found the average weight
of the normal gland to be 26.6-28.0 g. Weights above average were noted
in persons who came exclusively from districts of high elevation where
goitre is of frequent occurrence, e.g., from Bartin (42.5 g and 80 g), Djer-
kesch (44 g), Erzincan (49 g) and Erzurum (43 g and 55 g).
Animal goitre is not uncommon in Turkey, particularly in the northern
Kastamonu-Ilkaz region. Akcay 1070 examined the thyroid glands of 177
cattle post mortem; of these, 125 were affected with simple hyperplastic
goitre, 9 had colloid goitres and 8 were exophthalmic.
Since about 1945 the inhabitants of goitre regions in Turkey have been
supplied with iodized salt, and goitre posters and pamphlets have been
distributed. 1074
Lebanon
Physiographically the Lebanon consists of two parallel mountain chains
running the length of the country in a NE-SW direction-the Lebanon
range proper to the west, and the Anti-Lebanon to the east. Between these
two ridges is a high plateau, the Bekaa.
Goitre is endemic at several places on the slopes and in the valleys of
these mountains, particularly those on the inner sides facing the Bekaa
plain in the central section of the country. Ciaudo et al.1° 80 give the following
origin of 100 cases they had occasion to observe:
Kab-Elias . 18
Zable . . . 15
Deir El Harf 14
Hamana 13
Beskinta . 6
Hasroun . 4
Broumana 3
Salima . . 3
Miscellaneous 24
Total . . 100
Kab-Elias is situated on the eastern slope of the main Lebanon chain,

and overlooks the Bekaa. Zahle is similarly placed, deeply recessed between
two mountains. It is impossible to walk along the streets of these two
villages without noticing goitrous people.
In the narrow coastal strip between the Mediterranean Sea and the
western Lebanon foothills the disease is practically non-existent. Among
the 24 miscellaneous cases listed above, only four came from the seaboard:
one from Gebeil (Byblos), one from Chekka, one from Jounieh and the
fourth from Chiah. All these subjects, although born by the sea, were
descended from goitrous parents of mountain stock. It is exceptional if not
impossible to find a Beirut native with goitre; any cases that may be seen
there have originated elsewhere.
The goitres seen in the Lebanese mountains are of the diffuse parenchy-
matous type and often of considerable size; toxic symptoms are not uncom-
mon, and malignancy is occasionally met with. Chaia i o i 7 has made the
interesting observation-reminiscent of that by Calonne 1024 in the Belgian
Congo (see page 142)-that excessive or unusual physical effort may induce
thyroid enlargement. He noticed that goitre developed in a number of
young soldiers under hard training within six months of enlistment.
The social implications of goitre in the mountain areas of Lebanon,
and the need to institute preventive measures, have been emphasized by
Refet. 1081 He proposes the following regime for eventually ridding the
country of goitre:
(1) Examination by the district doctor of all primary schoolchildren
between the ages of 7 and 14 years, to eliminate if possible those who might
be sensitive to iodine medication.
(2) First year of prophylaxis: give each child one tablet of Iodostarin
(diiodotariric acid) or one tablet containing 0.001 g of sodium or potassium
iodide, regularly every Monday morning for 40 weeks. Stop during the
holidays.
(3) Second year of prophylaxis: one Iodostarin or iodide tablet per
child once a week for four weeks during each half-year.
(4) Third and fourth years of prophylaxis: continue the tablets weekly
for one month every half-year, as in the second year of prophylaxis, in cases
where the goitre has not disappeared.
An appraisal of radioiodine tests in the diagnosis of thyroid function
in Lebanese people has been made by Abu Haydar. 1076
Israel
Recent mass immigrations into Israel of Jews from all over the w o r l d -
people with different cultural, nutritional and climatic backgrounds which
they have tended to preserve in the new environment-provided Feldman 1082
with an opportunity to examine whether these differences are reflected in the
prevalence and type of thyroid disease in Israel. His study relates to Jewish
people in three groups of origin: European-American, African-Asian,
and native-born Israelis.
Thyroid glands taken at consecutive autopsies from 72 unselected
Jewish children under 15 years of age were of normal weight and showed no
pathological lesions. Of a total of 323 patients treated either surgically or
medically for thyroid disease during life in the five years from 1948 to 1953,
only five were infants or children under 15 years.
From these facts Feldman concludes that Israel is not a country where
goitre is endemic.
As for the adult population, Feldman found that 42 thyroids out of
110 taken at consecutive autopsies from individuals over 15 years old
showed pathological change-a rate of 38 % in random adult post mortem
examinations. The rate of thyroid disease among all adults clinically
examined by him during life for any reason whatsoever was 7 per 1000, or
approximately fifty times less than that disclosed after death. The reason
for this Feldman finds in comparing post mortem and clinical findings; the
post mortem examinations reveal that thyroid lesions are fairly common but
rarely become clinically manifest.
The type of pathological change seen after death was more or less the
same for all adults irrespective of birthplace. In the clinical material,
thyroid disease was observed more frequently in patients of European-

American origin. Feldman concludes from this that Jews born in Europe
and America either acquire more severe thyroid disease than the other two
groups or are more prone to seek medical aid.
Those interested in goitre occurrence among Jewish peoples in Europe
will find Greenwald's views absorbing. 787
Iran
Two centres of goitre occurrence have been noted in Iran. These are the
villages of Alischavaze and Kereshtek about 25 miles from Teheran. The
possibility of introducing iodized salt in this locality is being explored by
M. B. Mashayekhi (personal communication, 1953). Gaguik of the medical
school at Teheran University is testing the iodine content of different waters
in Iran in relation to goitre occurrences there.
The Indian peninsula a

The severe manifestations of goitre in the south-eastern Soviet Republics
of Uzbek, Tadzhik and Kirgiz, on the Pamir plateau, and in other remote
centres on the northern slopes of the central Asiatic massif (see page 75)
are repeated with equal intensity on the Indian side of this great mountain
barrier. In fact, the northern frontiers of the Indian peninsula extending
from Afghanistan through Kashmir and Jammu eastwards for more than
1500 miles along the southern valleys and foothills of the Himalayas into
Assam and Burma have a goitre reputation more formidable perhaps than
that of any other part of the world. The intensity of the disease is so great
in some places as to merit the term hyper- or super-endemic (Stott &
Gupta 1128). The goitre literature of the various countries that make up the
Indian peninsula is intermingled to such a degree that it is dealt with here
as a whole, and not necessarily with reference to political boundaries.
Geographical distribution
Descending into the north of West Pakistan from the mountain passes
of Afghanistan and Badakhshan-areas themselves not immune 372- one
enters the western end of the goitre zone at Chitral, a wild and desolate
region mountain-girt and mountain-intersected by the precipitous spurs and
slopes of the Hindu Kush. Immediately to the east, in the north of Kashmir
at the head-waters of the Indus, lies the district of Gilgit which, together
with Chitral, is famed in the annals of goitre and cretinism by the researches
of McCarrison. 1101, 1102, 1125 In the North-West Frontier Province of Pakistan,
on the edge of Kashmir, a considerable amount of goitre has been observed
by H. W. Waite (personal communication, 1954) in the Kagan valley and
hills of Hazara, and by French et al.1° 92 and Watkin et al. 1130 at Muzaf-
a Includes Afghanistan, Pakistan, Kashmir, Nepal, Tibet, India and Assam
farabad. From Gilgit the goitre belt extends south-eastwards through

Kashmir along the Karakoram range and over the districts ofBaltistan and
Ladakh into the north-west of India proper.10s3, 1119
Here, the endemic pervades the sub-Himalayan regions of Himachal
Pradesh (Kangra, Pathankot, Gurdaspur, Hoshiarpur, Hamirpur, Kyelang,
Kulu and the Spiti river 1084· 1096); the Shiwalak Hills and the districts of
Tehri, Kasauli,1107 Ambala 1093 and Dehra Dun; the former Province of
Kumaun 1113 (Almora and Naini Tal 1129); the almost inaccessible Hima-
layan habitations in the State of Nepal; 1086· 1088 and the low-lying plains of
Uttar Pradesh, including the Districts of Pilibhit, Bareilly,1089, 1100 Bahraich,
Gonda, Basti, and Gorakhpur, where Padrauna is especially noteworthy as a
goitre centre.1128· 1129 South-east of Gorakhpur and not far from Patna lies
the goitre district of Muzaffarpur studied by Sinha, Bose, Roychowdhury
and Gyani.1122· 1126 Thus, there is an almost continuous stretch of goitrous
country filling the entire area between the Gogra river and the southern
border of Nepal. On a journey through Tibet, Harrer 1094 saw highly
developed goitres at Drothang, the last stopping-place before Kyirong on
the Tibetan side of the Himalayan barrier.
Still farther east the endemic continues across the river Gandak
through Champaran and Purnea; it touches Darjeeling 1124 (also S. R. Sen
Gupta - p e r s o n a l communication, 1953) and the States of Sikkim and
Bhutan.1088, 1123 Due south of this area, goitre has been recorded in East
Pakistan at Dinajpur and Rangpur; 8 and in Assam there is an endemic of
some intensity at Goalpara 1097 and throughout the Lushai and Naga Hills
at places such as Tripura, Aijal, Imphal (Manipur) and Sibsagar 1090, 1119, 1121
(also A. K. Mitra-personal communication, 1948).
Apart from this great northern endemic, goitre is by comparison not
excessively acute elsewhere in India or Pakistan. Nevertheless, in Pakistan
the disease is a distinct problem in the Multan and Montgomery areas of
the west Punjab.1087• 1116 A recent epidemic (1955) in the Multan region
was investigated by Murray et al.1118 Goitre has also been noted by
McCarrison at Larkana on the lower Indus and it occurs sparingly on the
Pakistan seaboard of Kutch.11°4
In the State of Rajasthan (formerly Rajputana) goitre is practically
non-existent except in the Aravalli range and in the neighbourhood of the
tributaries of the river Luni near Ajmer.1104 South of the Luni and Aravalli
area by about 300 miles, goitre is fairly common along the banks of the
Narbada river, which flows westward to the gulf of Cambay between the
Vindhya range on the north and the Satpura range on the south; in both
these hilly regions the disease is not unknown.1104
The central Indian plateau of Madhya Pradesh is not conspicuously
goitrous, but the malady is usually to be found in the neighbourhood of
the southern tributaries of the Jumna and in the Jhansi and Lalitpur uplands
where these rivers originate.1104 On their goitre map of India, Megaw &
I
PREY ALENCE AND GEOG RAPID CAL DISTRIBUTION 155
Gupta 1117 mark endemic centres between the Kaimur range and Jubbulpore;
and there are reports of the disorder in the high country east of Jubbul-
pore affecting the Surguja and Ranchi districts of Chota Nagpur, and
Sambalpur in Orissa (C. Thomson-personal communications, 1951-52).
Throughout southern India goitre is found but sparingly. It has, how-
ever, been noted by Bodas & Deshmukh 1085 in and around the hill station of
Mahableshwar in the Sahyadri ranges of the Western Ghats about 200 miles
south-east of Bombay. McCarrison also saw goitre in this general area, at
Bijapur, and farther south on the slopes and submontane tracts of the
Western Ghats, particularly at Coimbatore and in the Nilgiri Hills. The
Madras side and the Eastern Ghats are practically goitre-free with the
exception perhaps of Arcot, where McCarrison records occurrences along
the banks of the Cheyyar river in the vicinity of Arni. 1104
Thus, in summary, a competent cartoonist charged with the task of
brushing-in the goitre areas on a map of the Indian peninsula would heavily
underline the hollows under the entire length of the Himalayan " eyebrow ",
lightly cover an irregular and fragmented area of secondary importance
across the central plateau from West to East Pakistan, and merely touch
some minor grey-spots in the Deccan and extreme south.
Degree o f prevalence
In 1917, McCarrison 1105 estimated that the whole of India probably
contained about five million goitrous people. He records that in some
Himalayan villages 60 % of infants still at breast were sufferers, and it was
difficult to find a man, woman or child free from the disease. Thirty-five
years later, Ramalingaswami, 1119 after reviewing all the statistical evidence
available in the intervening period, reached the conclusion that the pre-
valence of endemic goitre in India had not changed appreciably in recent
years and that McCarrison's estimate of five million affected persons was
probably still valid in 1952. A later estimate (1959) puts the total at nine
million. 1098
Hospital and dispensary returns 1097, 1119 give an idea of the relative
severity of the disease in different parts of the Indian peninsula. The
greatest number of cases coming for treatment is encountered in the Dehra
Dun, Gonda and Gorakhpur Districts of Uttar Pradesh (formerly the
United Provinces) where an average of 100 OOO persons presented them-
selves in 1940 and almost half that number in 1949. In Bihar, prevalence
is about the same as in Uttar Pradesh, the most grossly affected district
being Champaran. Sinha, Bose & Roychowdhury 1126 found an average
rate of 11. 7 % among 8493 persons examined in the Muzaffarpur district
of Bihar, with percentages rising to 50 and even 70 in one or two villages.
The Punjab (particularly Kangra District), Bengal, and Assam (parti-
cularly Goalpara District) each yielded about 30 OOO cases in 1940. In
Assam some 34 OOO cases reported for treatment in 1949. The figures are
as follows:
1940 1949
Punjab (All) 30 OOO
Punjab (East) JO 508
Uttar Pradesh JOO OOO 44 723
Bihar .. 100 OOO
Bengal (All) 30 OOO
Bengal (West) 8 295
Assam 30 OOO 33 999
Madras 8 258
Bombay 926
Considering that only a small proportion of sufferers seek hospital

treatment, the actual number of affected persons must be several times
greater than the hospital returns. The results of some recent goitre surveys
confirm this belief (see Table XVII).
TABLE XVII. PREVALENCE OF GOITRE IN VARIOUS PARTS OF I N D I A IN RECENT YEARS
IPrevalence IofNumber I Year
I
Region of goitre persons of Authority
(%) surveyed survey
Kashmir, Karakoram
Mountains 90 - 1945 Allen-Marsh 10"
Uttar Pradesh, Dehra Dun 32 554 1945 Ramalingaswami 1119
Uttar Pradesh, Bareilly 26 133 1947 Lyall 11"
East Punjab, Shiwalak

Hills 32 5042 1952 Ramalingaswami 11"
East Punjab, Shiwalak

Hills 37 1337 1952 Ramalingaswami 1119
Bihar, Purnea District 50 (3 villages) 1952 Ramalingaswami 1119
Bihar, Ranchi District 70 563 1952 Thomson (peraon

communication, 1952)
West Bengal, Darjeeling 67 8204 1953 Sen Gupta &
Swarup 112c.
The annual report of the Public Health Commissioner with the Govern-
ment of India for the year 1945 records a 70 % goitre rate among school-
children in Ambala, East Punjab. 1093 During their 1955 survey of 319 school-
children in Multan District, West Pakistan, Murray et al.ms found visible
thyroid enlargement in 41.3 % of boys and 72.3 % of girls. The nutritional
appraisal of the all-Pakistan armed forces conducted in 1956 by French et
al., 1092• 1130 revealed an overall thyroid enlargement rate of6.8 %; but among
the men examined at Muzaffarabad the rate was no less than 31 %- The
Pathankot-Kangra-Gurdaspur region on the frontier between north-west
PREVALENCE AKD GEOGRAPHICAL DISTRIBUTION 157
Pakistan and Kashmir is heavily goitrous, showing rates of from 30 % to 90 %

in the areas of Kandi and Andhar. A stream running through this district
has been called the Gilhari Khud (" goitre stream") since ancient times. 1096
In Sikkim State a goitre rate of 61.3 % has been found at altitudes between
5000 and 6000 feet. 1123
Cretinism and deaf-mutism

Be they old or new, all descriptions of the goitre endemic in the heavily
affected areas of northern India refer especially to the prevalence of cre-
tinism, deaf-mutism and idiocy; these most tragic of the sequelae of goitre
are as much a part of the endemic as the goitre itself. According to Stott
et al., 1129 affected Yillages in the Himalayan tract haYe an average goitre
rate of about 40 lo, with some 4 of deaf-mutes. Stott and his colleagues
have delved deeply into the incidence and distribution of deaf-mutism in
the United Provinces (now Uttar Pradesh); their survey has not been
bettered by anything published since. From various data they calculated
that in 1921 there were 25 OOOcongenital deaf-mutes in the United Provinces
alone, a figure substantially the same as that in 1911. In Stott's opinion the
number of congenital deaf-mutes in the age-group 0-5 years is vastly under-
estimated because the parents of these unfortunate creatures hesitate to
report their children as defective until all hope is lost, clinging as long as
possible to the belief that speech and hearing are merely delayed.
Etiological factors
(1) Pollution. McCarrison 1101, 1102 made a notable contribution to
knowledge of the factors that influence thyroid enlargement when investi-
gating the circumstances surrounding the occurrence of goitre in the nine
neighbouring Himalayan villages collectively known as Gilgit. Eight of
these were situated one above the other on the same water-supply, which
in its dowmvard passage in surface channels to and through the successive
villages became increasingly polluted by human and animal excreta. The
ninth village-Barrois-was located some distance apart and had its own
water-supply, a spring of exceptional purity not subject to pollution.
This village was free from goitre; but the disease prevailed in the other
eight, with a rate which was least in the village at the highest level (11.8 %)
and gradually increased until it became 45.6 % among the general popula-
tion in Kashrote, the Yillage at the foot.
From these observations McCarrison concluded that the increasing
intensity of goitre as one came down stream might be due to the obviously
increasing impurity of the water-supply. To prove the point he administered
to 35 volunteers, and to himself, a twice-daily drink containing a large
quantity of the suspended matter filtered from the grossly polluted goitre-
producing water issuing from Kashrote, the most severely affected Gilgit
village. In about a fortnight 10 of the 36 volunteers, one of them being
McCarrison himself, developed noticeable thyroid enlargement; 5 had

