INTRODUCTION:
Endemic goitre is a type of goitre
occurring due to the deficiency of iodine. It is associated with the
enlargement of the thyroid gland .It is a common
disease occurring in any individual at any time in an endemic area. It's
uncommon to occur in new-borns at the time birth. However it is seen in girls
between the ages of 12 to 18 and in boys from 9 to 13 years of age. [4] Goitre is commonly found occurring in the far north and
far south. It is independent of changes in climate. A few common centres of
goitre are the hilly regions of the Alps, Himalayas etc. However it is also
common in the low lying regions and even at sea
level. A few examples are the Great Lake basin between Canada and USA. Goitre attacks the population irrespective of
the colour, race, nationality etc. The variation may either be severe attacks ,
mild attacks or moderate attacks [3].
Several attempts had been taken by the
World Health Organisation to eliminate iodine deficiency . Initially, WHO worked on
characterising the iodine deficiency, but now its attention has turned towards
preventing iodine deficiency since the incidence of goitre attacks have
increased multi fold. In the year 1992, the World Health
assembly had taken the initiative to eradicate iodine deficiency as a public
health problem. [7]The relationship between use of iodine in our diet and the
eradication of goitre goes back to antiquity. The French chemist, Boussingault,
had incorporated the use of iodine in salt in the
beginning of the 19th century [1]. This proved to be the exact remedy for
goitre attacks. Since then several attempts had been made to make salt
iodisation mandatory. After a number of international meeting, USI (universal salt iodisation) - iodisation of salt for both animals and
mankind, was found to be the preventive measure of goitre. [9]
The number of people around the world
suffering with goitre is not clearly known. However the count may be around 200
million. An important fact to be noted is that, the
geographical distribution of goitre hasn't altered in the last hundred years,
but the intensity of the disease has decreased. This evident change had been
noted in all the well developed nations where the standard of living is very high. [3] Care must be taken, to not over
consume iodine. It may lead to several other complications. Chronic increase in
iodine intake may result in sub clinical hypothyroidism with clinical symptoms
like enlargement of the thyroid gland.
The improper function of the thyroid gland is
because of the iodine enhancement of thyroid autoimmunity and reversible
inhibition of the thyroid activity due to excess intake of iodine. This is popularly known as Wolff-Chaikoff
effect. [8]
However, by monitoring the iodine content in our diet we can prevent thyroid dysfunction.
[2]Iodine induced hyperthyroidism is the major side effect of increased iodine
consumption [5]. It often occurs in individuals above the age of 40 years with
multi nodular goitres. This results in the inability
of the gland to monitor the excess iodine in the body. [6]
Nevertheless, the need to reduce the
risk of goitre attacks is at call. People living on meagre quantities of salt
tend to be more susceptible to goitre attacks when there
is war, recession, epidemic outbreaks etc. . . . Statistics show that many
countries of the world were severely attacked during the nutritional privations
of war. [3] A study explaining the geographical distribution of endemic goitre
on continent basis is provided.
NORTH AMERICA:
Starting with Canada, moving west to
east, the incidence of goitre was seen in British Columbia and in the Pemberton
valley. The peculiar feature about the occurrence of goitre in Pemberton stated
by Keith was that the English officers settled here
initially were affected with goitre and then the disease was even seen in
cattle, like pigs and horses. This made the officers vacate the valley. [16]
Later in 1949, Mac Dermot has suggested the administration of iodine supplement
in food and drinking water. Owing to this one
suggestion, the Pemberton meadows is now very healthy and goitre free. [21]In
Saskatchewan, accounts of goitre are seen. According to Binning, the occurrence
of goitre in school children since the start of 1934
has been greatly reduced due to the administration of iodine. Goitre is also
found to occur down south in regions surrounding the city of Regina. [10,11] In
the United States of America , the incidence of goitre has reduced considerably
due to the use of iodised salt in food . But it's
still considered as a Major threat to the nation. Studies state that nearly one
million men suffer with hypothyroidism.