transitory swellings and 21 were unaffected. Concurrently, 31 other young
men consumed, in the same circumstances, the same suspended matter
after it had been boiled. None developed goitre.
These early experiments are mentioned here because they offer the
first experimental proof of an assertion constantly recurring throughout
the goitre literature of primitive countries-namely, that excessive amounts
of organic material in water, whether the actual bacteria themselves or
some toxin produced by them, can exercise a goitrogenic effect and thus
raise the bodily demand for iodine in the same way as can the excessive
concentration in drinking-water of an inorganic chemical constituent such
as calcium.
Confirmation of this point of view is afforded by McCarrison's later
experience in a boarding-school at Sanawar, not far from Kasauli in the
outer Himalayas.11° 7 Here, goitre had persisted for many years and at the
time of McCarrison's inquiry was affecting no less than 66 % of girls over
15 years of age. Investigation showed that the school water-supply-a
spring-was subject to bacterial pollution from human and animal excreta.
A new and clean supply was introduced; within a few years goitre had
entirely disappeared from the school.
In this connexion one recalls the modern thesis of Hettche, 1095 who
concludes from his epidemiological and etiological study of goitre as
revealed in one hundred years of research, that the disease is caused by
an injurious substance of the urochrome group occurring in contaminated
water-supplies. The toxic agent is said to bind copper in the serum and can
be used to produce goitre experimentally in animals, but the production
of goitre may be prevented by simultaneous administration of iodine.
McCarrison also found that goitres developing spontaneously in well-fed
experimental animals confined in dirty cages could be prevented by
increasing the consumption of iodine proportionately to the unhygienic
conditions under which the animals were living.
(2) Lime-rich waters and soils. The frequent association of goitre with
limestone rocks and with drinking-water rich in lime has been noted from
earliest times. McClelland's 1114 extensive medico-topographical studies in
places as far apart as Bengal and the North-West Provinces led him to the
conclusion, published in 1835, that magnesian limestone formations were
primarily responsible for the propagation of goitre in India. There is little
new under the sun, for, one hundred years later, Stott and his colleagues 1129
advanced very much the same view and pointed to a direct correspondence
between the distribution of goitre in the United Provinces and drinking-
waters and soils of high calcium content. Moreover, many villagers in
this area know that it is a " chuna " water containing a large excess of lime
and coming from limestone rocks that is the peculiar cause of goitre.
They recognize it by its hardness, heavy consistency, astringent taste,
PREYALE!\CE AND GEOGRAPHICAL DISTRIBUTION 159
limy smell, and above all by the fact that it remains warm in all seasons
whereas good (non-goitrogenic) water invariably keeps cool.
(3) Poverty and faulty diet. Others among the many who have observed
goitre in India point to poverty and insufficient and imperfect dietary as
the main conditions in which the disease originates. Bramley 1086 noticed
this in Nepal and Tibet in 1833; Macnamara 1116 refers to it; and so do
McCarrison & Madhava, 1109 who, in discussing the genesis of goitre in
India, attach much importance to faulty and unbalanced diets. C. Thomson
(personal communications, 1951-52) links poverty with the goitres seen in
villages below the Ranchi plateau in Bihar ,vhere a cheap dietary composed
largely of sweet potatoes is used extensiYely instead of cereals. Stott &
Gupta 1128 correlate the distribution of goitre in the Padrauna tehsil of
Gorakhpur with the distribution of bhat and hangar soils. Broadly speaking,
the superendemic areas are confined to the sandy bhat soils, which yield
food produce of low quality. Villages on hangar soil, which yields high
quality food, are generally goitre-free.
(4) Iodine deficiency. Early chemical investigations by McCarrison
et al. 1112 provide no evidence that in Himalayan India the incidence of
endemic goitre is in inverse ratio to the iodine content of soil and water.
In the heart of the endemic zone, as well as in the Himalayan foothills,
two places adjacent to one another may have approximately the same
amount of iodine in their soils yet goitre may be prevalent in one and not
in the other. Similarly, one locality may have a water supply containing an
appreciable amount of iodine and yet be a focus of endemic goitre, while
another locality may have a water supply containing less iodine and yet
be free from endemic goitre. This is because the iodine level in Himalayan
soils and waters is not the determining factor in goitre causation here. As
has already been mentioned, bacteriological impurity in water is the essential
goitrogenic agent, although it is true that this effect may be mitigated and
controlled in proportion to the quantity of iodine present in the water.
On the other hand, Murray et al. 1118 find that the chief factor determining
the occurrence of goitre in the Multan area of West Pakistan is the iodine
content of the local drinking-water. Eight representative samples used by
goitrous people in this region were compared in respect of iodine content
with control samples from Kasur, about 200 miles distant, where goitre is
unknown. The eight Multan waters had an average iodine content of
3.6 µ,g per litre usually associated with a high degree of hardness. By
contrast, water from the non-goitre district of Kasur had an iodine content
of 10.8 µ,g per litre.
Goitre has long been known in the Multan region of West Pakistan.
Macnamara 1116 described it there in 1880; Chaudhri 1087 noted a rate of 60 %
in the villages of the Kabirwala tehsil in 1929; and Wilson 1131 referred to it
in 1941 in connexion with her fluorosis investigations in that area. According
to recent reports 1118 medical observers are convinced that goitre has greatly
increased in the Multan area and in West Pakistan generally since 1947
when, owing to the partition of Pakistan and India, unusual movements
of populations have taken place and additional water-pumps have had to
be installed on old sites to cope with the increased requirements. Apparently
the new water-supplies do not always have an adequate iodine content.
Animal goitre in India
Bramley 1086 records that during his sojourn in Nepal, where goitre is
notorious among men, women and children of all ages, it was by no means
uncommon to find animals such as the buffalo, goat, sheep, and dog similarly
affected. On one occasion he saw a goat bring forth a kid with a goitre as
large as its head. Animal goitre is also specifically mentioned as occurring
among dogs, cats and birds in the super-endemic areas of Gonda and
Gorakhpur in Uttar Pradesh. A. K. Mitra (personal communication, 1948)
gives an interesting account of goitre among calves in the Subsagar district
of Assam, an area where human goitre also prevails. Thyroid glands from
goats and sheep slaughtered at Bareilly, a district of human goitre, were
examined (1959) by Dutt & Kehar. 1089 About 10% of the goats were
goitrous, but no thyroid enlargement was seen among the sheep.
McCarrison, 9 on the other hand, rarely came across goitre in animals.
In the course of ten years' residence in the Chitral and Gilgit districts he
saw only two cases in dogs, one in a horse, and one in a goat. Altogether
McCarrison examined 116 mules, 101 dogs, 150 cows, 100 sheep and goats
and 101 ponies belonging to the villagers of Gilgit, but did not encounter
a single case among these 568 animals. No history of goitre in domestic
animals was obtained by Murray et al. 1118 during their survey in the Multan
region of West Pakistan.
Preventive measures
Despite the etiological complexity of the Indian goitre endemic it is
not denied, even by those who show that the cause of goitre in India is
impure water or excessive calcium intake rather than a primary iodine
deficiency, that the easiest and cheapest way of preventing the disease is
to provide the necessary supplementary requirement of iodine in iodized
salt. Here, as Ramalingaswami points out, India is confronted with a
difficult problem.
Except for a small quantity of rock salt mined at Mandi in Himachal
Pradesh, the bulk of the salt produced in India is a coarse crystalline pro-
duct obtained by solar evaporation of brine. About three-quarters of this
is made up of sea salt and the remainder is obtained from inland salt lakes.
Efforts are being made by the Salt Expert Committee of the Government
of India to improve permanently the quality of Indian salt, but in the mean-
time ways are being explored of iodizing the currently used crude salt
as uniformly as possible. This is important not only because of the impera-
tive need to begin fighting endemic goitre at once, but also because it is
not easy to persuade people in the endemic areas, who have been accus-
tomed to crude crystalline salt for centuries, to change over suddenly to
refined salt.
To obviate the losses of iodine from salt iodized with iodides which can
occur in the humid atmosphere and strong sunlight of India, iodization
of salt with iodate is preferred. Experiments have already been carried out
by C. Thomson (personal communications, 1951-52) in the Ranchi goitre
district which prove that this method of iodization is effective and harmless.
Under the direction of J. C. Ohri a "goitre pilot survey project" was
begun in 1954 with the object of comparing the prophylactic value of iodide-
fortified and iodate-fortified salt as a goitre control measure in the Pathan-
kot-Kangra-Gurdaspur area of the northern Punjab. 1096 Results are awaited
with intense interest.
Ceylon
Pendant on the Indian subcontinent hangs the pear-shaped island of
Ceylon, approximately the size of Holland and Belgium combined, and
inhabited by about seven million people. The south-west-central area,
where population density is greatest, is mountainous, wet, and goitrous;
the rest of the country to the east and north is flat, dry, and comparatively
goitre-free. Heavy rainfall and high temperatures in the south-west region
where goitre chiefly occurs have led to intense weathering and chemical
leaching of the ancient crystalline rocks of which Ceylon is mainly composed,
giving rise to laterite or lateritic soils according to the degree of leaching.
Waters throughout the island are soft; and those from the highly leached
goitrous areas in the south-west have a low iodine content. These are the
essentials.
Greenwald, 992• 1132 who has probed into the history of goitre in many
countries, finds only three original mentions of the disease in Ceylon prior
to Wilson's 1133· 1131 survey of 1950, one in 1843, one in 1849 and one in
1894; these all relate merely to occasional occurrences in the Galle district of
the extreme south-west. From this he concludes that goitre was not com-
mon in Ceylon until quite recent times.
In the course of nutrition surveys carried out by workers of the Medical
Research Institute at Colombo during the years 1947-49 it was reported
that goitre was endemic in certain rural parts of the island. Early in 1950,
Wilson 1133, 1134 was asked by the World Health Organization on behalf of
the Ceylon Government to ascertain whether the amount of goitre reported
in these surveys constituted a serious public health menace. She examined
722 Ceylonese children and adolescents-317 boys and 405 girls-attending
rural schools in ten different parts of the island, six in the wet region of the
south-west and four in the dry region of the north. The results are shown
in Table XVIII.
11
TABLE XVIII. PREVALENCE OF GOITRE AMONG CEYLONESE CHILDREN

AND ADOLESCENTS IN TEN DIFFERENT P A R T S OF CEYLON
I
Boys Girls Iodine
Situation of villages content
number
examined
percentage
with goitre
number
examined
I percentage of water
with goitre (µg per litre)
Wet region
1. On coastal strip, inland 20 15.0 50 38.0 2.2
2. On sea coast 50 18.0 50 40.0 5.3
3. On 6oastal strip, inland - - 50 22.0 -

4. On foothills, inland 45 13.3 26 23.1 -
5. On hills, inland 50 6.0 50 56.0 2.7
6. At 5000 feet, inland 27 11.1 30 40.0 1.4
Total
I
192
I
12.5
I 256
I 37.5
I
Dry region
7. On sea coast - - 50 6.0 -
8. On coastal lagoon 50 Nil 30 6.7 -
9. On Jaffna peninsula 50 Nil 50 12.0 6.6
10. On plateau, inland 25 Nil 19 5.3 61.0
Total
I
125
I
Nil
I 149
I
8.0
I
In general, prevalence is highest in the section of the country where rain-
fall is highest. This covers the Central, Western and Sabaragamuwa
Provinces, which include the coastal strip between Colombo and Galle.
The drier eastern and northern provinces of the island are not seriously
affected, although a rate of 12 % was found by Wilson among girls in a school
on the Jaffna peninsula in the extreme north.
As is usual, girls and women of child-bearing age are the chief victims.
Among boys incidence is only moderate and few goitres are seen in men.
Toxic symptoms are rare in Ceylon and no cases of cretinism or deaf-
mutism are recorded. Animal goitre is also unknown.
Drinking-waters are generally soft and therefore the hard-water factor
cannot be incriminated; but some waters, notably in the coastal villages
numbered 1 and 2 in. Table XVIII gave evidence of faecal and bacterial
contamination which could decrease the amount of available iodine. It is
evident that waters from the wet goitrous regions are much less rich in
iodine than those from the dry non-goitrous localities.
Adverse economic circumstances and shortage of rice owing to imported
supplies from Burma having been cut off during the 1939-45 war have in
recent years obliged many Ceylonese communities, particularly in the south,
PREVALENCE A"'.'ID GEOGRAPHICAL DISTRIBUTION 163
to subsist on restricted dietaries inadequate in protein and supplemented

with local vegetable foods not largely consumed in normal times. Wilson
conceives it possible 1134 that insufficient intake of the right kind of protein,
and an increased intake of anti-thyroid material ingested from the unusual
foods consumed during the war might be sufficient to interfere with iodine
metabolism and hormone synthesis and so cause thyroid enlargement.
There is, however, no proof of this.
As a goitre-preventive measure, potassium iodide tablets were distributed
in some areas as a result of Wilson's survey and recommendations, but there
is little sign that the preventive programme continues to be pursued with
vigour and determination.
Burma
Goitre is prevalent in the mountainous parts of Burma, particularly
throughout the Chin Hills in the west of the country, the Kachin Hills in the
north, and the Shan States on the east. The western and northern goitre
areas are contiguous ,vith the endemics covering the Lushai and Naga
Hills of eastern Assam.
Statistics gathered by Raymond 1136 from groups of villages in the Chin
country show that the disease is commoner among children than among
adults; but the adult goitres are much larger and frequently give rise to
serious pressure symptoms. Incidence is higher in females than in males
and is always greatest at puberty and pregnancy. Water-supplies are
singularly pure and free from faecal contamination, and therefore are not
incriminated; but dietary deficiency of vitamin A is notorious, and Raymond
regards this as the most important single goitrogenic factor operating among
the Chin Hills people.
On the north and east, where Burma abuts on China, goitre rates are
exceedingly high in the Myitkyina area; also around Bhamo, Namkham
and Shwegu in the Northern Shan States; and on the Burma-China road in
the neighbourhood of Lashio and eastwards towards the Sahveen river. 1129
Secluded valleys in the Shan States are particularly affected, according to
Robertson, 1204-1206 and the disease seems often to be confined to certain tribes.
Seagrave 1137 mentions that in the limestone hills of the Namkham area at
least half the population suffer from goitre.
An exceptionally large number of cretins and deaf-mutes are seen in the
Burmese goitre areas.11 29• 1135 Among the Kachins who inhabit the valleys
and steep hill-sides along the north and north-east frontiers the enormous
rate of 10 per 1000 is recorded by Stott et al. 1129 The Kachin people drink
water from hill streams impregnated with lime and customarily eat large
quantities of lime in powdered form. Stott and his colleagues believe that
this peculiar habit is in large measure responsible for causing goitre among
these northern Burmese peoples.
Thailand
Goitre is prevalent in the north and north east of Thailand. Towards
the end of November 1955 and continuing through January 1956, Ramalin-
gaswami 1139 surveyed the region and found overall rates of 58 % in the
northern Provinces of Chiengmai and Chiengrai, a high percentage of the
goitres being pathological. By contrast, the north-eastern Provinces of
Ubol and Udorn showed fewer cases (21 % and 15 % respectively), the vast
majority being mild. As the disease is so highly endemic in Chiengmai and
Chiengrai, Ramalingaswami recommended the institution of a control
programme with iodized salt and the collection of additional survey data
in the northern Provinces.
Klerks 1138 who was assigned to this programme during the two years
1957-1958 assessed the situation in boys and girls of 7 to 12 years of age as
shown in Table XIX.
TABLE XIX. PREVALENCE OF GOITRE AMONG BOYS AND GIRLS IN THAILAND
Boys Girls
Province
I I
examined with goitre examined with goitre
Chiengmai 1013
I 19.7 945 27.5
Uttaradit 300 40.3 281 50.9
Prae 869 37.3 861 41.7
Lam pang 200 36.0 216 46.3
Chiengrai 474 43.5 513 54.8
Total . ..
I
2856
I 32.3
I
2816
I
40.6
The fact that there is no governmental salt monopoly in Thailand is the

greatest obstacle to a programme of salt-iodization. Even provincially, or
in limited local areas, such a measure would at present be difficult to control
because of the large number of individual retailers who draw their supplies
from all sorts of different sources. Moreover, some communities do not
use much salt but rely for seasoning on fish sauce, not a suitable medium
i to which to introduce iodide or iodate. Every endeavour is being made to
overcome this problem; one suggestion is that in the goitre areas iodate
might be incorporated in the vitaminized premix already being added to
polished rice used in beriberi areas (Van Eekelen 1140).
Indo-China (Cambodia, Laos and Viet Nam)

Reports of goitre come from three parts of Inda-China: (1) the moun-
tainous region extending northwards from Vientiane through Luang-
prabang into the Yunnan Province of China; (2) the upland area of North
Viet Nam (formerly Tanking) lying to the north of Tuyenquang; and
(3) the Mekong delta of South Viet Nam (formerly Cochin-China) with
Cantho as its centre. Apparently goitre does not o c c u r - o r only sparingly-
in the great Annam mountain chain curving in a half-circle through Viet
Nam from Kamkeut in the north to Saigon in the south. Lower and middle
Laos, and the plains of Cambodia (with the exception of Cochin-China
in the very south), are goitre-free. It may also be mentioned here that
goitre is known to occur in the Kingdom of Thailand on the west of Indo-
China, for the most part a low-lying country; 1261 two recent unpublished
accounts are those of Ramalingaswami 1139 and Klerks.11 38
The authority on the first of these Inda-Chinese goitre areas is Jean-
selme 1142 who, when journeying up the Mekong river from the south, first
saw " neang " (the name by which goitre is known among the people of
northern Laos) in the country beyond Vientiane. As he penetrated further
into this calcareous mountain region, Jeanselme observed that the disease
became more and more pronounced. At Luangprabang, a sizeable town
situated on the confluence of the Mekong and its tributary the Nam Khan,
he saw some enormous tumours, mostly among women.
Somewhat to the east, goitre is prevalent along the Tranninh river and
in the region between Borikan and Xiengkhouang where about half the
population is affected. North of Luangprabang, up the river Nam Hu, the
disease is of common occurrence on both banks as far as the village of
Moungngoi; but beyond this point in the direction of Laichau along the
valley of the Nam Ngoua, a tributary of the Nam Hu, prevalence appears to
diminish, and in the riparian villages of the Black River (Song Bo), on
which Laichau is situated, goitres are neither frequent nor voluminous,
even among women.
The second goitre region in Inda-China lies across the Red River (Song
Koi) to the north-east of the first in the northern part of Tanking (upper
North Viet Nam). It comprises the area between Tuyenquang and Kao-
bang, including Chem Hoa Chow and the steep escarpments and gorges
through which the Song Garn and the river Claire flow south to join the
Red River near Tuyenquang. Its northern edge touches the Chinese Province
of Kwangsi.
Various writers have called attention to goitre in this section of Indo-
China-notably, Clavel in 1890 (Tuyenquang), Sadoul in 1890 (upper
Black River), Billet 1141 in 1896 (Upper Kaobang), Jeanselme 1142 in 1910,
Le Roy des Barres in 1923, Cloitre 1069 in 1930, and Tran Kiem Phan in 1937
(see Leuret rn 3) . Only the northern hilly parts of the area beyond Tuyen-
quang are affected; goitre does not exist on the low-lying swampy delta
around Hanoi where rice is grown. Jeanselme examined 377 prisoners
(283 men and 94 ,vomen) from delta provinces and did not find a single case.
Upstream on the Red River, however, from Ta Than as far as Man Hao
goitre is endemic on both banks. It is here that the upper Viet Nam endemic
passes from Indo-China into Yunnan (see page 176).
The third, less well recognized, zone of goitre in Indo-China is the Bassac
strip of Cochin-China in the extreme south which has recently been stig-
matized as goitrous for the first time by Leuret. 1143 It consists of the seven
Trans-Bassac Provinces-Hatien and Rachgia on the Gulf of Siam,
Chaudoc, Longxuyen, Cantho and Soctrang along the Bassac, and Baclieu
on the shores of the China S e a - a n d the two Cis-Bassac Provinces of
Sadee and Vinhlongh.
, This vast region is entirely alluvial, semi-liquid, semi-solid, traversed by
thousands of canals and small channels. Hot and humid, it lies practically
at sea level with no irregularities other than the low dykes and road bridges
of the rice fields. Springs and wells are unknown; drinking-water is provided
by the rains of the winter nd summer monsoon seasons, and by the canals
at all seasons. No systematic goitre survey has been carried out in the area,
but Leuret 1143 considers it significant that he was called upon to. operate on
29 goitres in a continuous period of 22 months, especially in a region where
the people do not characteristically appeal to western medicine until they
have exhausted the resources of the witch-doctor. Moreover, even when
patients must eventually have recourse to the modern medical and surgical
clinics of the west, they display a maximum ofresistance in regard to surgery.
This is more particularly true .of goitre, which is regarded at most as a dis-
figurement to be borne without complaint. Under these circumstances,
29 goitres operated upon by one surgeon within 22 months in a region not
ordinarily deserving the appellation " endemic " must denote a relatively
high general incidence. Confirmation of this belief was forthcoming from
Leuret's second series of surgical cases in which there were. 12 goitres out of
93 operations of all kinds.
Malaya
Polunin 1146 has gathered together all the available information on goitre
in Malaya and has himself considerably added to it. His maps are models
of what goitre maps should be. Visible thyroid glands are common in most
of the undeveloped mountainous inland areas, the over-all rate being about
40 %- By comparison, the rate among communities near the sea is only
between 1 % and 2 %-
In the northern third of the country, the areas chiefly affected are the hills
and valleys of Kedah and Upper Perak. A health survey of the State of
Kedah in 1935-36 revealed 131 cases of goitre in the dist.ricts of Sok and
Jeneri. On the banks of the Chapar, a tributary of the Sok river, there were
two kampongs (Banggol Batu and Banggol Berangan) where all the inhabi-
tants were goitrous and the children had a cretinous appearance.
In Perak goitre is a serious problem in the remote district of Belum at the
head-waters of the Perak river. Polunin examined 102 people in Belum over
PREYALENCE AND GEOGRAPIDCAL DISTRIBUTION 167
14 years of age and found 48 with visible thyroid enlargement. Three other
districts in Upper P e r a k - t h e kampongs of Ulu Kendrong, Klian Malau,
and Ulu Jepai-also show high rates, especially among women.
Goitre is extremely common in the central states of the country-notably,
in and around Kuala Betis and along the Nenggiri river in Kelantan; in
the basins of the rivers Aring, Trengganu and Tembeling in Trengganu;
and especially in the Ulu Jelai area of Pahang extending from the Cameron
Highlands south-eastwards across the Telom Jelai-Kechil watershed as far
as Kuala Lipis. Goitres among trout introduced into mountain streams
in the Cameron Highlands have been reported by Le Mare, 1144 who also
mentions the prevalence of the disease among the human population in that
locality.
Other goitre centres in Malaya are found along the western slopes of
the main mountain chain-for example, at Ulu Luit and Ulu Langat in
Selangor, and at Ulu Beranang in Negri Sembilan. In the kampongs situated
near Alor Gajah some 10 to 20 miles from the Malaccan coast prevalence
is much less than in central Malaya, and on the extreme south coast of
Johore and in Singapore goitre is practically non-existent.
Polunin's data are summarized in Table XX. In a total of 1328 people
- 6 1 8 Malays and 710 aborigines-dwelling in the inland parts of Pahang
and Upper Perak, and on the western slopes of the central mountain chain,
the goitre rate was 39.5 % for the Malays and 40.8 % for the aborigines.
The disease is not confined to any particular geological formation; indeed,
the only goitre-free area is one where limestone predominates.
Malayan waters are usually soft and their iodine content is exceedingly
low. Seven samples drawn from rivers draining inland areas where goitre
incidence is high gave values from 0.2 µ,g to 0.6 µ,g of iodine per litre. Iodine
deficiency is therefore considered to be the primary cause of goitre in
Malaya; calcium excess does not enter into the problem.
Indonesia
Centres of endemic goitre are found throughout the whole length of
the Indonesian archipelago, from Sumatra in the west to Timor in the east.
The following summary of affected localities is compiled from the papers
of Pfister, 1160-116* Donath, 1150 van Bommel, l H , Eerland, 11·51-1153 Eerland,
Noosten & Vos, 1f r 1 oosten,11· 59 Elsbach, 1155 van Gulik, 1157 Simons, 1167 and
others (see bibliography).
Sumatra
The northern and central volcanic regions inhabited by the Batak
people, including the high plains of Groot-Atjeh; the plateau of Gajo-
Loeos; the Lokop valley; the Alas valley; the east coastal plains of Bindjai
and Deli in the dusun of Upper langkat: the Siantar Uluan country; the
TABLE XX. PREVALENCE OF GOITRE IN RELATION TO GEOLOGICAL FORMATION IN M A L A Y A
Number of people Percentage

examined with goitre
Locality and race Geology
males Jtemalesf total males ftemalesf total
Pahang, Ulu Jelai

Aborigines granite 185 161 346 39 67 52
Ma lays limestone 230 190 420 22 52 36
Upper Perak
}
Aborigines 87 76 163 6 43 23
quartz porphyry,
limestone, granite
Malays 53 50 103 21 74 48
Western slopes of main
mountain chain •
}
Aborigines 117 84 201 21 55 35
quartz 'porphyry
and granite
Malays 50 45 95 38 58 47
Total . . . 722 606 1328 25 57 40

I I I I I I I
Coastal regions of Johore
}
Aborigines alluvium on 46 22 68 2.1 Nil 1.4
granite
Malays 76 40 116 Nil 2.5 0.8
Total . . .
I I ,122
I
62
I
184
I
0.8
I
1.6
I
1.1
Alor Gajah district, Negri

Sembilan
- limestone 31 42 73 6 17 12
* From Kuala Chenka in Perak through Selangor and Negri Sembilan to Lenek in Johore
mountain region of Sinaboeng and Sibajak; the whole area around Lake
Toba, including the peninsula of Samosir; Mandailing; the slopes of
Mount Ophir; the country surrounding Lake Koto as far as Padang-
Pandjang on the west; and Solok and Padang on the south. At the southern
end of Sumatra, goitre is prevalent along the Barisan mountains, particu-
larly in the sub-department of Lebong in the area of the river Ketuan; also
at Moeara-Aman and Benkoelan; and in the valleys of the rivers Batang
Hari and Komering.
As far back as 1883, Marsden 1158 wrote in his history of Sumatra that
" the natives of the hills through the whole extent of the island, are subject
to those monstrous wens from the throat, which have been observed of
the Vallais, and the inhabitants of other mountainous districts in Europe".
Today, incidence is still exceedingly high, amounting in some places to
more than 80 % in women and .60 % in men. Cretinism and deaf-mutism
are common.
Particularly goitrous are the inaccessible mountain tracts occupied by

the Batak peoples in the north-Gajo-Loeos (Atjeh), the Alas valley, and
all the country surrounding Lake Toba southwards to Padang and Solok.
The whole region has a volcanic geology and parts of it are almost entirely
covered with vast layers of light tuffaceous rocks and soils. According to
Eisbach 1155 the population of the Gajo-Loeos live in a perpetual state of
iodine deficiency. Drinking-waters contain only between 0.6 /Lg and 2.8 /Lg
of iodine per litre, and Alasland agricultural soils analysed by von Fellen-
berg for van Bommel 1147 showed an iodine content no higher than the
lowest values recorded for soils from European goitrous areas.
Java
The chief endemic foci in Java are the Residency of Kedoe; the Dieng
plateau; the villages around Wonosobo, Garoeng and Magelang; the
Tengger mountains; and, above all, Kediri, a district in the centre of the
country south-west of Soerabaja dominated by the two volcanoes Wilis
and Keloet. South-east of the Residency of Kediri, near Blitar, is Pena-
taran, where goitre is said to be endemic; the disease also occurs in the
remote limestone wilderness of Lodojo, and in a narrow strip to the south
of the Brantas river.
The prevalence of " gondok ", as goitre is called in Java, is normally
about 60 % among schoolchildren in Kediri, but may often be 80 % and
in some villages has been known to reach even 100 · Eerland, 1152 who
has studied this area closely, recorded 126 cretins, a much larger number
of cretinoids, and nearly 2000 deaf-mutes. He says that the normal thyroid
gland of Javanese peoples living in non-goitrous areas is smaller than that
of the European and averages 11.9 g. The so-called " normal" gland in
the goitrous Kediri district has an average weight of 52 g i n males and 57 g
in females. In a random sample of 249 goitrous subjects from Kediri, 67 had
goitres weighing over 500 g (1 lb). The two largest weighed respectively
2850 and 2930 g, or bet,veen 6 and 6.5 lb. Toxic goitre is rare in Java.
Superstitions regarding the cause of goitre include belief in " goitre
images". Near Penataran close to the source of the Soemberdandang
stands a Hindu goitre image with the head of an elephant. People believe
that at certain times this image pours water from its trunk into the nearby
wells and streams, and that anyone drinking this ,vater will inevitably
contract goitre.
Bali
Expert studies of ancient Javanese medical texts written on copper and
on lontar leaf indicate that goitre has afflicted the island of Bali for perhaps
ten centuries. With certainty the disease has been known there for a hundred
years; it is mentioned by almost every writer on goitre in the Dutch East
Indies since 1856.
The plateau of Tjatoer in the north-east section of the island is the

major seat of the endemic. Anyone who has witnessed market-day at
Kintamani when people come together from the whole plateau will be
convinced of this at a glance. Moreover the area provides another striking
example of the extraordinary selectivity of the goitre noxa. At the end
of a path leading off the main road between Singaradja and Kintamani lie
two villages-Lampoe and Tjatoer-quite different in character although
only a few hundred yards apart. Lampoe is the home of about 100 Chinese
traders, established there for three generations and much intermingled by
marriage with the native Balinese. Food is varied; water is boiled before
use; there is not a single case of goitre. Tjatoer, on the other hand, contains
some 700 pure Balinese belonging exclusively to the Bali Aga race, the ori-
ginal inhabitants of the island. These people lead quite different lives from
their immigrant Chinese neighbours. Poverty-stricken, unwashed, and
commercially undeveloped, they subsist on a monotonous diet of maize
and rice; water is drunk unboiled from a goitrogenic spring cursed by
Dewa Belanga (see below). Goitre is very prevalent in Tjatoer.
Noosten, 1159 to whose exhaustive description of goitre in Bali we are
indebted for the foregoing, also gives an intenseiy interesting account of
the traditional beliefs concerning the infliction of thyroid disease by the
goitre goddesses Dewa Ajoe Bengkala and Dewa Belanga, and of the
lengthy and involved festivals (slametans) celebrated, often at great cost,
to placate these ill-disposed deities and exorcize their evil spirits. Noosten
also details some of the complex mediaeval concoctions prescribed as
remedies for goitre in Bali, and gives examples of the secret incantations,
or mantras, recited when these medicines are administered. He illustrates,
too, some of the magic figures and devices scratched or engraved on the
cooking vessels in which the recipes are prepared. These primitive signs
are supposed to enhance the magic power of the drug.
From all his patient collection of facts and folklore about goitre in
Bali, Noosten concludes that preoccupation with the disease, and in fact
the whole goitre concept, is deeply rooted in the Balinese people. No
better evidence of this can be found than in the words uttered when a
Balinese wishes emphatically to protest his innocence: " Apang gondong
tiang toesing nawang ", which means " May I get goitre i f I know anything
about i t " .
Celebes and Timar

Goitre occurs at Madjene and at Maros on the west coast of Celebes
(Donath 1150 and Noosten 1159). Two other centres are marked on Noosten's
map of this oddly shaped island, one almost at the tip of the northern arm
in the neighbourhood of Kotamobagoe and the other near Masamba in
central Celebes due north of the Gulf of Bone.
In Portuguese Timor, goitre is known throughout the north-east section

of the island between :\1:anatuto on the north coast and Kailaco on the
south (Noosten 1159). Most modern statistics from this region are those of
Fraga de Azevedo, Franco Gandara & Pedroso Ferreira 1156 whose survey
(1958) revealed an average rate of 10 % in the two upland localities of
Laclubar and Fato-Berlio. The fundamental cause of goitre in this area
appears to be lack of sufficient iodine in the water supply, coupled with a
diet predominantly carbohydrate and low in fat and protein.
Indonesian Borneo
In central and south-eastern Borneo goitre is reported 1159 to occur at
the following places: (1) along the Melawi valley, in the neighbourhood
of Sekajam, and in the Sipoeak river area; (2) on the Apo-Kajan plateau
and in the Kotei or Mahakam river basin to the north-centre of the country;
(3) on the banks of the Barito river, and at Meratoes and Martapoera in
the south-east of the country. Details of incidence and other features of
the endemic in central Borneo are lacking.
Goitre prophylaxis in Indonesia

Preventive measures were first introduced in 1927, when iodized salt
(1 : 200 OOO) was distributed throughout the Dieng plateau and Tengger
area of Java. By 1930 prophylaxis had been extended to the Gajo and
Alas regions of Sumatra, and in 1933 the Kediri Residency of Java followed
suit. 11 50 , 1159, 1166 Writing in 1939, Simons 1167 pronounces the step justified by
the favourable results and makes a plea for its extension. He affirms that
iodized salt is completely harmless.
At the time these preventive measures were introduced, salt was manu-
factured under monopoly and in block form only at the salt works on the
island of Madoera off the north-east of Java. The method of iodization is
unique. In view of the high temperature to which the salt is exposed in the
brick-making machine, it is essential to avoid incorporating iodine in the
salt before it passes into the machine, otherwise iodine will be lost in
the process. Instead, each salt brick destined for prophylactic use is soaked
after it has been made with 1 ml of a solution of potassium iodide and sodium
thiosulfate in water. The liquid, containing 3.3 mg of potassium iodide
per ml, is poured from a small spoon into a hollmv on the top of each
brick, and by capillary action spreads evenly throughout the entire brick.
In this way 3.3 mg of iodide are absorbed by each 600-g brick, giving an
iodization level of 1 in 200 OOO (Donath 1150).
Around the year 1939 or 1940, the level of iodization was raised from
1 in 200 OOO to 1 in 100 OOO, and experiments were made by Van Veen me
(also personal communication, 1950) in the goitrous Kintamani plateau
of Bali to see whether the crude sea salt used by the Balinese population
could be iodized in granulated instead of brick form without loss of the
added iodine. It was proved that if the loose salt were stored dry in bamboo
containers near the fire according to local custom, no loss of iodine occurred.
North Borneo
Goitre is endemic over a large area of North Borneo; it is regarded with
much aversion by all natives and is responsible for a great deal of the
inbreeding and degeneration which has occurred there (Clarke ;1172 Mazat ;1174
Regester; 1175 F. Heim-personal communication, 1953). In the country of
the Muruts and Dusuns, primitive aboriginal peoples living in the southern
part of the Colony roughly south of a line joining the northern shores of
Brunei Bay on the west coast with Mount Trusmadi in the interior, the
principal endemic areas are : the Bokan country, Ulu Kinabatangan,
Tomani area, Bole district and Ulu Mengalong.
The best modern account of goitre in these communities is by Regester 1175
who emphasizes the ubiquity of the disease; wherever he went, the great
majority of people had clearly visible fullness of the thyroid. Exophthalmic
goitre, toxic or degenerative changes, myxoedema and cretinism he never
saw.
On a two-week medical mission into the Murutjungle in 1958, Mazat 117 4
encountered a 90 % occurrence of colloid goitres " of huge dimensions ".
In contrast to Regester, he saw typical signs of cretinism akin to those
recorded by Clarke. 1172
The disease also occurs sporadically in the hills to the west of the Ken-
ingau plain, in the Dalit, and between Melalap, Tenom and Kamabong.
Other goitre centres that have been named are the Pansia district of Sipitang;
Bundu Tuhan in Ranau; the Tambunan hills, especially Monsak village;
the Lanas district of Tulid; and the hill regions of Kudat.
Systematic clinical surveys have not been made, but reports from
medical officers fix the goitre rate at anything between I % and 25 %.
F. Heim (personal communication, 1953) describes the prevalence at three
Minokok villages in Upper Kinabatangan as "rather high", and a rate
of 33.6 % has been recorded among 1014 natives examined in the Bokan
country. 1173 The disease is between two and three times as frequent in
females as in males. Usually the thyroid swelling becomes apparent about
puberty and may reach a very large size in adult life. Thyrotoxicosis is rare.
The goitre centres are mostly situated in jungle-clad hilly country of
sand and limestone through which the streams and rivers run rapidly over
stones and boulders. Clarke 11 72 found it an unusually interesting experience
to conduct clinics in areas where cretinism is endemic. The hill Kwijaus
and the Muruts living in the secluded goitre-bearing hills of the middle
Padas between Kamabong and Bole are particularly affected. Briefly,
outstanding features are reduction in height, often with disproportionate
shortening of the limbs, a general physical podginess with thick dry skin,
short thick fingers, protuberant abdomen, perhaps umbilical hernia, dull
expressionless faces, noses with widely patent nostrils and depressed bridges,
thick lips, exaggerated bossing of the skull, and various degrees of mental
retardation. Many of the good-natured dwarfs show a specious giggling
brightness; not a few are deaf or dumb, or both. The worst cases, sub-
human in appearance, are seldom seen, as they are hidden in the jungle
at the approach of strangers.
Some half-hearted attempts have been made to supply the natives
with iodized salt in certain areas of the interior by means of air-drops or
by overland routes. In Heim's experience (personal communication, 1953)
the natives would readily take to iodized salt and in some instances have
themselves requested the Government to arrange for its purchase.
Sarawak
T. Harrisson (personal communication to I. Polunin, 1146 1951) who
has made a special study of goitre in Sarawak, states that the disease is
common in certain inland areas, sometimes to a serious extent, whereas
other inland areas not far distant are completely non-goitrous. This im-
munity applies particularly to the Kelabit country, which covers the upper
Baram river district in the interior of the 4th and 5th Divisions of Sarawak.
Here the people are goitre-free because they use an iodine-rich salt derived
from local salt springs, of which there are about twenty or thirty in the
neighbourhood. By contrast, in the areas of the interior where goitre occurs,
Kelabit salt is unobtainable and people rely solely on imported salt.
Samples of Kelabit salt have been chemically examined by B. W. Simp-
son (personal communication to I. Polunin, 1146 1951), who found an iodine
content of 10.5 mg per kg (i.e., 1 in 95 240), and later by M. M. Murray
(personal communication, 1955) who found 65.2 mg per kg (i.e., 1 in 15 330).
Even the lower of these levels would be quite sufficient to prevent goitre
in a community regularly using this salt.
W. G. Evans (personal communication, 1955) writes that some of these
protective salt springs in the Kela bit country are no more than a wet seepage
out of the ground; the local people, having first prepared the ground, insert
a hollow tree-trunk deep into the origins of the ,vater to make what is in
effect a narrow well. The saline ,vater is then siphoned out and subjected
to a lengthy evaporation process by vigorous boiling over a wood fire. The
salt thus produced is a very valuable commodity in the Kelabit outlands
and although it is not possible to place a monetary value on it because
cash is so little used in these parts, it can be said that a few ounces are sufficient
payment for a hard day's work.
The natives fully appreciate that their freedom from goitre is due to
their use of this salt, and for this reason Kela bit salt is not only esteemed
for its protective virtues but also has a reputation as a curative for existing
goitre.
China (mainland)
Endemic goitre is of ancient lineage in China. From time immemorial
travellers penetrating into the fastnesses of its northern, western and south-
western provinces have been struck by the evidences of human misery and
degradation due to goitre and cretinism; their diaries and journals are full
of vivid impressions which these scenes have made.
The Chinese term for goitre is Ying, meaning a tassel hanging from the
neck. Lee 1193 cites references showing that the disease was known in China
in the third century B.C. and that its treatment by alcoholic infusion of
seaweed was practised at that time. Marco Polo 388 saw goitres in the
Chinese Turkestan provinces of Kashgar and Yarkand when on his famous
travels from Venice to the court of the Grand Khan about the year 1275.
Six centuries later, Hosie 1186• 1187 speaks of the " enormous and unsightly "
goitres he encountered when journeying through the Provinces of Szech-
wan, Kweichow and .Yunnan in western China; and Warwick 1215 makes
similar references to the prevalence of the malady in many sections of the
Great Wall, along which he explored for a thousand miles in the early 1920's.
Other Western writers who recount like experiences in different parts
of China are Hewett, 1185 Lewis, 1194 Bolt, 1179 King, 1190 Rock, 1207 Miller, 1199-1201
Maxwell, 1198 McClendon, 1197 and Robertson. 1204- 1206 In recent years Oriental
medical scientists have themselves added greatly to the documentation.a
The main goitre belt begins in the north-east of the country in the
neighbourhood of Shanhaikwan on the southern border of Manchuria
(now the North-East Administrative Area of China); it follows a westward
semicircular route across the mountainous watershed north of Peking into
Chahar and Suiyuan, and then turns south through the Province of Kansu
as far as Chinghai. From thence it extends through Sikang and the western
regions of Szechwan and Kweichow into Yunnan, the most goitrous
province in all China. With the possible. exception of Tsungming Island in
the mouth of the Yangtse where goitre has been noted by Maxwell, 1198 all
the coastal provinces, including those of the great plain in the east-centre
of the country, are virtually goitre-free, at least so far as the simple endemic
variety is concerned; but everywhere in these provinces cases of Graves'
disease are frequent. Indeed, of all goitre cases brought to Miller's 1201
attention in these areas about 60 % were toxic. A good goitre map of China
is given by Liu & Chu. 1196
Northern China
On a journey from Peking northward to Jehol via the plain of Chihli,
Tungchow, Yenchiao, San-Hohsien and Chichou, Bolt 1179 found well-
marked endemic goitre nests in the mountainous country extending up into
the Feng Shui Ti district. Throughout the fertile plain of Chihli to the east
a See references 1177, 1180, 1188, 1189, 1191-1193, 1196, 1202, 1203 and 1208-1213 in the bibliography.
of Peking, drinking-water is hard, but only occasional thyroid enlargement

was seen; in the mountainous region farther north, however, the water is
obtained largely from shallow surface wells and is undoubtedly soft. It is
almost always boiled before use. Here, by a rough and ready method, Bolt
estimated the goitre rate to be 40 % in men and 60 % in women. When
questioned about their neck growths the people affirmed that they were due
to a lack of something in the water and even claimed that they arose because
the water was soft. This recalls conditions in Malaya (see page 167) and
suggests an absolute deficiency of iodine as the cause, and not pollution or
the presence in water of any other goitrogenic factor. Bolt also noticed the
peculiar fact, which may or may not be relevant, that the shells of hens
eggs in this vicinity are much thinner than usual and that many of them are
so deficient in lime salts as to leave the egg membranous in places.
Writing of this area, Adolph & Ch'en 1176 mention especially the intensity
of the disease near the \Vestern Tombs and Eastern Tombs (Imperial
Burial Grounds) situated respectively to the south-,vest and north-east of
Peking in the Province of Hopeh. Entire villages in these regions are
reported to be almost 100 % goitrous. Analyses by Adolph & Ch'en show
that the iodine content of water and foodstuffs from the environs of these
mausolea is generally speaking less than that of foods and water collected
in non-goitrous parts of Hopeh and the neighbouring Provinces of Shantung
and Shansi. Adolph & Whang ms also found adequate amounts of iodine
in vegetable foods from the Soochow-Shanghai area, where simple goitre is
extremely rare or non-existent.
The goitres of North C h i n a - a n d this is particularly true of the Peking
district-are of the non-toxic type; the swellings vary in size from that of
a hen's egg to that of a melon (Bolt 1179).
Western China
During his several expeditions through the Provinces of Kansu,
Szechwan, Kweichow and Yunnan in western China, Hosie 1186, 1187 saw
goitre at many places, in both sexes, and at all ages. King rno confirms that
parts of Kansu, particularly the high plateau south of the Mongolian border
watered by the upper reaches of the Yell ow River (Hwang Ho), are very
goitrous. Spring water or the water of mountain streams in which the roots
of willows or other trees are exposed is the native explanation of the cause.
The disease is also prevalent in the Gold River district on the China-
Tibetan border where a survey has been carried out by Liljestrand. 1195 It is
frequent, too, in the Sungpan region to the north-west of Szechwan. Here,
the people eat Ching salt and Tsou salt, both of which contain barely
sufficient iodine ( 1 : 111 OOO and 1 : 170 OOO, respectively) to protect against
the action of any strong local goitrogenic agent. It is believed by Cheng &
Ku 1180 that the customary high cabbage dietary of the Sungpan people is
responsible for tipping the scales to the side of iodine insufficiency.
But, of all goitrous Chinese provinces, the one about which most has
been written is Yunnan on the borders of Burma in the south-west: Writing
of Kakatang, a village on the Weisi-a tributary of the Mekong river-in
northern Yunnan west of Likiang, Rock 1207 says: " What sights one can
behold in such a place as Kakatang ! Nowhere have I seen goiter so pre-
valent as here. The people carried regular pouches in their throats like
certain monkeys when they fill up with peanuts. One man, half blind, was
loaded down with a goiter so huge that the weight of it dragged down his
lower jaw, making it difficult for him to keep his mouth closed."
The most impressive accounts of goitre in Yunnan are those by
Jeanselme 1142 and by Robertson. 1204- 1206 The former entered Yunnan from
the south after completing his goitre survey of Indo-China and saw many
cases in the villages and market-places frequented by the mountain-dwellers
between Man Hao on the southern border and Kunming (Yunnanfu), the
capital of the province. Jeanselme estimated the over-all rate in Kunming
to be 20 %, and he records that the disease is no less severe in the prefecture
of Kai Hoa, lying farther to the east. At Tali, and all around the great lake
on which Tali is situated, Jeanselme saw many myxoedematous cretins with
wan and puffy faces and unsteady gait.
Conditions as revealed by Robertson's survey some thirty years later
were no different. He was concerned chiefly with the health status of
peoples living along the route of the great Burma-China highway and in
the adjoining country. Inspection of the adult population of both sexes
working in labour gangs during the construction of the road disclosed a
goitre rate of 80 % in some gangs, the average in all gangs being over 50 %.
Robertson was much struck with the patchy distribution of the Yunnan
endemic. In the north-west, the people all along the valleys of the Salween,
Mekong and upper Yangtse rivers are very heavily affected, but the disease
is not so evident west of Pao-shan. Similarly, on the road from Kunming
to Hwei-tsheh in the north-east there are villages in which almost everybody
has a goitre, whereas Hwei-tsheh itself is not markedly goitrous. Robertson
explains the patchy distribution on geological grounds. In the western part
of the province, before one comes to the canyons of the Mekong and
Salween, the country is composed of irregular ranges of upper grasslands
and undulating plains where pastoral agriculture is intensively practised.
Much of this country is on porous limestone soil and it is here, in remote
villages, that goitre is evident both in man and in his flocks and herds.
Throughout the lower-lying parts of the province where rice, potatoes,
wheat, and fruits and vegetables of all sorts are cultivated, the disease is not
so prominent.
Others who have commented on goitre occurrences in this general area
are A. J. Broomhall (personal communication, 1950), who speaks of the
frightful goitres seen in the Si-Chang district of Sikang, and Galt,11 84 who
describes the disease as fairly common among the Tai and almost universal
among the mountain Kaws inhabiting the Kiulungkiang (Chili) region of

southern Yunnan.
From his exhaustive studies, Robertson 1204-1206 concluded that extreme
environmental iodine deficiency aggravated by an excessively hard water-
supply is the cause of goitre in Yunnan. Proof of this is seen in the fact
that the disease is not usually so severe, if it exists at all, among communities
in West China who are accustomed to using local salts rich in iodine-for
example, the salt mined at Nanlang in Szechwan. The salt derived from
Yunnan mines is deficient in iodine and Robertson suggested that as a
partial preventive measure it should be mixed with Szechwan salt in equal
parts.
To arrange systematic goitre surveys in Yunnan and to organize pre-
ventive measures, an advisory committee entitled the Yunnan Anti-Goitre
Association has been formed under the honorary presidency of the Governor
of the Province.
Southern China
Jeanselme 1142 refers to Simon's observation of goitre among mountain-
dwellers in the environs of Lungchow, a town in the Province of Kwangsi
close to the North Viet Nam border. Farther to the east, Lewis 1194 un-
expectedly came upon a strong focus of goitre in the Province of Hunan
when journeying over the mountains between Lanshan and Lienchow.
Nearly at the top of the ridge is a village where he saw greatly enlarged
thyroids in large numbers. The villagers told him that the disease was of
long standing and that practically the entire adult population were victims.
North-East China (formerly Manchuria)

Yamaguchi of the Manchuria Medical College, Mukden, was the first
to take up the scientific study of goitre in former Manchuria. He published
his results in the Journal o f the South Manchuria Medical Society in 1921,
but in spite of much effort the present writers have not been able to see
Yamaguchi's original accounts and it is believed that many who quote
him can never have seen them either. Apparently the reports cover the
incidence of the disease according to locality, sex and age, and call atten-
tion to the possibly decisive role that an excess of lime in drinking-water
may play in causation. Yamaguchi's work was continued by his colleagues,
and between 1935 and 1939 detailed studies of the Manchurian endemic
and its relation to environmental iodine supply were published by Kodama,
Suzuki & Masayama, 1191 Takei and his colleagues, 1211- 1213 Takamori, 1209, 1210
Noda, 1202 and others. No recent accounts of goitre in former Manchuria
appear to exist.
The principal focus lies in Jehol, the proYince in the south-west of
North-East China (formerly Manchuria) adjoining Hopeh in North China.
Here, the endemic may be regarded as continuous with that already described
12
as occurring along the Great Wall north of Peking. It particularly affects

the: district of Pingchuan and the north side of the Wall, but is also severe
farther to the north and north-west at Lingyuan, Chengteh, Luanping,
Lunghwa, Chihfeng and Weichang.
The goitre prevalent in Jehol is classified by Takei 1212 and Takamori 1209
as belonging to the Alpine type and is commonly associated with deaf-
mutism, idiocy, cretinism and myxoedema. The goitre rate varies between
10 % and 60 % and may be as high as 85 % in the Pingchuan area. Chinese
and Mongolians are equally prone to the disease and immigrant Japanese
rapidly become victims; a Japanese non-commissioned officer acquired
a goitre four months after entering the country and a consular police
official contracted a second-degree thyroid enlargement (Dieterle's scale)
within nine months of being stationed at Pingchuan. As usual, incidence
is higher in females than in males; infants are occasionally affected.
East of Jehol, goitre occurs in the basin of the river Liao and in the
upland parts of the Liaotung peninsula, where Siuyen (west of Antung)
and Huanjen are especially mentioned. Elsewhere in former Manchuria
there are goitre pockets to be found throughout the eastern hills, for example
at. Tunghwa and Mishan which lie 300 and 600 miles north-east of Antung
and Mukden, respectively. Other centres are found at Hulan and Suihwa
immediately north of Pingkiang (Harbin), and throughout the Khingan
Mountains in the extreme north at the head-waters of the Nonni river
(McClendon; 1197 Noda 1202).
The results of various analytical and biochemical investigations have
been advanced by the Mukden medical school and their associates as
evidence that the principal cause of goitre in former Manchuria is insuffi-
ciency of iodine in soils, 1202 water 1191, 1208 and local foods. 1212 By themselves,
the data are not wholly convincing unless other factors are taken into
account. For example, well-waters from Jehol, where goitre is rife, register
from 4 µ,g to 14 µ,g of iodine per litre, a level at which goitre would not
normally be expected to arise. It must be remembered, however, that
waters in the Jehol area are so excessively hard that an iodine level of
even 14 µ,g per litre may fail to protect. At Talien (Dairen), on the goitre-
free tip of the Liaotung peninsula, the water contains 24 µ,g of iodine
per litre.
Studies by Noda 1202 not only in Jehol but throughout the whole of
former Manchuria show that the amount of iodine in soils where goitre
prevails is distinctly less than that in soils from non-goitrous districts, thus:
Prevalence of goitre Soil iodine
(µg per kg)
Nil (peninsular Liaotung) 2249
Nil (Upper Sungari). 1 567
Under 10% . 1 397
10% to 5 0 % . 1 053
Over 50% . . 791
The highest rates are in areas underlain by pre-Cambrian and limestone

formations.
There are no recent reports regarding preventive measures in former
Manchuria, but twenty years ago treatment by means of iodine was carried
out in parts of Lingyuan, one of the worst districts of Jehol, and marked
improvement was noticed after about two months. Of 9 children treated
under 10 years of age, 6 recovered; of 56 between 10 and 20 years, 12
recovered.
Recent preventive drive
Establishment of the People's Republic of China in 1949 brought
organized improvement into every branch of public health, including
co-ordinated efforts to assess the extent of goitre and stamp it out. Since
1958 the application of prophylactic and therapeutic measures has leapt
ahead in practically all endemic areas.
The campaign has involved examination of 7 585 311 persons of whom
592 702 were found to have goitre. This means an average rate of 7.8 % ;
but, as seen in Table XXI, rates vary locality by locality from 2.8 % in
Kirin Province (North-East China, formerly Manchuria) to 82.3 % in the
mountainous far western Province of Kansu.
The chief prophylactic method adopted is the supply of iodized salt; but
traditional drugs containing iodine, iodized oil, and potassium iodide in
fairly large doses are also employed. One year after the introduction of
TABLE XXI. PREVALENCE OF GOITRE IN CHINA
Locality ! Individuals Number Percentage Percentage

Province I(no. of areas surveyed)! examined with goitre with goitre range
Kirin Li Shu 454117 12 837 2.8

Hopeh Changchiakou (3) 8 536 1 249 14.6
Ching Lung (3) 2 308 1 632 70.7
Yi 326 811 49 021 15.0

Shansi Tai Ku & Hsin Yuan 4135 2 244 51.8 34-61
Chieh Hsiu (5) 2 962 705 23.8
Honan Lu Shan 422181 130 581 24.1

Nanyang 6352418 391 334 6.1 1-38
Hupeh Huang Chan 9 950 1 540 15.5 9-34
Hunan Chien Yang 438 888 1-70
Kansu Hsu Kou & Kao Chia 1 893 1 559 82.3
7585311 592 702 * 7.8
* Total excludes Hunan; number examined is not available.

iodized salt (1: 5000) into Changchiakou, re-examination of the populace

disclosed no new goitre cases in that area. In Hunan, re-examination of
264 goitrous individuals two months after the introduction of iodized salt
(1 : 100 OOO or 1 : 50 OOO) revealed a reduction in the circumference of the
neck in 63 % of.these cases. Similar satisfactory results with iodized salt,
iodine-containing drugs and iodized oil have been obtained elsewhere in
China.1182, 118a
Animal goitre in China
Imperfect calcification of hens' e g g s - a common occurrence in the
mountain country north of Peking-has already been mentioned as possible
evidence of iodine. deficiency. From the same area comes Geil's observation
(see Warwick 1215) that goitrous antelope are not unusual in the Imperial
Forest Preserve at the Tung Ling or Eastern Tombs. Robertson 1205, 1206
suggests that iodine deficiency is the cause of abortion in cows in Yunnan
Province, and preliminary observations led him to believe that many
horses and cattle in West China suffer from lack of both salt and iodine.
Korea
Apparently the only part of Korea where goitre is endemic is the Kangai
neighbourhood in the northern hilly section of the country. Here, according
to Mills,1216· 1217 simple goitre is quite common in various stages of develop-
ment, and the Koreans have a saying that anyone who drinks the water
that drains from the decaying roots of the edible pine will develop the
disease.
Smith 1218 suggests that in all probability the fact that no part of the
Korean peninsula is far removed from the sea, and that sea foods are a
large factor in the diet of the people, accounts for the comparative rarity
of endemic goitre in the country. On the other hand, at the time of writing
(1928), he could discern that cases of hyperthyroidism were on the increase
throughout Korea.
A survey of the nutritional status of Korean military forces conducted
by Williams et al.1219 in 1956 disclosed virtually no evidence of goitre.
Palpable thyroid enlargement was observed in only 0.8 % of individuals
examined.
Taiwan
Goitre is exceedingly common in Taiwan. Maxwell 1198 records that
in certain mountain villages almost all the inhabitants have the disease.
Affected areas include the Oka area of Taipeh (Taihoku) District in the
north, the Taiko neighbourhood in the west, the Chiushe-Houli-Fengyuan
area in the centre, and the regions of Pinan and Dainan in Taitung (Taito)
District in the south-east of the island. Surveys of prevalence have been
made by Kawaishi, 1227 Hashimoto & Kyo, 1225 Hashimoto & Sha, 1226 Ka-
waishi & Hashimoto, 1254 Chen, 1220-1224 and Ko. 1228- 1233 Some representative
results are shown in Table XXII.
TABLE XXII. PREVALENCE OF GOITRE IN T A I W A N
Number Number
Area of people of people
Percentage
with goitre IBibliographical
reference no.
examined with goitre
Entire island (over-all

prevalence) 318116 26 979 8.5 1227
Oka district of Taihoku 23 463 6 200 26.4 1225
Pinan and Dainan
I
districts of Taite 4 060 745 18.3 1226
The rate in the north and west was highest at Sek:itokei in the Oka
area (45.4 %) and lowest at Taiko (17.2 %). Cases were especially numerous
in the region of the Kanwen delta (40. 7 %) and in the basin of the Tansui
river. Rates in the Pinan and Dainan regions of Taitung varied from 5 %
at Miwa to 26.7 % at Rika. The highest rate (63.5 %) was recorded by
Kawaishi & Hashimoto 1251 in the Shirakawa of Mizuho in the foothills
on the mid-eastern side of the country. Topographical features of the
endemic region have been thoroughly investigated by Ko. 1228-12a1
Evidence points strongly to the fact that insufficient iodine intake is the
main cause of goitre in Taiwan. Ko 1230 incriminates the sandy and alluvial
soils characteristic of practically every goitre area in the country, and
believes that nutritionally-deficient vegetable foods grown on these soils are
largely accountable. Kawaishi 1227 considers, however, that mere iodine
deficiency is not entirely responsible and that geochemical and climatic
factors which raise the demand for iodine must also be taken into account.
Since hypercalcaemia is rather common among goitrous people in Taiwan,
a deranged calcium metabolism is regarded by Kawaishi as possibly asso-
ciated with goitre causation. Sai 1235 examined this question but could find
no statistically significant relationship between the blood-calcium level and
the type and extent of thyroid enlargement in cases of endemic goitre in
Taiwan. There was, however, a tendency for the urinary excretion of
calcium and potassium to be greater than normal in both endemic goitre
and Basedow's disease.
On returning to his native Yillage-Chiushe in central Taiwan-after an
absence of some years during the 1939-1945 war, Chen 1221• 1224 was struck
by the noticeable increase in simple goitre. Formerly, goitre had not been
prevalent to any marked degree in this district and its emergence suggested
the existence of some goitrogenic influence engendered by wartime condi-
tions. Indeed this is probably true; the local dietary had perforce changed
from one of rice, potatoes, green vegetables, pork, beef, sea-food, lard and
peanut oil, to a less vital diet consisting of cabbage, potatoes, bean leaves,
cassava, wheat, and the seed-oils of rape and flax. Little wonder that ,
physical disabilities obtruded-with evident thyroid enlargement among the
first symptoms.
Over nine years and eight months, May 1945 to December 1954, Chen 1223
administered therapeutic doses of iodine (average dose 1.5 mg daily) to
2838 goitre patients in the Chiushe area. A favourable response was
observed in 63.3 % of cases.
In regions where human goitre is endemic, thyroid enlargement also
occurs among pigs. Kobayashi 1234 examined the thyroids of 200 castrated
male and female pigs and found no less than 81 % of enlarged thyroids in
those from Oka village. One gland weighed 550 g. In Hwalien (Karenko)
District, where there is a 65 %-70 % rate of human goitre, 48 % of pigs were
affected. Histological sections taken from thyroids which outwardly appear
normal reveal cellular changes indicating that so-called " normal " glands
from this area are already in a pre-goitrous state before visible etllargement
begins. Castration has no influence on the development of goitre in pigs.
Japan
There is general agreement that, compared with other countries in the
same geographical region, simple goitre is not a problem of any magnitude
in the main islands which make up Japan-Honshu, Hokkaido, Kyushu,
and Shikoku. On one occasion, McClendon went looking for goitres in
likely places in the interior but could find no more than four cases among
20 OOO inhabitants (McClendon, 1258-1262 Aschoff, 1239 Papellier, 1275 Kawaishi
& Hashimoto 1254).
Comparative absence of the disease is ascribed by some to the widespread
and regular habit of eating seaweed. In Japan seaweed is served in a variety
of ways as a constant article of diet and an amount of 10 g (dry), or even
more, is often the portion for one person at a meal. On average, 10 g of dry
seaweed would contain about 5 mg of iodine.
However, as Greenwald 1243 has pointed out, Japan is not by any means
free from simple goitre. There are foci in mountainous inland localities, and
on the coast, where thyroid enlargement is common; indeed, the rate may
be quite high. For example, in Gumma (Gunma) Prefecture in the interior
of the country north of Tokyo, Hichijio 1246 found I I. I % of goitres among
the 16 202 boys and girls he examined in 1953. Four years later, on a
resurvey of Gumma children, he found 8 % in boys and 14 % in girls; and
in one mountainous locality no less than 32 % of boys and 46 % of girls were
seen with goitre. 1247 A rate of 22.4 % has been recorded by Hichijio 1246
among children in Shizuoka Prefecture. These rates contrast with about
2 % in the coastal town of Fujisawa south-west of Tokyo.
PREVALENCE AND GEOGRAPHICAL DISTRIBUTIO)< 183
Similarly, in Gifu Prefecture north of Nagoya in central Japan, Kat-

sumata & Murakami 1252 examined 2434 girls and young women, of ages
13 to 26 years, at 15 different girls' schools and silk mills in 13 different
localities, and found undoubted thyroid enlargement in 1242 (50 %) of these
subjects. Rates varied from 5.4 % in a school at Seki situated on the plains
at the edge of the mountains to 61 % in a school at Funatsui, a town high
in the Japanese Alps.
It is true that the great majority of these enlargements (96 %) were not
visible to the naked eye and were only determinable on palpation. Never-
theless, the high prevalence of palpable thyroid enlargement among girls
in the Gifu area indicates that the zone is potentially goitrous. Katsumata &
Murakami 1252 refer also to the occurrence of puberal goitre in Aichi Prefec-
ture south-east of Nagoya and mention likewise that the Prefectures of
Hyogo and Okayama at the western end of Honshu are not immune.
The prevalence, however, is slight; a survey by Morinaga 1268 in 1950 showed
only 4.6% of cases among 1480 children (6-14 years) at schools in the
vicinity of Yakake in Okayama Prefecture, and 4.7 % among 1516 out-
patients attending Yakake hospital.
At Kamikitayama in the Yoshino district of Nara Prefecture, the
southernmost part of Honshu, Watanabe et al.1 292 saw goitres in 19.6 % of
children in their early school years. But among children in middle school
life the rate had jumped to 31.6 % (26.6 % in boys and 32.8 % in girls).
Other Prefectures in Honshu to which reference is made in the goitre
literature of Japan are Tochigi, 1276 Chiba, 1249 Toyama 1269 and Tottori. 1274
Goitre foci are known also in Hokkaido, the most northerly island of the
country. Here, surveys have been made by Fujii; 1240-12 J2 Hashiba, Ogawa &
Otsuka; 1245 Inoue et al.; 1251 Maeda et al.; 1263 Morikawa et al.; 1267 Okii; 1273
Takata; 1285, 1286 Takeda et al.: 1287 and Usubuchi & Murotani. 1291
In the Hidaka highlands to the south of Hokkaido a rate of 3.05 % has
been recorded among a total of 4683 primary, junior and senior high-school
minors of ages 6 to 18 years. Incidence increases towards the east of the
Hidaka region, reaching 7.31 to 12 lo at the coastal villages of Erimo,
Meguro and Shoya situated at the tip of the Erimo peninsula. Horoizumi,
on the west coast somewhat north of Erimo, is another goitre centre. In the
south-west of the island Okii examined 2234 people in and around Esashi
and found an over-all rate of 2.3 %, the highest rate being in the area of
Kamomejima. Fujii 1240 describes goitre as endemic in a fishing village in
Matsumae-gun at the extreme south-west of Hokkaido island. The offshore
islands of Rebun, Rishiri, and Teuri to the far north-west of Hokkaido are
also reputed to be goitrous (Usubuchi & Murotani; 1291 Inoue et al.1 251).
Shikoku island contains a markedly endemic area in Ehime Prefecture to
the west. And on Kyushu, the only black spot appears to be Wakamatsu, a
town right on the very northernmost extremity of the i s l a n d - a situation
exactly similar to that of Rebun and Rishiri (see above) and many others,
and full of provocative interest vis-a-vis the generally accepted theory of

goitre genesis.
Field surveys and laboratory research on goitre among goats, dairy
cows, beef-cattle, pigs and sheep in the endemic Nagano and non-endemic
Toyama Prefectures of Honshu have been the immediate concern of Taka-
mori and his colleague Yuki in a series of eight papers. 1277 - 1284 Exceptionally
heavy losses of newborn lambs and kids in Nagano during recent years are
attributed to iodine deficiency for which the only preventive recommended
by Takamori and his school is the iodization of animal-feeding salt in the
proportion of one part of potassium (or sodium) iodide in every 1000 or
5000 parts of salt, depending on local circumstances. In Hokkaido, the
geographical coincidence of goitre in the animal population-horses
particularly-and in the human population has been noted by Maeda
et a l . 1 2 6 3
Philippines
According to Miller, the Filipinos show the highest goitre frequency of
any people residing in the Orient. The disease, he says, seems to be almost
as prevalent in the Philippine Islands as in Switzerland. 1200 , 1201
Early records collected by Greenwald 1296 prove that goitre was known
in the Province of Batangas at the end of the eighteenth century, in the
Province ofTayabas in 1845, and among the Bontoc Igorots in the highlands
of northern Luzon at the beginning of the present century. In 1905, Dun-
can 1293 reported its prevalence in a tribe living at Macabebe on the marshy
northern shores of Manila Bay.
No systematic modern survey of prevalence has been made, but case-
histories and hospital records relating to the number, type and provenance
of thyroid patients operated upon in Philippine hospitals between 1909 and
1948 have been studied and analysed by various writers. These show that
goitre is found in nearly all the 49 provinces composing the archipelago
(Lopez-Rizal & Padua; 1299 Reyes; 1302 Erickson; 1294 Estrada, Nery & De
Vera; 1295 Recio 1301).
The chief goitre region in the Philippines is the Province of Nueva
Ecija in the central valley of Luzon where the twin municipalities of Pefia-
randa and Papaya are notorious as the home of goitre in the Islands. Other
centres in Luzon are: Bangued and Manabo in Abra Province in the north-
west; the Bontoc district; the Province of Isabela on the east side; the area
round Manila including Bulacan, Macabebe in Pampanga, and Cavite; the
Bataan peninsula; and Tayabas and Batangas in the south of the island.
In the central islands of the archipelago there is goitre to be found on
Panay at Capiz and Iloilo, and on Negros and Cebu. Nichols 1300 noted the
disease at Taytay, a town situated in the north of the island of Palawan;
he remarks that as Taytay is on non-calcareous soil the goitre occurrence
cannot be associated with excess of lime. Actually, the geological formation
PREVALENCE AND GEOGRAPlliCAL DISTRIBUTION 185
there consists of a water-laid volcanic tuff. In Mindanao, the southernmost

part of the Philippines, goitre has been recorded at Lanao and in the valley
of the river Sindangan.
On the basis of a comparison between the relevant hospital returns for
the 15 years up to 1924 and those for the two-and-a-half years following the
liberation of the country at the end of the 1939-45 war, Recio 1301 concludes
that thyroid disease has increased in the Philippines during recent years.
Oceania
Soils are much richer in iodine than the rocks from which they are
derived. Eminent authorities who have critically examined the iodine cycle
in nature believe that precipitation of iodine from the atmosphere is by far
the most important agency through which soils are iodine-enriched. The
explanation that iodine is mainly concentrated in soils as a residual com-
ponent resulting from the weathering of underlying primary rocks is unten-
able, since such a process would call for the destruction and removal of
incredible tonnages of other less-soluble rock or soil constituents.
Atmospheric iodine originates from the sea; it is liberated from sea-
water by oxidation and is carried inland by winds either in a gaseous state or
adsorbed on floating particles of dust. Air-borne iodine is brought down by
rain or snow; the first rains of any rainy period contain more iodine than
the later rains. Addition of air-borne oceanic iodine to soil through rain or
snow is a slow process; hundreds of thousands of years are required to
build up an iodine-rich soil in this way.
During the Ice Age the older iodine-rich soils were swept away and the
whole course of soil evolution began afresh. New soil-making materials
were generated by the grinding-up of virgin crystalline rocks containing,
at the most, one-tenth the average iodine content of mature agricultural
soils. As the ice cover receded, replenishment of the iodine in glacial and
postglacial soil materials b e g a n - a process which is still in progress in some
countries (see Geochemistry o f Iodine 312).
As an introduction to goitre in Australia, New Zealand and the islands
of Melanesia, this digression into the geochemistry of iodine is excused on
two grounds. First, Australia and New Zealand are among the countries
in which the frequency distribution of goitre may be correlated with the
areas and extent of quaternary glaciation where soils have not yet been
sufficiently saturated with postglacial air-borne oceanic iodine. As Hercus 1304
himself remarks in reference to the distribution of simple goitre in New
Zealand: " Speaking generally, our immature, recently deposited soils
predispose to the development of goitre, and all parts of New Zealand can
be said to be goitrous." Secondly, the digression affords an opportunity
to put on record that due recognition has not apparently been given to the
fact that it was an Australian medical officer, Harvey Sutton, 1331 who in
FIG. 7. SOUTH-EAST AUSTRALIA, TASMANIA AND NEW ZEALAND
i)
the course of goitre studies in New South Wales and Victoria was the first
to notice and explain correctly the relationship between rainfall and goitre
incidence, and to offer a reason why iodine is preferentially fixed in upper
soil layers rather than in the deeper horizons of the same profile.
His accurate assessment of what happens during an important phase of
the iodine cycle is characteristic of other similar investigations in Austral-
asian countries. No peoples have faced the goitre menace with more effi-
ciency and more energy, and none are nearer its final conquest. Thanks to
Hercus and his school, New Zealand's contribution to local iodine know-
ledge is fuller than that of probably any other country; and it is not difficult
to predict that the recent elucidation by Clements & Wishart 1316 of the
goitrogenic influences operative in parts of Tasmania will always rank among
the classic researches in this field.
New Guinea
Politically, the island of New Guinea is divided into West New Guinea
and the Territory of Papua and New Guinea, which is a United Nations
Trust Territory administered by Australia. Running the whole length of
the country from west to east is a central mountain backbone with peaks
rising to between 12 OOO and 16 OOO feet (3500 and 5000 m). Lying off the
east of New Guinea are the islands of New Britain and New Ireland, which
form part of the Territory of Papua and New Guinea. Also belonging to
the group are the Admiralty Islands, including Manus island, and the two
northernmost Solomon Islands, namely, Bougainville and Buka.
The distribution of goitre throughout the New Guinea islands is patchy.
Noosten 1159 mentions three affected localities in West New Guinea-namely,
the region around Doreh Bay at the north-east corner of Vogelkop, the
Timorini area, and the banks of the river Digoel in the south-east of the
country. In the territories to the east under Australian mandate, known
goitre centres are: a village close to Mount Toma about 30 miles from
Rabaul in New Britain; a collection of villages in the Hydrographers'
Range on the north-east coast of Papua near Buna; and a group of Papuan
villages situated in the mountainous country at the head-waters of the
Angabunga river about 40 miles inland from the coastal area west of Port
Moresby.
The last-named focus was discovered by Clements 1305 during a medical
survey in the western portion of the Central Division of Papua undertaken
for the Papuan Administration in 1935. Here, Clements saw no goitre
among the Roro tribe on the coast, or among the subcoastal Mekeo tribe,
who inhabit a dozen or so villages scattered at irregular intervals inland
along the banks of the Angabunga river. But, higher up, at an altitude
of about 6000 feet (2000 m) under the shadow of Mount Edward Albert,
the highest peak in the Owen Stanley Range, he found chronic parenchy-
matous goitre in four villages-Ikuwei, Maini, Kailape and Tura.
188 !1. C. KELLY & W. W. SNEDDEN
Distribution is highly localized. Other villages high on the mountain

sides, in apparently similar positions to those affected, were found to be
free from goitre; and within the goitrous villages themselves many people
have continuously drunk water from the same source as the goitred people
without contracting the disease. The malady is confined to adults, the great
majority of sufferers being women. Onset is associated with first pregnancy
and no woman becomes pregnant after having developed a thyroid enlarge-
m e n t - a feature, Clements remarks, unusual in a population with a high
birth-rate. The natives believe that in women goitre is the result of eating
pig during the period of pregnancy; many pigs are eaten in a feast which
may last a month. Diets excessively rich in protein and fat are among
the many that have been branded as goitrogenic; if this be true, a month's
feast which includes a high proportion of pig fat might well impose an
unaccustomed thyroid stress, especially during pregnancy.
Profoundly stimulated by Clements' findings, McCullagh 1307 put
forward his plan for the extinction of goitre in New Guinea. To his energetic
and refreshing action the Territory owes the initiation and development of a
novel preventive f o r m - o n e which might with advantage be followed in
other regions of the world similarly placed.
McCullagh confirms earlier views on the wide distribution of goitre
throughout the Territory-extending from the border between the Dutch and
British halves of Guinea in the west to the tip of Bougainville, the northern-
most island of the Solomon group, far to the east. He estimates that at least
one-third of the 300 OOO people who live in the goitre areas and are thus
exposed to goitrogenic influences, whatever they may be, actually develop
the disease.
McCullagh's revolutionary but wholly practical preventive method is
depot injection of iodized oil. Apparently it is not administratively possible
to spread iodized salt easily throughout the affected a r e a s - " To achieve
this over all the years of pre-adult and early adult life would be a difficult
task." Instead, from the results of an investigation in Melbourne, McCul-
lagh advocates a single injection (one millilitre) of iodized oil to " provide a
continuous supply of iodine over a period of two years." With larger
volumes it may be possible to establish depots lasting up t.o five years. An
extensive anti-goitre campaign with iodized oil as first defence is now under
way. Evaluation of its effectiveness will be made known in 1960.
Around Hollandia, on the north-east coastal margin of Netherlands
New Guinea, goitre is recognized as a problem among goats. Sheep are
only slightly affected. The goitrous condition responds to the administration
of potassium iodide through drinking-water (Zwart 1308).
Australia and Tasmania

Systematic goitre surveys in Australia are relatively few in number and
in any case have been directed to areas already known to be or suspected
of being goitrous. As more surveys are undertaken it is possible that other

goitre regions will be uncovered. The disease has not been recorded among
the aborigines, either formerly or at the present time. Soon after the arrival
of the first white settlers, the aboriginal peoples moved out of districts
now recognized as goitrous and are today living in apparently non-goitre
areas, for the disease has not been observed among them (Clements 1303).
Queensland
Reports by school medical officers suggest that the town of Cairns in
the north of Queensland, and parts of the Atherton Plateau, which lies
directly to the south-west of the town, are mildly goitrous. The prevalence
rate is unknown, however (Sutton 1331). There are rumours of occurrence
in the country between Toowoomba and Cunnamulla 200 to 300 miles west
of Brisbane, but there is no official confirmation of this.
New South Wales
Examination of 75 OOO children in rural districts and an additional
10 OOO in towns (Sutton 1330, 1331) revealed considerable areas of goitrous
country in the Great Dividing Range, which runs down the eastern part
of New South Wales from the Queensland border in the north to the
border of Victoria in the south. These areas lie in several large river valleys,
particularly the populous Hunter river valley, and in fertile plateaux
throughout the range. The percentage rates (given in parentheses for boys
and girls respectively) were highest in such places as Grafton near the north-
east coast (0.42, 4.35), Armidale in the New England Range (0.76, 3.57),
Tamworth at the head of the river Namoi (6.33, 12.0) and Muswellbrook
in the Hunter valley (5.5, 11.27).
Excluding the town of Grafton already mentioned, the incidence is less
marked in the extreme north-east corner of the State, that is, in an area
bounded by Wallangarra, Armidale, Coff's Harbour and Tweed Heads.
To the south, in the area bounded by Bathurst, Albury, Eden and Wollon-
g o n g - b u t excluding Canberra-incidence is comparatively slight. There
is a small endemic area between Camden and Yerranderie, 50 miles to the
west of Sydney. A map showing the relative prevalence of goitre in these
different sections of New South Wales is given by Sutton. 1330 Among
children at two schools in the Sydney suburb of Bondi, Clements 1310 found
an over-all thyroid enlargement, palpable or visible, of 7.9 % in boys and
17.3 % in girls.
Canberra
In 1947, the city of Canberra ,vas found to be in a goitrous area. A
survey by Clements 1310 revealed the rates shown in Table XXIII among boys
and girls in three age-groups between 6 and 14 years. It is seen that the
prevalence is higher in girls than in boys, particularly in the 12-14 years'
age-group.
TABLE XXIII. PREVALENCE OF THYROID ENLARGEMENT AMONG CHILDREN IN CANBERRA
Age-group 6-8 years 9-11 years 12-14 years
Sex boys girls boys girls boys girls
Number examined 177

I 186 198
I 160 177
I 164
number I % j numberj % jnumberj % j numberj % j number] % j number] %

Thyroids:
palpable 22 12.4 41 22.0 49 24.7 59 50 28.2 61
36.9 37.2
visible . 8 4.5 10 5.4 11 5.6 16 10.0 9 5.1 22.5
37
Total
30
16.9 51 60 75 46.91 59
I33.3 I 98 59.7
·I 127.41 130.31
Shortly after the foregoing facts came to light, an iodine prophylaxis

project was started in Canberra under the sponsorship of the Australian
Department of Health. The scheme consisted of administering to pregnant
and lactating women, infants, children and adolescents, once a week, a
tablet containing 10 mg of potassium iodide. The tablets were distributed
through infant welfare centres and schools. The result& over five years
have been reviewed by Clements; 1303, 1311 Table XXIV shows the per-
centage rate of visible goitre among Canberra children in the 9-11 age-group
at each successive examination.
TABLE XXIV. PREVALENCE OF VISIBLE GOITRE A M O N G CANBERRA CHILDREN IN

9-11 AGE-GROUP AFTER INTRODUCTION OF IODINE PROPHYLAXIS
Boys Girls
Year
number
examined I percentage with
visible goitre
number
examined I percentage with
visible goitre
1947 198 5.6 160 10.0

1948 236 2.1 215 5.0
1951 140 0 124 0
1952 299 0 281 1.7
In 1951, results from one school were not available, and in 1952 the
survey was limited to children who had resided in Canberra for the previous
three years. Nevertheless, the incidence throughout shows a marked
downward trend and the results clearly demonstrate the effectiveness of
this method of goitre prevention and its suitability for infants and young
children whose intake of iodized table-salt would at that age be negligible.
Regarding goitre prevention in Canberra, Hipsley 1320 has drawn atten-
tion to the convenience of adding iodized salt to bread at the time of baking,
TABLE XXV. PREVALENCE OF THYROID ENLARGEMENT AMONG CHILDREN IN GIPPSLAND
Age-group ] 6-8 year s 9-11 year s 12-14 year s
s g_ s b_ s i s bo;s � gi��s
i
l - - b _:-: _ _ _ _ :-�_ _ ,_ _ _ :- - - �; � J
N"m"'�::am,O,a 1 1 1: l
1
number[ % \ number[ % j number] % ] number] % [ number] % j number] %

Thyro i ds :
palpable . 40 23.2 45 30.61 35 29.2 34 128.61 17 27.9 17 23.6
i
vi s ible . . 23 13.4 25 17.0 21 ! 17.5 30 I 8 '13.1 30 41.7
1 120.2
Total
I 63
136.61
70
I I
47.6 56 146.71
.
i
1'
64 53.s
I
2s 47 65.3
as has been customary in the Netherlands since 1943. The method has
recently been adopted in Canberra and now replaces the distribution of
iodide tablets to schoolchildren and to expectant and nursing mothers.
Victoria
Gippsland, the wide littoral area lying between the mountains and the
sea at the south-eastern end of Victoria, is the home of goitre in this State.
Starting at Melbourne and moving eastwards through Gippsland for about
200 miles one would find goitre in the following succession of closely
neighbouring towns and hamlets: Dandenong, Noojee, Warragul, Leon-
gatha, Traralgon, Walhalla, Sale, Bairnsdale, Stratford, Bruthen in the
Tambo valley, and Buchan and Orbost in the valley of the river Snowy.
The districts of Dargo and Omeo in the Bowen Mountains to the north of
Gippsland, where rainfall is heavy and frequent, are also affected.
Prevalence is comparativ<c>ly heavy. In Bairnsdale, one of the chief
towns of Gippsland, rates of 20 % to 33 % in boys and of 32 % to 47 % in
girls were recorded by Summons 1329 in 1927. Of 14 boys between the ages
of 12 and 14 attending the junior technical school at Sale, 8 had goitre.
Clements' more recent Gippsland figures (1948), 1310 given in Table XXV,
show little, if any, improvement on the earlier ones.
It will be noticed that the maximum rate in boys is in the 9-11 years'
age-group, whilst in girls maximum intensity occurs between 12 and 14
years of age.
On the other side of Victoria to the west of Melbourne goitre is much
less evident, but minor occurrences have been noted in scattered and
localized areas around Ballarat, Geelong, Colac, Bendigo, Ararat, Hamilton
and Warrnambool.
South Australia
The only endemic goitre area in the State of South Australia lies in the
Adelaide Hills, part of the Mount Lofty Range to the east of Adelaide.
This closely settled farming region extends to about half a million acres
(200 OOOha) and has a population of approximately 20 OOO. Jungfer, 1321
who supervised a child health survey in the area, found a general goitre
r te in the" 10 years and over" age-group of 21.1 % among girls and 4.1 %
among boys. The rates were somewhat higher (26.6 % and 11.1 %, res-
pectively) in a selected group of "ten-plus" children who had been born
in the Adelaide Hills and had been permanently resident there up to the
time of Jungfer's survey.
Western Australia
"Goitre is not a problem of any importance in Western Australia.
Hospital records show very few cases and no evidence of endemic areas
in the State." This statement by the Commissioner of Public Health (1943)
is confirmed by Clements, 1303 who. writes that despite a deliberate search for
goitre in the south-western corner of the State where a number of trace-
element deficiency diseases occur in animals, endemic goitre has not been
recorded.
Northern Territories
There are no reports of goitre occurrence in the Northern Territories of
Australia.
Tasmania
Practically the whole of Tasmania is goitrous. The disease has been
known in the island since the last century, but the first serious study of the
problem was not made until 1949, when Clements examined 8000 school-
children and found visible goitres in approximately 6 % of boys and 20 % of
girls in the age-group 12-14 years. He also noted that 'at least 20 in every
100 adult women had a goitre, and pointed out that the annual death-rate
from thyrotoxicosis in Tasmania had been significantly higher than the
Australian average for at least 70 years. 1312, 131e
Accepting world experience that endt:;mic goitre is due to inadequate
dietary iodine intake, and following the Canberra precedent noted above,
Clements succeeded in promoting a preventive scheme whereby tablets,
each containing 10 mg of potassium iodide, were distributed by the health
authorities to all children up to the school-leaving age of 16 years. In 1954,
five years after the prophylactic procedure was introduced, a second survey
was made to determine its effects. This involved the examination of some
20 300 children between the ages of 5 and 17 years. As may be seen from
Tables XXVI and XXVII, the results were almost entirely contrary to
expectations.
In the first place, the 1954 survey showed a marked increase in goitre
prevalence among both boys and girls in each age-group, with the exception
of girls 12-14 and 15-17 years of age. Secondly, the goitre rates for each
year of age in both boys and girls from 5 to 8 years in the 1954 survey (see
TABLE XXVI. PREVALENCE OF VISIBLE GOITRE AMONG CHILDREN IN T A S M A N I A

BEFORE AND AFTER IODINE PROPHYLAXIS
I
1
1949 survey 1954 survey
Age-group
Sex
I I
(years) number percentage number percentage
examined with visible with visible
goitres examined
goitres
5 M 217 0
I
675
I 5.03
6-8 M 1218 1.39 3286 I 8.12
!
9-11 M 1376 3.71 2769 9.02
12-14 M 1180 6.44 2727 9.90
15-17 M 190 3.5 444 5.85
I
' I ; I
5 F 184 2.7 694 I 5.90

6-8 F I 1259 3.1 3099 9.61
9-11 i F 1364 8.51 2733 12.58
12-14 F 1675 20.8 3344 16.74
15-17 F 253 23.3 535 22.99
I
I
TABLE XXVII. PREVALENCE OF VISIBLE GOITRE AMONG CHILDREN IN TASMANIA,

FOR EACH YEAR OF AGE FROM 5 TO 8, IN 1954 SURVEY
Boys Girls
Age
I
(years) number percentage with number I percentage with
examined visible goitres examined visible goitres
l
I
5 242 7.8 303 8.2
I I
6 489 10.0 486 11.1
7 I 546 11.7 550 11.4
8 I 460 10.8 450 12.2
I I
I !
Table XXVII) were similar: this is in marked contrast to the results obtained
in the 1949 survey, when there was a substantial difference in prevalence
between boys and girls, and steep increases from the youngest children to
the older age-groups. The 1949 pattern of prevalence was similar to that
observed in other Australian surveys.
To find an explanation for these unexpected rises in prevalence during a
five-year iodine regime, the reliability of the standards of diagnosis was
checked and confirmed, the efficiency of the system of tablet distribution
was verified, and the over-all prevalence figures for 1949 and 1954 were
subjected to mathematical analysis and re-study district by district.
When in this way the country was partitioned into six districts and data
were related strictly to the districts in which they had been gathered, and
13
not lumped with others for the island as a whole, it was found that in three
districts there had been a general fall in prevalence since 1949, proving that
iodine had been effectively doing its work, but that in two, or possibly
three, other areas there had been a steep rise. The over-all rise in prevalence
seen in the figures as a whole was due to the sharp rises in these three in-
dividual areas. The district-by-district analysis of data also confirmed the
improved rates among older girls, and established that the higher rate
among young children in 1954, as compared with 1949, was real and not
due to some error of diagnosis or irregularity in the distribution or altered
potency of the iodide tablets. This feature remained the most remarkable
of the 1954 survey.
These findings led Clements & Wishart 1316 to consider the possibility
that there might be two causes of goitre in Tasmania-a straightforward
iodine deficiency operative in some districts and a goitrogenic agency
predominant in others. Strong support for the goitrogen hypothesis was
found in two interrelated sets of circumstances. In 1950, just one year after
prophylaxis by iodide tablets began in Tasmania, the Commonwealth
Government introduced a free-milk scheme for schoolchildren to stimulate
milk consumption throughout Australia for health reasons. To meet the
increased demand for milk occasioned by this scheme, particularly in the
autumn and winter months when cows are usually dried-off; farmers were
obliged to keep their herds in production all the year round. Accordingly,
they extended their plantings of chou-moellier (Brassica oleracea var.
acephala, marrowstem kale), a crop available for direct grazing through
the winter months when grass is burnt off by frost.
Between the years 1948 and 1953 the area in Tasmania sown to chou-
moellier increased from 83 acres (34 ha) to 235 acres (95 ha) and the quantity
of chou-moellier and kale seed sold in the country during these same six
years increased from 23.7 to 214.9 hundredweights (from about 12 to 110
quintals). The districts where chou-moellier cultivation increased most were
found to correspond exactly with those where goitre incidence had increased
between the 1949 and 1954 surveys.
Chou-moellier belongs to the Brassica genus, members of which may
contain the goitrogen r.-5-vinyl-2-thio-oxazolidone. Since the goitrogenic
activity of this substance may be destroyed by heat, and since all vegetables of
the Brassica genus eaten directly by Tasmanians are cooked, Clements &
Wishart reasoned that the goitrogenic effect might be transmitted indirectly
to the human subject through milk from cows fed on chou-moellier. Patient
research from several different angles yielded strong supportive evidence
for their point of view. This included the fact that the rise in goitre rates
among young children coincided with their .increased consumption of milk
under the free-milk scheme; the fact that regular weekly doses of 10 mg
of potassium iodide failed to prevent the development of goitre in these
children; the fact that milk from chou-moellier-fed cows administered
experimentally to humans and to laboratory animals clearly interfered

with their 131 1 uptake; and the fact that marked thyroid hyperplasia deve-
loped in calves born of cows which had been fed on chou-moellier. Evidence
was also forthcoming that milk containing a goitrogen could be produced
by cows grazing on pastures heavily contaminated with certain cruciferous
weeds.
Final proof of the hypothesis set up by Clements & Wishart 1316 requires
the actual isolation of the goitrogenic substance from milk and a demonstra-
tion of its anti-thyroid potency on human subjects. Nevertheless, their
findings are more than indicative that much of the goitre in Tasmania is
due to goitrogenic interference with a vital step in the synthesis of thyroxine
which cannot be overcome by iodine administration. Clements & Wishart
are careful to stress, however, that this does not affect the fact that a large
amount of the goitre endemic in Tasmania and elsewhere in Australia is
due to straightforward iodine deficiency and is therefore amenable to
iodine preventive measures.
Such was the position in 1956. Since then, a systematic investigation of
the thioglycosides (and their aglycones) of chou-moellier and of cruciferous
weeds prevalent as contaminants of pastures in goitrous areas of Tasmania
and southern Queensland has been made by Bachelard & Trikojus 1309
in association with the Goitre Sub-Committee of the National Health and
Medical Research Council. They have succeeded in isolating a substance
called cheiroline (y-methylsulphonyl-propyl-isothiocyanate) from the fruit
and leaves of turnip weed ( Rapistrum rugosum) and, by experiments on rats,
have proved it to be goitrogenic. Further work is in progress to determine
whether this and other isothiocyanates can be absorbed and transferred
to the milk of cows grazing on pastures contaminated with cruciferous
weeds.
Turnip weed (Rapisrrum rngosum) grows profusely around Warwick
in southern Queensland and it is interesting that endemic goitre among
children in this area occurs only in the valleys where turnip weed is prolific.
Comparatively large doses of potassium iodide (10 mg twice weekly) are
without effect upon epidemic goitre caused by goitrogens of this type.
Administration of thyroid substance is the preferred therapeutic method
(Clements 1315).
On the question of prophylaxis and treatment, an observation by Cle-
ments 1314 remains unexplained. Following the detection of goitre among
children at Hopewood House, Bowral, south-west of Sydney, a number
of changes were suggested in the dietary regime, including the substitution
of iodized salt for powdered kelp which had been given on account of its
iodine content and as the sole source of sodium chloride. At the next
examination, some six months after the change, a noticeable reduction in
the size of the enlarged thyroids was seen. Experiments to determine
whether the kelp contained a goitrogenic substance proved negative.
Animal goitre in Tasmania

An outbreak of congenital goitre in lambs on alluvial river flats in the
Huon valley south of Hobart was reported by Southcott 1326 in 1945. Since
then occurrences have been noted in the Derwent valley and at several
places in the southern midlands. Goitre also appears to be prevalent
among farm horses in Tasmania, and occasional cases suggestive of iodine
deficiency have been seen in calves in various districts (Green 1317).
New Zealand
Goitre is endemic in both the North and South Islands and affects
Maoris and Europeans alike. There is a tradition that the malady was in
evidence among the Maori peoples long before the beginnings of British
settlement; their language has for many generations contained the word
",tenga" (sometimes "tena ") meaning goitre. 1334 , 1335 Among European
colonists the disease was first mentioned in 1882 by C. Nedwill (cited by
Hercus 1345) who noticed its frequency in and around Christchurch. In
1889 (invariably given wrongly as 1888), Hacon 1343 recorded the widespread
occurrence of goitre throughout the Provincial District of Canterbury; and
from inquiries conducted in 1910 Colquhoun 1337 concluded that the whole
country was goitrous. Greenwald 1342 asserts that no credible evidence
exists that goitre was a disease in New Zealand before the advent of Euro-
peans. He adduces this as sound argument against the generally accepted
modern view that endemic goitre is a consequence of environmental iodine
deficiency.
Medical inspection of recruits during the 1914-1918 war, when 1680
men out of 135 OOOexamined were rejected for active service on account
of goitre, brought the problem more directly to public attention and system-
atic surveys were thereupon undertaken. In 1920 Hercus & Baker 1348
examined 15 OOOschoolchildren in the age-group 5 to 12 years in Canter-
bury and Westland (South Island) to find 32 % with markedly enlarged
thyroid glands and a further 29 % with glands sufficiently palpable and
visible on deglutition to constitute pathological enlargement. This pre-
liminary survey was later greatly extended to cover many thousands of
children in both the North and South Islands and medical examination was
coupled with chemical determinations of iodine in a large number of re-
presentative soils and waters collected throughout the entire Dominion
(Hercus and co workers; 1344, 1347, 1349, 1350, 1353, 1354 Shore & Andrew 1359-
1362).
In these surveys the southern section of the South Island (Otago and
Southland) showed an average goitre rate of 26 % rising to 30 % and 40 %
in the Taieri and Clutha valleys west and south-west of Dunedin. In the
central and northern portion of South Island (Canterbury, Nelson, Marl-
borough) the rate was much higher, exceeding 60% in South Canterbury
and around· Christchurch. Observations at the government maternity
hospital in Christchurch revealed 60 % of mothers with goitre and approxi-

mately 8 % of babies born with thyroid enlargement, sometimes to a degree
sufficient to interfere with normal flexion of the head at delivery.
The North Island Provincial Districts of Wellington, Taranaki and
Hawke's Bay had an average goitre rate of 21 %; there were black spots
in the Hutt valley (41 %) north-east of Wellington, and in the west coastal
county of Wanganui, where the rate reached 46 %- Other fairly goitrous
districts of the North Island were found in the mountainous parts of Auck-
land, where rates of 30 % were recorded among schoolchildren in the
Counties of Taupo and Rotorua, and in the Waikato and Piako valleys
to the west of Rotorua. Shore & Andrew 1359 record rates of 47 % in boys
and 56 % in girls at Gisborne. Only New Plymouth in the west of Taranaki
Provincial District, and the Thames and Coromandel peninsula in the north
of Auckland, have rates under 10 %.
The iodine analytical determinations yielded data which fully sustain
the iodine-deficiency theory of causation. Though anomalies were encoun-
tered, the whole body of facts was too large and the inverse relationship
between goitre prevalence and environmental iodine supply too consistent
to be fortuitous. Broadly speaking, it was found that in New Zealand
iodine is lowest and goitre highest on the recent alluvial soils of river
valleys, on porous soils derived from siliceous volcanic rocks, and on
marine sandstones and greensands-indeed, on all clayless sandy soils and
gravels from which iodine is easily leached out by weathering. By contrast,
goitre is low and iodine high in regions underlain by igneous rocks (granite,
basalt, andesite) yielding clayey soils and fertile brown or red loams rich
in iodine.
As a result of these exhaustive investigations, iodized salt was officially
introduced into New Zealand on a voluntary basis in June 1924. At first
the salt was inadequately fortified at a level of 1 part of potassium or sodium
iodide in 250 OOOparts of salt. Three years later, wide and detailed inquiries
in grocers' shops and in a representative sample of Canterbury homes
revealed that of all salt bought for table and culinary purposes only 5 % was
of the iodized variety. By 1934, following a vigorous educational campaign
by the Department of Health, the proportion had risen to 30 ; . In 1940,
yielding to the pressure of enlightened medical opinion, the New Zealand
Government raised the iodide standard to 1 part in 20 OOO parts of salt,
and the New Zealand Iedical Research Council's Thyroid Research Com-
mittee recommended that salt iodized in this proportion should become
the standard domestic salt of the country and that non-iodized salt should
be supplied only to people asking specifically for it. Although this policy
has not yet been wholly adopted, approximately 80 % of the population
today use iodized salt of the 1 : 20 OOO strength, at least at table.
Despite the fact that the more potent salt (1: 20 OOO) was not introduced
until 1942, a notable decline in the prevalence of thyroid enlargement
among schoolchildren had already become apparent by that time. In 1951

Tolley 1364 made a survey of the children living in the South Canterbury
and North Otago school areas with the object of comparing the prevalence
among them with that found by Hercus and others 25 years previously.
She found the average rate for both these districts to be 25 %, as compared
with 62 % in 1925. The almost complete disappearance of gross goitrous
enlargements accounted for most of this fall. On the other hand, Tolley
found that the number of "incipient" enlargements (i.e., palpable and
small visible goitres) was still relatively high, indeed somewhat higher than
the 1925 figure. From this she concludes that either the iodine intake is
still too low, even with salt iodized at the 1 : 20 OOO level, or that some
unknown factor is responsible.
Reviewing Talley's results in the light of their own experience, Clements
& Wishart 1316 suggest that the residues of incipient goitre may be due to
the action of a goitrogenic substance of a character similar to that suspected
to operate in Tasmania (see page 194). They recall that in New Plymouth,
at one time regarded as virtually goitre-free, the rate of visible thyroid
enlargement among children rose from less than 2 % in 1927 to 53 % in
1933 (Mecredy; 1356 Shore & Andrew 1361). Chou-moellier, along with other
species of Brassica, has been grown in and around New Plymouth for many
years. It may well be that changes in the pattern and extent of Brassica
cultivation, or of the cultivation of other possibly goitrogenic crops, have
not been sufficiently investigated in relation to goitre occurrence in New
Zealand.
Animal goitre in New Zealand
Domestic animals are not exempt from thyroid disease in New Zealand.
Hercus 1345, 1349 has seen goitres, sometimes of large size, in sheep, cattle,
pigs and dogs-especially fox-terriers. In racing stables cases have been
known of horses developing goitre during training. Of particular interest
has been the occurrence of epidemic thyroid enlargement in lambs. 1338,
1339, 1355, 1363 Symptoms suggesting acute iodine deficiency among sheep
led to serious loss of lambs in the Wanaka district of South Island in 1929.
The trouble was overcome by means of iodized licks. 1355 More recently, a
severe outbreak of goitre accompanied by heavy neo-natal mortality in
lambs from kale-fed ewes has been described by Sinclair & Andrews. 1363 A
few moderate cases were also observed among lambs from pasture-fed
ewes, but these did not appear to be associated with unusual mortality.
In both pasture-fed and kale-fed groups goitre was prevented and the iodine
status of the lamb thyroids raised by dosing the ewes with potassium iodide
during pregnancy.
South Pacific Islands
Absolute proof that goitre can be endemic in an extreme mantlme
environment is found in the South Pacific. Proximity to the sea does not
PREVALENCE AND GEOGRAPHICAL DISTRIBuTION 199
necessarily protect all the peoples inhabiting the islands scattered throughout
the 18 million square miles of ocean from the Marianas in the north to
Norfolk Island and Pitcairn Island in the far south. The disease occurs
in Fiji and cases have been reported from Tonga, Samoa and the Cook
Islands.
Fiji Islands
A survey by members of the Otago Medical School, New Zealand,
found goitre endemic in the valley of the Singatoka, the second largest
river in the island of Viti Levu. Many villages containing both Fijians and
Indians are dotted along its banks, and simple goitre is endemic in both
races, except in the Fijian villages near the mouth of the river ,vhere much
sea-food is eaten (Hercus 1304). L. ·wills (personal communications, 1950
and 19 51) also reports " plenty of goitre all round the island in spite of
fish and marine life in the menu." She saw many visibly enlarged thyroids
among pregnant Fijian women.
Growing concern at the apparently increasing goitre incidence among
the Indian population in western and northern districts of the Colony has
prompted the South Pacific Health Service to make iodate-fortified salt
available in Fiji.
Tonga or Friendly Islands
According to the Chief Medical Officer 1365 and to Simmons, 1369 Tongans
exhibit a certain amount of goitre which points to iodine deficiency. Some
fish is eaten but not a quantity large enough to supply the full iodine require-
ment.
Samoa and the Cook Islands
Occasional sporadic cases of simple goitre have been reported from
Samoa and the Cook Islands. but the incidence is so low as to merit the
term goitre-free being applied to these islands (Hercus 1304). In a thorough
nutrition surYey of 365 Cook Islanders of all ages chosen at random in
66 family groups from the village of Arorangi on the island of Rarotonga,
Faine & Hercus 1366 noted only one mild case of thyroid enlargement; the
large consumption of fish and sea-foods must prm·ide a sufficiently high
iodine intake.
Hawaiian Islands
Goitre is not endemic in the islands of the Hawaiian group; never-
theless, the non-toxic nodular variety is by no means rare. Examination
of hospital records by Freeman 1367 revealed this type of goitre in more than
25 % of 423 patients ,vho had undergone thyroid surgery at The Clinic,
Honolulu, during the twenty years to 1950.
Several studies have shown that there is sufficient iodine in drinking-
water and local foods in Hawaii to prevent thyroid disorders that might
result from lack of iodine. A conjecture that the high frequency of cleft
palate in Hawaiian children might be associated with low metabolic rate
in their mothers was proved by Henderson & Krantz 1368 to be unfounded.
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HEALTH SIGNIFICANCE
OF ENDEMIC GOITRE
AND RELATED CONDITIONS
F. W. CLEMENTS, M.D., D.P.H., D.T.M.*
NATURAL IIlSTORY OF ENDEMIC GOITRE

IN AFFECTED PERSONS
The Enlargement Process

Age of onset
Goitre can occur at any age in a person living in an endemic area. In
localities where the incidence is high it is not uncommon for babies to be
borne with a goitre. In other areas, where this does not occur, pre-school
children may have a visible enlargement of the thyroid gland. The highest
incidence of endemic goitre in most goitrous areas occurs in girls 12 to
18 years of age, and in boys 9 to 13 years of age. Where an enlargement
of the thyroid does not occur before school age it is reasonable to assume
that the supplies of iodide available in the particular locality are sufficient
to meet the requirements of the child for a certain number of years after
birth, but for a high percentage of children there comes a time when the
needs of growth or of other physiological events-for example, the onset
of puberty and the taking of vigorous exercise-create demands for the
thyroidal hormone which cannot be satisfied with the limited amounts
of iodide available, and compensatory enlargement of the thyroid gland
follows.
An interesting observation, that has not yet been satisfactorily explained,
is that even in the most goitrous areas of the world not all people suffer
from thyroid enlargement. McCarrison 70 found only about 90 % of the
population of the Gilgit Valley in Kashmir affected, and he considered this
one of the worst-affected areas in the world. In many other highly goitrous
* Senior 'fedical Offi..:er in Charge, Sodal Paediatrics, The Institute of Child Health, University of
Sydney, Australia
- 235 -
236 F. W . CLEMENTS
regions not more than 50 % of the female adolescent and adult population
have a goitre. If a simple goitre does not appear during childhood or
adolescence it is rare for it to make its first appearance in adult males, but
it is not at all uncommon for this to happen to women during pregnancy
or lactation. Lawson Tait 114 was one of the first to recognize the " step-
wise" enlargement of the gland in women with each succeeding pregnancy.
When people, and especially children, move from a non-goitrous area to a
goitrous place, a significant number will develop a goitre, some within
six months of arrival, 47 others not for three or four years. 111
It should be appreciated that sporadic goitres, indistinguishable clinically
from those occurring in endemic areas, are found in up to 4 % of pre-
adolescent and adolescent girls in non-goitrous areas. Some writers con-
sider this condition a physiological enlargement. This is true in the sense
that it represents an increased physiological demand for thyroidal hormone,
but basically the enlargement is an expression of an inadequate supply of
iodide in these children at the final stage of hormone synthesis. In such
girls there may be some constitutional factor which results in high iodide
requirements.
The hyperplastic phase

The initial enlargement of the thyroid is the direct result of the relatively
prolonged action of one of the components of the thyroid-stimulating
hormone (TSH) of the anterior pituitary gland on the cells of the thyroid.
It is generally agreed that the increase in the amount of TSH in the blood
is the outcome of a lower than normal concentration of thyroidal hormone
in the peripheral blood acting upon a .sensitive mechanism in either the
pituitary gland or the hypothalamus. 39 The low concentration of thyroidal
hormone in the blood is due to insufficient iodide being available for the
manufacture of the hormone.
Clinically, this type of enlargement presents as a uniform soft swelling,
usually involving most of the gland, although occasionally one lobe is more
enlarged than the other. The hyperplastic phase is of relatively short
duration, and it is not often that the physician has an opportunity of
examining the gland while the enlargement is actually in progress. Once
the hyperplasia has reached the stage when the iodide being trapped
by the gland is equivalent to that trapped by a normal non-enlarged
gland, the gland structure starts to change to a colloid goitre.
Histologically, the initial enlargement consists of hyperplasia of the
cellular components of the acini. The normal rounded acini with their
dense, homogeneously staining colloid become distorted by ingrowths and
invaginations of the lining epithelium, apparently the outcome of intense
multiplication of the cells aimed at increasing the capacity of tlie gland to
trap more iodide. from the blood passing through it. The amount of stainable
colloid is reduced by the cellular overgrowth. Klinck 60 has described the
HEALTH SIGNIFICANCE AND RELATED CONDITIONS 237
microscopical appearance of the thyroid glands from 10 infants and children

who had gross enlargement of the gland which interfered with breathing or
caused death by suffocation. These glands were apparently in the stage of
acute hyperplasia. Most of the follicles were obliterated, or slit-like. The
cells lining the follicles were columnar, tall, and closely packed together.
Subendothelial masses of hyperplastic thyroid cells were found in some
cases. Klinck believed these changes to have been brought about by the
action of a goitrogen.
If the cause of the hyperplasia is removed, be it iodide deficiency or the
action of a goitrogen, while the gland is in this phase it sometimes becomes
smaller, and may even return to normal.
The colloid goitre

This is the resting stage of the gland and is the condition of the goitre
felt in most children with an endemic goitre. Clinically, it is indistinguishable
from the gland during the hyperplastic phase, being a uniform soft enlarge-
ment. Histologically, the gland is a mixture of hyperplasia with the return
of colloid to the acini. The ratio of hyperplasia to colloid will vary through
the full range. The colloid goitre resembles the normal gland except that
the luminae of the acini are larger and the walls are reduced to a thin layer
of flat cubicular cells. In most glands there are projections of the cellular
linings of the acini into the colloid; these are presumably the remnants of
infoldings of the epithelium during the hyperplastic stage. The total iodide
content of colloid goitres approximates to that of normal glands, but the
concentration of the iodide (measured in terms of dry gland) is significantly
less than in the normal gland-0.1 , instead of about 0.2 { 75
Theoretically, once a balance has been established between the iodide
demands for thyroxine synthesis and the supplies available at this particular
stage in gland function, there should be little or no change in the size or
histology of the thyroid-so long, at least, as the physiological status of
the person remains unchanged. In clinical experience, however, this seldom
seems to happen. Both the supplies of iodide at the site of synthesis of
thyroxine and the demands for the hormone fluctuate, with the consequence
that there are periodic bursts of hyperplasia, often in localized areas of
the gland; hence the frequent occurrence, histologically, of hyperplasia
adjoining areas of colloid in the same gland. When supplies of iodide
increase, or the physiological demands for the thyroidal hormone decline,
portions of the gland undergo involution.
Since the process of thyroid enlargement in the hyperplastic phase and
the maintenance of the resting (colloid) phase are designed to meet
the normal physiological needs of the body for thyroidal hormone, it
follows that these stages, at least, of endemic goitre are associated with
euthyroidism.
238 F. W. CLEMENTS
Adults who move into a goitrous area from a non-goitrous region

occasionally develop a colloid goitre for the first time. The sequelae are
similar to those noted for endemic goitres arising in childhood.
Variations in Prevalence of Goitre in Children

By localities
The Study-Group on Endemic Goitre, convened by the World Health
Organization in 1952, 120 suggested that the most convenient age-groups
for the study of the prevalence of endemic goitre in a locality are the new-
born, schoolchildren and service recruits. A number of surveys have been
made in different parts of the world on schoolchildren and, although the
standards used by the investigators may have differed, rendering strict
comparison impossible, the figures do offer some idea of the variation in
prevalence. A sample of the results of surveys which lend themselves to
comparison is given in the table below. Unfortunately, the results of many
surveys have not been recorded by age and sex.
VARIATIONS IN PREVALENCE OF VISIBLY ENLARGED THYROIDS IN

THREE AGE-GROUPS IN DIFFERENT LOCALITIES
Prevalence (%)
Age-group
(years)
B c E F J
A
I I I D
I I I
G
I
H
I
I
I
Males
6-8 0.5 - 2.7 8.6* 3.9* 6.0 13.4 4.5 1.4 8.1
9-11 1.2 3.1 5.4 - - 13.0 17.5 5.6 3.7 9.0
12-14 3.8 5.0 3.8 14.2** 9.3** 16.0 13.1 5.1 6.4 9.9
Females
6-8 1.8 - 8.7 10.2 * I 5.0* 6.5 17.0 5.4 3.1 9.6
9-11 4.9 5.2 13.6 - 19.5 25.2 10.0 8.5 12.6
12-14 13.0 14.6 12.0 1 *·1 10.9** 21.4 41.7 19.5 20.8 16.7
I
A . Cincinatti, Ohio, U S A " F. New Zealand 47
B. Oregon, U S A " G. Victoria, Australia 15
C. Tennessee, U S A 79 H. Canberra, Australia 15
D. El Salvador 11 I. Tasmania, 1949"
E. Belgian Congo 12 J. Tasmania, 1954"
• Age-group 5-9 years •• Age-g"roup 10-14 years
The sex difference is marked in most localities, and there is a wide range
of prevalence. Localities A and B were surveyed by the same investigator,
as were localities G, H, I, and J. The Gippsland District of Victoria (G)
is an area of high endemicity compared with Cincinnati and Oregon.
Secular trends
Workers in widely separated parts of the world have reported an in-
crease in the incidence of endemic goitre following the First and Second
World Wars. Such an increase apparently occurred in Eastern Europe, 68
Western Europe, 6 , 55• 58 England, 28 Taiwan, 14 and New Zealand. 99 In this
connexion it is of interest to read in Hirsch's work 48 the records of epi-
demics of goitre in France at the end of the eighteenth and in the early part
of the nineteenth century. Various explanations have been offered for these
"epidemics", including changes in the food and water supply, and specific
deficiency of iodine. No direct evidence has been brought forward m
support of these various claims.
An annual epidemic of goitre in children attending three schools in
Southern Tasmania has recently been studied. 37 It was noted that the same
children appear to be affected each year, and these constituted some 30 %
of those studied. No differences were found in the physical environment,
economic status, way of life, dietary pattern, or milk consumption of these
children compared with those who had a normal thyroid gland throughout
the period of study (boys, 18 % ; girls, 25 %) and those who had a constantly
enlarged thyroid (boys, 29 % ; girls, 22 %).
The seasonal increase in size appears to coincide with the spring flush
of pastures and weeds, and lends further support to the hypothesis advanced
by Clements 18 that a food goitrogen present in the milk and originating in
weeds or fodder is responsible for the epidemics. There was some evidence
that susceptibility to the food goitrogen may be an inherent characteristic
of the children affected.
Sequelae of Colloid Goitre in Childhood
After introduction of prophylactic iodide

When increased amounts of iodide are given to children with an estab-
lished endemic goitre, which is usually predominantly in the colloid phase,
the gland frequently becomes smaller and, while remaining uniform in
consistency, becomes firmer. In the author's experience a well-established
goitre, in children living in an area where goitre has been shown by iodide
prophylaxis to be due to iodide deficiency, does not usually disappear even
with the prolonged administration of adequate amounts of additional
iodide. Similar results have been reported from southern Hungary, where
only 16 % of children with enlarged thyroids responded to iodide therapy. 115
However, Eugster 31 reports that " 76 per cent of the people who moved
to a goitre-free region lost their goitre after 20 years ". The possibility that
in some localities simple goitre may be due to the action of a goitrogen
might explain this disappearance. When the goitrogen ceases to operate
240 F. W . CLEMENTS
the gland becomes smaller. This was observed to happen with a number
of drugs which had be.en prescribed for a variety of conditions and which
were found to produce goitre. The goitre disappeared on cessation of the
therapy; this has been recorded for iodides, 7, 77, 101 resorcinol, 10 and thio-
cyanate. 5, 92
If a well-established goitre due to. iodide deficiency is detected in a
young child and adequate iodide prophylaxis is continued throughout the
remainder of the growing. period, the thyroid gland increases little in size
compared with the over-all growth of the. child, so that such children may
reach adulthood without a visibly enlarged thyroid. If the prophylaxis is
continued throughout adult life, special attention being paid to the in-
creased demands during pregnancy and lactation, it is unlikely that un-
favourable sequelae will occur either in the thyroid gland, in the general
health of the person, or in the growth, development or health of sub-
sequent generations.
The introduction of adequate prophylaxis in a goitrous area brings
about a sharp fall in the incidence of goitre in children, as numerous workers
have testified. 16 , 33, 46• 56, 78, 81• 100, 107 A careful study, made by the author
over a number of years, of the child population of a city in a moderately
severe goitrous area revealed that the drop in incidence was largely due to
prevention of the development of goitres in children as they moved into the
age-groups usually affected, and to the prevention of palpably enlarged
thyroids from becoming visibly enlarged.
Effects of treatment with thyroid

An interesting development, several years ago, was the re-discovery,
by Greer & Astwood, 40 that the administration of thyroid preparations to
children and adolescents brought about the disappearance of visible goitres.
As Greer & Astwood point out, this fact was established by numerous clini-
cians, mainly in Europe, in the 70's and SO's of the last century, and was
then lost sight of for over 70 years. A group of workers 51 in Czechoslovakia
recently had a similar experience with thyroglobulin. The wisdom of this
form of treatment and prophylaxis could be questioned; the results are
presumably achieved by suppression of the secretion of the TSH of the
anterior pituitary by maintaining an adequate blood-level of thyroidal hor-
mone from exogenous sources. One wonders how long this form of treat-
ment could be continued without permanently affecting the capacity of the
anterior pituitary to produce TSH.
In absence of treatment or prophylaxis

When additional iodide is not taken or treatment along lines similar
to those indicated above is not given there is usually a progressive enlarge-
ment of the thyroid gland with advancing age through childhood. In many
localities with a high incidence, a marked increase in size occurs in girls

in the pre-adolescent phase up to the menarche. These girls frequently
exhibit an increase in thyroid size with each menstrual period for a few
years. The progressive increase in size stops somewhere between 15 and
18 years of age. The author has not recorded a pre-adolescent spurt in
goitre size in boys. Stocks 110 collected together the results of surveys made
by a number of workers and related the prevalence of thyroid enlargement
at various ages to the prevalence at the age of 12 years. These he com-
pounded into a single set of figures for each sex. His results are expressed
graphically in the figure below.
INCIDENCE OF THYROID ENLARGEMENT AT YARIOUS AGES, EXPRESSED IN TERMS

OF FREQUE"'\'CY AT 12 YEARS OF A G E *
, ...,
1.0 1--------------c-.d•- ==•.....--,---------j 1.0
..
-
"'
Q)
Cl
\
c:
Q) 0.8 L - - - - - - - - - - ' ' - - - - - - - - - - - - - - - 1 ' - - - - - - - j 0.8
E \
Q)
Cl
\ d'
c: \
Q) \
·e
0
- \
-
>- \
:5 \
0
"
>-
aj 0.4 L _ _ . L L . _ _ _ , , , _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ---l 0.4

C
"
Q)
0.2 L_.._L___L- L---1--l----'----'----'---'---'-----'----!....J 0.2

5-6 7 10 11 12 13 14 15 16 17-19
Age (years)
* Graph drawn from data compiled by Stocks 110
It can be seen that there is a rise in the rate of thyroid enlargement

up to 12 years of age in both sexes, and that this continues in the girls into
early adult life. However, in boys the rate commences to fall after 14 years
of age, thus confirming the clinical impression that many youths lose their
goitres in adolescence and early adult life.
From adolescence onwards a goitre behaves in one of the several ways
indicated in the next section.
16
242 F. W . CLEMENTS
Sequelae of Endemic Goitre in Adults
Development of a nodular goitre

The clinical experience of physicians in goitrous areas is that although
simple goitres often disappear in adult males, it is not common for this to
happen in adult females, particularly those who bear children. Regular,
adequate iodide prophylaxis against endemic goitre is frequently difficult
to maintain in many highly goitrous areas. From the clinical histories and
the appearance of the thyroid it would seem that goitres in women repeatedly
go through periods of hyperplasia alternating with the resting phase, with
subsequent involution leading to the formation of nodules within the gland
substance. 93
The nodules may be single or multiple; the latter are more often scattered
irregularly throughout the gland tissue than distributed symmetrically.
Small nodules are not easy to detect clinically and frequently are only
found at operation, biopsy or autopsy. Large nodules may produce pressure
symptoms, especially those in the lower pole, which if on a pedicle may
become a true intra-thoracic goitre. 94 Wegelin 117 found that nodules were
rare in children under 10 years of age. In a survey of some 22 OOO school-
children in Tasmania, I detected nodules in slightly less than 2 % of the
children between 9 and 15 years who had a visible goitre. Nodules become
increasingly common after 15 years of age, and the prevalence of nodular
goitres varies from one section of the population to another. Histologically,
the repeated alternate hyperplasia and involution results in a marked
increase in connective tissue in the stroma of the gland, and the arteries
often show progressive endarteritis with a corresponding reduction in the
supply of blood to the acini, which degenerate to colloid retention cysts;
sometimes these cysts are of enormous size. 104 The cells lining them are
flattened to such an extent as to suggest that there could be very little or
no activity.
Macroscopically, the cut section of the thyroid often suggests that the
nodule is encased in a fibrous capsule; this is not a true capsule, but merely
the arrangement of the hypertrophied connective tissue, some of which is
seen to contain remnants of glandular material.
In some goitrous areas the processes of alternate hyperplasia and
involution occur so frequently that the outcome is a very large nodular
goitre hanging down on to the chest wall. These goitres often contain cysts,
some of which, on section, are found to be haemorrhagic.
Persistence of a colloid or nodular goitre with euthyroidism

This is the usual sequel, at least in one phase of an endemic goitre. The
only disadvantage is the aesthetic one. Clinical experience, once again,
HEALTH SIG IFICANCE AND RELATED CONDITIONS 243
suggests that this is more likely to happen during the third and fourth
decades of life, for in later life a significant number of people, especially
women, suffer from mild degrees of myxoedema.11 2
Persistence of a colloid or nodular goitre with hypothyroidism

Many of the earlier textbooks claimed that, by definition, endemic
goitre is always associated with euthyroidism. This is undoubtedly true of
the uncomplicated endemic goitre during the hyperplastic and colloid
phases, but once degenerative changes with the subsequent formation of
nodules occur it is reasonable to argue that the condition is no longer
endemic goitre. The progressive destruction of epithelial elements by the
overgrowth of the stroma and the pressure of enlarging colloid spaces
gradually reduce the capacity of the thyroid gland to produce thyroxine.
Because the processes of hyperplasia and involution are more frequent
in females than in males, often being associated with repeated pregnancies, 114
it is not surprising that myxoedema of this origin occurs much more fre-
quently in women than in men; Osler 84 gives the relative proportions as
about 6 : 1. This form of myxoedema, because of its slow onset, is difficult
to detect. Since the development of this condition is generally postponed
until the fifth or sixth decade, the accompanying reduction of physical and
mental activity is often attributed to age by the patient and her friends.
Physicians with long experience in goitrous areas are aware of these changes
in many of their female patients with long-standing goitres.
Clinically, the signs and symptoms of myxoedema which arises in this
way are not different from those described in textbooks; it is probable that
much of the earlier descriptive material was drawn from patients with
myxoedema of this origin.
Development of secondary thyrotoxicosis

Several writers have drawn attention to the possibility that endemic
goitre predisposes to secondary toxic goitre. The evidence is indirect and,
while it is not conclusi,e, it nevertheless strongly supports such a hypothesis.
Campbell 13 compared the distribution maps for thyrotoxicosis and endemic
goitre in the British Isles and concluded that " in the British Isles exophthal-
mic goitre is more likely to occur in connection with an area of endemic
goitre". McClendon 71 showed that in North America the geographical
distribution of thyrotoxicosis coincided ,vith the areas of high incidence of
endemic goitre. The same author worked out the number of cases of
exophthalmic goitre per 100 cases of endemic goitre for various zones in
Europe. This analysis failed to show a consistent relationship; for example,
much higher figures for toxic goitre were obtained for certain parts of
Northern Italy and Germany than for Switzerland, where the incidence of
endemic goitre has always been considered to be very high. More recently,
244 F. W . CLEMENTS
Saxen & Saxen 97 have shown that the incidence of toxic goitre in Finland
is considerably higher in the rural areas with a moderate or high incidence
of simple goitre than in the rural areas with a low incidence of simple goitre.
The approximate ratio of toxic goitre in the non-goitrous, moderately en-
demic and severely endemic areas was 1: 2: 3.5. In Australia, Wyndham 121
was the first to show that in the State of New South Wales "there seems to
be, therefore, a natural tendency for these non-toxic goitres to become hyper-
plastic and hyperfunctional in middle life". Later Clements, 17 in an Aus-
tralia-wide study, showed that the death-rates for thyrotoxicosis were
highest in the states with the highest incidence of endemic goitre, and lowest
in the states where endemic goitre does not occur. Reviewing some of this
evidence, Rundle 94 concluded that " there is powerful evidence from goitre
maps that endemic goitre predisposes to thyrotoxicosis ". This conclusion
seems justified for certain parts of the world, more particularly North
America, the British Isles, and parts of continental Europe and Australia,
but the evidence in respect of other parts of Europe and many of the econo-
mically under-developed areas of the world is inconclusive or non-existent.
It is surprising that McCarrison 69, 70 and Stott and his co-workers 111, 112
failed to record toxic goitre in the highly goitrous valleys of the Himalayas
and India. In the high plateaux of the Andes, where several surveys have
been made, there are only passing references to toxic goitre. Mahorner 73
was told that toxic symptoms .do occur in the Indians of Guatemala who
have large goitres, but apparently saw none himself in an extensive visit.
Kimball 57 has made no reference in his survey of several Central and South
American countries to the existence of toxic goitre, nor have Scrimshaw and
his team in their various surveys in Central America.11, 98 The one exception
on the American continent is Mendoza Province, Argentina, where
Perinetti 88 found a relatively high prevalence of toxicity superimposed on
nodular goitre.
The irregular occurrence of thyrotoxicosis as a sequel of endemic goitre
throughout the world raises two questions: Has the condition been over-
looked in the localities where it has not been reported ; and do the sequelae
of endemic goitre differ in different localities? More intense, carefully con-
trolled surveys will answer the first question. The answer to the second
question may be bound up with the question of the etiology of endemic
goitre.
Endemic goitre and carcinoma of the thyroid
The WHO Study-Group on Endemic Goitre 120 considered this subject
briefly, reviewing the literature then available. The members of the Group
were impressed with the suggestive character of the data, but felt that, at
the time, it was not possible to form a firm opinion on whether endemic
non-toxic goitre predisposes to carcinoma of the thyroid. Sokal, 103 after
an extensive review of the American literature on endemic goitre, thyro-
toxicosis and carcinoma of the thyroid, came to the conclusion that thyroid
cancer arises more frequently in toxic than in non-toxic goitre. He set a
figure of 1 , expectancy of carcinoma during the lifetime of a patient
with nodular goitre and further expressed the opinion that carcinoma was
twenty times more common among persons with hyperthyroidism than
among those with euthyroidism.
More recently Miller, 76 after a review of patients at the Ford Hospital,
Detroit, has expressed the opinion that Sokal's estimate that three-quarters
of the cases of carcinoma arise in pre-existing nodular goitres is too generous.
In Miller's series only 6 out of 14 patients with non-papillary cancers gave
a history of goitre of over one year's duration. Saxen & Saxen 97 in Finland
were unable to find any difference in the mortality rates for carcinoma of
the thyroid between rural areas where endemic goitre was rare and those
where it was moderately or highly prevalent. Miller 76 has doubts whether
this question can be solved with existing data.
Endemic goitre and carcinoma in general

Spencer 105, 106 has recently drawn attention to the possible influence
of the thyroid in mali g n ant disease. He found a correlation between the
prevalence of endemic goitre and the number of deaths from malignant
disease. He points out that endemic goitre leads to hypothyroidism.,
with its accompanying reduced output of thyroidal hormone and, sub-
sequently, lowered metabolic rate. He quickly denies that these conditions
should be considered a primary cause of cancer; he suggests rather that
thyroid function or dysfunction may be associated with susceptibility or
immunity to cancer. He offers the hypothesis that hypofunction of the
thyroid may be associated with premature senility of tissue cells, which
in some way is associated with norm.al mitotic actiYity. Ellerker 29 has
demonstrated a clinical relationship between non-toxic goitre and malignant
disease of the breast.
SEQUELAE I PROGE:'l.r OF GOITROUS PARENTS
Cretinism
Endemic cretinism has been reported from a number of countries
where endemic goitre occurs. Before proceeding to discuss this, it is
proposed to discuss cretinism in general.
The derivation of the word " cretin " is unknown. A number of
suggestions has been made from time to time: that it is a distorted form
of the French word chretien-a Christian-meaning that those so called
could not sin; that it came from the Latin creta, referring to the chalk-like,
greyish-white faces of the victims: that it originated in the Rhaeto-Romanic
246 F. W. CLEMENTS
language sometime in the sixteenth century and was applied to dwarfs; 8, 34, 48
that it is derived from th.e Latin creatura, meaning a creature, and came
through the Romansh language of the Orisons, creatura-cretira-cretin. 9
Whatever the precise origin of the word it was. apparently used in a written
document for the first time by Felix Platter, 89 in 1614, to describe a parti-
cular kind of person occurring in population groups in the valleys of the
Alps in sufficient numbers to warrant identification. 74 Platter noted the
relatively wide distribution of cretinism, having read that it occurred in
Egypt and having observed it himself in Carinthia and in his native
Switzerland. ·The condition must have been common, for he reported
that many children were affected.
His description covers the salient features: disproportion of the body
(large head and short limbs, and immense tongue), deaf-mutism and
mental retardation. He recognized that not all of these cretins had thyroid
enlargement.
European writers in the eighteenth and nineteenth centuries frequently
drew attention to the co-existence in the same localities of endemic goitre
and cretinism. De Quervain, 25 however, recognized that in any group
of so 0called " cretins " there are likely to be a number of different types
and that the signs displayed will depend upon the degree of active thyroid
tissue present. In his own words: " Le cretinisme endemiq ue est loin
de presenter toujours le meme tableau. II y a d'abord des differences de
degre."
Then, in 1871, Fagge 32 in England published accounts of another
form of cretinism which occurred in people who had not, at any time
in their lives, lived in a goitrous district. To this condition, Fagge gave
the name" sporadic cretinism". In the 80 years since Fagge's observations
a considerable number of studies have been made on cretinism. However,
almost all of them have been on the sporadic form. As a result of these
investigations it is now possible to define a number of types of cretinism.
One classification based upon current knowledge is:
1. Congenital thyroid aplasia.
2. Familial congenital goitrous cretinism.
3. Acquired athyroidism.
4. Acquired hypothyroidism.
5. Endemic cretinism.
Congenital thyroid aplasia

This condition is also known as congenital myxoedema 38 and congenital
athyroidism. As the term implies, persons suffering from this condition
are born without any functioning thyroid issue. Hamilton, Reilly
& Eichorn 42 confirmed this when they showed that there was no·accumula-
tion of radioiodine in the neck. The hypothesis has been advanced by

several writers 27• 72 that this condition arises as a result of failure of the
thyroid "anlage" to develop from the oral portion of the mesobranchial
arch.
In a non-goitrous area this type of congenital cretinism predominates.
In a series of 60 cretins from the USA and Canada who were examined
by Osler, 8* only seven had a goitre and three out of five children in one
family were goitrous cretins (see next section). In their series of 115 cretins,
Wilkins, Clayton & Berthrong 119 found six with goitres.
Cretins have been reported 101 with tumours in the neck which appeared
to be enlarged thyroids. As Benda 8 has pointed out, howe-ver, in most cases
the tumour is probably a remnant of the fourth pharyngeal pouch. The
presence of any active thyroid tissue can be demonstrated by a test with
radioactive iodine; if it is negative, the case can be classified as congenital
thyroid aplasia.
Congenital thyroid aplasia is seldom recognized at birth, although in
retrospect it is possible to recall that many of the features characteristic
of this condition were present then. The baby is usually heavier than normal
and has a large head with a wide-open anterior fontanelle and an open
frontal suture. The limbs are short compared with the length of the trunk;
the skin is greyish-white, dry, wrinkled and scaly, with loose folds about
the wrists, hands and neck. The tongue is often protruding. X-ray examina-
tion of the b o n e s - a n d for this purpose the distal epiphysis of the femur
and pelvis is most useful-shows delayed development of ossification
centres. In the skull, the cartilaginous disc between the clivus and the
spheroid body is clearly to be seen. Feeding such a baby is slmv and tedious,
and despite the amount of food eaten little or no weight is gained.
Throughout life physical growth is extremely slo\v, so that by the time
adulthood is reached the true congenital thyroid aplastic is not more than
4 feet (1.2 m) long and, owing to the marked cun'ature of the spine, the
standing height is seldom more than 3 feet (0.9 m). Many of the epiphysial
centres remain open throughout adult life. The nose is broad and flat and
the thick puffy skin, especially around the eyes, gives the face a full apathetic
appearance. Dentition is delayed. So constant are these signs in persons
with congenital thyroid aplasia throughout the world that a number of
writers have suggested that they would appear to h a w belonged to one
large family.
Parallel with the failure of physical growth there is an absence of mental
development. The congenital thyroid aplastic remains an idiot, incapable
of caring for himself. Because there is no mental development, these
people do not learn to speak and it is doubtful if they comprehend the
spoken \Vord; thus they are deaf-mutes. They utter some harsh unintelligible
sounds from time to time. All movements are slow and awkward, and
they walk with a shuffling unsteady gait.
248 F. W. CLEMENTS
This form of cretinism is unmistakable and, as stated above, the de-

scriptions have been built up from a detailed study of persons so afflicted
living in non-goitrous areas. One of the most interesting comments in this
regard is that made by Osler, 84 that none of the cretins investigated by him
came from the goitrous districts of Canada or the USA.
Infants and children with congenital thyroid aplasia respond to oral
administration of dried thyroid gland or thyroxine. The results will depend
upon the age of the child when the treatment is commenced and the
thoroughness with which it is maintained.
The recent report by Ainger & Kelly 3 of three siblings in a family with
cretinism, two without thyroid enlargement and one with a small enlarge-
ment, whose parents were cousins, is of considerable interest. Examination
of the genealogical background of this family revealed at least twelve
additional closely related people who may have been similarly affected.
This led the authors to suggest that in this family the cretinism was due to a
specific inherited defect which, because of the history, was probably a
Mendelian recessive factor.
Familial goitrous cretinism
In the last 15 years or so a number of highly important obser.vations have
been made in the USA and Great Britain on a comparatively large number
of goitrous cretins. 42, 67, 72, 102, 108 Intense biochemical studies on many of
these people have enabled a classification of goitrous cretins based upon
the specific defects in the metabolism of thyroxine to be developed. 23 , 52
On the basis of present knowledge, it would appear that there are at least
four categories; further work may reveal more.
Group I. These subjects lack the ability to oxidize iodide and form
iodotyrosines, although the thyroid is able to concentrate iodide effectively.
Group 2. Members of this group can synthesize thyroid hormone,
but cannot de-iodinate monoiodotyrosine and diiodotyrosine which are
normally formed in the hormonogenic process.
Group 3. The members of this group lack the ability to couple iodo-
tyrosines into iodothyronines (thyroxine).
Group 4. This group is characterized by abnormal iodinated polypep-
tides in the serum.
Elaboration of the biochemical and clinical features of these various
categories is outside the scope of this chapter. The interested reader is
referred to the original papers by Stanbury and his co-workers (see the
chapter Physiology o f endemic goitre on page 261 of this monograph and
Stanbury & Querido 109) and to the appropriate chapter in the book by
Hsia. 52
From the point of view of endemic goitre and its sequelae, the real
interest in this series lies in the familial character of the defects. Hsia has
suggested that in categories 1 and 3 the defect is transmitted by an auto··
somal recessive gene. Stanbury, who has identified and defined Group 4,
has not ventured an opinion about the hereditary character of the defect
but has reported that 3 out of 6 patients studied by him showed familial
incidence of the disease. The possible significance of these developments in
any consideration of the etiology of endemic cretinism is discussed later.
Acquired athyroidism and acquired hypothyroidism
As the names imply, these are variations in degree of the same condi-
tion. In the one there is complete failure of thyroid secretion; in the other
there is partial failure leading to the development of a degree of myxoedema,
hence the use of the term "juvenile myxoedema ", which is sometimes
applied to those so afflicted.
A number of writers 21· 27, 38, 62, 85 claimed that the condition followed
an infectious disease, for example, measles and whooping cough, in cases
they had studied. It is of interest that F agge 's original case occurred after
an attack of measles with erysipelas. 32 Other writers attribute the cause to
birth injuries which extended to involve the thyroid gland. A hypothesis
advanced by McGirr & Hutchison 72 is that, in fact, some of these subjects
possess enough thyroid tissue at birth to meet the needs up to that time and
perhaps for some time after, but this later proves insufficient for the increased
needs of the larger child.
It is obvious that the clinical appearance of children affected by either
of these conditions will be influenced by the age of onset. The older the
child the less marked the effects, especially in respect of mental development
and growth. The amount of deficiency of thyroidal hormone will likewise
affect the severity of the clinical signs.
Acquired athyroidism has most of the features of the congenital form.
Pale or yellow skin, thinning of the hair, coarseness of the skin, and arrested
osteological development dating from the time of onset. The hands often
have a spade-like appearance. Hearing and speech may be affected, de-
pending upon the age of onset of the condition, and, in general, will bear a
relationship to the degree of mental retardation. The presenting features
are usually failure to gro\V at a satisfactory rate and mental retardation.
In the last few years attention has been dra,Yn to two other types of
acquired thyroid enlargement in infants and children. Marked thyroid
enlargement has been reported in a number of newborn infants whose
mothers had taken one of the therapeutic antithyroid drugs during preg-
nancy.1, 22, 30, 36, H , 50, 87, 9·5 T,vo infants, one of whom died shortly after
birth, showed full cretinism; and a third displayed definite hypothyroidism.
The thyroid of the cretin who died showed much vascular enlargement,
with marked hyperplasia of the glandular tissue; the acini, which were lined
with low columnar epithelium, contained no colloid. 50 The other cretin
proved extremely difficult to feed-partly, perhaps, because of the large
tongue-and failed to gain weight. But a week after the condition had been

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WORLD HEALTH ORGANIZATION

F. W. CLEMENTS - J. DE MOERLOOSE - M. P. DESMET

* Endocrinological Insritute, Slovak Academy Q( Sciences, Brmislara, Czechos!o}·akia

in Italia et in Alpibus nationi Medullorum est genus aquae, quam qui

mixed together ", and he recommended incision in its treatment. 15 He

The Middle Ages

In the Middle Ages Rogerius Salernitanus ( Chirurgia Roger ii, 1170), of

wont to be afflicted: who besides their innate simple-mindedness, the head

Anatomy and physiology of the thyroid

(London, 1656), contains this description of the gland: " . . . it contributes

thyroidectomy (in 1856-57) on various animals, the majority of which later

The 19th and 20th centuries

The 19th century witnessed substantial progress in biological and

In 1845, a special commission was appointed by King Carlo Alberto

four zones, in which the incidence of goitre was inversely proportional to

Present-day practice in the prophylaxis of goitre is based on the teachings

1. Backing, Liang (1933) Arch. Gesch. Med. 26, 121

Goitre, as this survey shows in detail, occurs with varying intensity in

and new soil-making materials were generated by the grinding-up of virgin

PART I - T H E AMERICAS AND EUROPE

a 1 mile l.6 km.

The coastal valley of Bella Coola, 270 miles north-west of Vancouver,

Stonewall, both in the Winnipeg area, 85 % of the children were sufferers.

United States of America

Except for isolated pockets of high incidence in Kansas-especially where

Distrito federal 3 309 367 165 468 5

Puebla 1 691 950 406 066 24

Michoacan 1470837 385 359 26

Mexico 1443681 425 886 30

Guerrero 952 037 261 811 27

Hidalgo 861 521 303 282 35

Morelos 291119 135 661 46

Tlaxcala 290 592 108 972 37

Total .. 10 311104 2 192 505 20

More recent experience in Mexico 60 confirms the existence of very high

Since the establishment of the Institute of Nutrition of Central America

Nodular goitres are common in the highlands of Guatemala; by con-

TABLE II. CASES OF GOITRE AMONG CHILDREN IN NICARAGUA

Number of Number Percentage

Carazo Santa Teresa 157 85 54.1

Diriamba 223 44 19.7

Jinotepe 438 57 13.0

Masaya Nindiri 90 20 22.2

Masaya 224 32 14.3

Managua San Rafael del Sur 117 62 53.0

Las Maderas 72 28 38.9

Managua 457 98 21.4

Matagalpa Matagalpa 355 81 22.8

C. Darfo 161 7 4.4

Total 2 427 550 22.6

These statistics indicate an average goitre rate of 22.6 { In the districts

More recent surveys by INCAP (N. S. Scrimshaw-personal communi-

The Peruvian expert, Dr Arce Larreta, examined a total of 3540 persons

Many cases of cretinism and deaf-mutism were found. Reverte Coma 92

T A B L E Ill. PREVALENCE OF SIMPLE GOITRE A M O N G COLOMBIAN

1. Antioquia 20 058 9 374 46.73

Total ...... 183 243 96 435 52.62

Among those who have made recent contributions to knowledge of

From Colombia, the South American goitre zone passes southwards