Moving east to west along the land area of America , the disease has
very severe attacks and occurs mainly in Appalachian range ,states bordering the Great Lake
, westward through North Dakota , and far western states of Montana , Utah ,
Idaho , Oregon , Washington, D.C.
Rowntree stated that the occurrence of goitre was always 5 per 1000. But
when manpower during war had become scarcer, the only
significant reason was that hyperthyroidism was more frequent than
hypothyroidism. [17]
Regions of Mexico also shows high rates
of goitre attacks which are very severe and comparable with those occurring in
the Alps and the Himalayas. A survey had been done by
Stacpoole and his two colleagues. They examined one million people in eight mid
central states having a population of 10 million. The survey covered 3756 towns
and villages within the 858 townships. The rate of
goitre incidence was 20%. [20] In the land of Costa Rica, Garcia had discovered
that 10.6% of the males in a mental hospital were goitre patients. When he had
performed 1000 autopsies, he found 45 goitre cases. [15] De Girolami and Fallas
Díaz stated that the Costa Rican endemic was mail by
caused due to the lack of iodine in the drinking water and, monotonous diet and
hard water. People of this region also suffered from. Cretinism and deaf
mutism. [14]
Central America with all its towns shows
the prevalence of goitre. The state of Guatemala has numerous case of
nodular goitres. People are treated with both iodide and iodate. This has
brought down the incidence of goitre to a great extent. Survey shows that the percentage
of goitre had decreased from 51% to 16% with iodate
and 60% to 23% with iodine. [18, 19]. In Honduras, less than 14% of the
population have a goitre which is visible from the exterior view with 1%
existence of discrete nodules. According to the INCAP goitre survey, Borjas and
Scrimshaw had examined 12,292 school children and 352
adults. After this survey they discovered that nearly one fourth of this
population had a pathologically enlarged thyroid gland. [13,12] Other regions
like El Salvador, Nicaragua , Panama,
Cuba , Dominican Republic also show traces of goitre in their
population with varying levels of intensity
SOUTH AMERICA:
Initially Majority of the South Americans where goitre
victims due to their sluggish lifestyle. They suffered with the endemic goitre
for nearly thirty years or more [27]. Staring with
the country of Columbia, this nation had a very prolonged goitre condition.
Study States that local drinking water contains some lime and calcium sulphate
etc. can result in goitre [38]. Based on numerous surveys and studies, the nation of Columbia has introduced the use of
iodised salt as major cure for goitre for patients and in order to prevent its
occurrence in the future. [24, 23] Moving eastwards from Columbia, the next
country with high incidence of goitre cases is Venezuela.
It was seen that the earlier nomadic population didn't show the prevalence of
goitre but after colonisation, goitre case rates have increased. [22] A
Radioiodine clearance and also been performed. This was carried out by Roche
and his colleagues in Bailadores and Tabay which lie
within the Venezuelan Andes. [34, 33] In Ecuador, there is a history of 120
years and more of goitre cases. However not all the towns are affected. There
are a few towns which show the absences of endemic goitre since the region comprises of food containing common salt which is
the best source of iodine [23, 29]. Both men and women are equally affected. It
occurs mostly after puberty and during the adolescence. Animals are also
affected. Horses, pigs Lambs etc. tend
to show thyroid enlargement. [37]
In the country of Peru, deaf mutism,
goitre, cretinism is very common. The government of this nation is now trying
to make the use of iodised salt compulsory. It must include 1 part of iodine in
10000 parts of salt. Salazar has explained the
present day scenario of Peru with regard to endemic goitre. According to him,
the regions at higher altitude in the central part of the state are the most
affected. [36] Burga, the man in charge of the Peruvian goitre campaign had
studied the differences in goitre conditions with
respect to the geographical distribution.
According to his study, he found that low lying areas were more affected
at than the higher parts of the state. In the highlander, he found that goitre
occurrence was very common among the adolescents
(nearly 30%). [25, 26] Study by Monge shows that the southern region of Peru,
has a toxic goitre (Basedows syndrome). It is very common in this region. [30]
Chile is not a goitrous country. Romero, had observed that the inhabitants of Santiago did not exhibit the general
characteristics of goitre and possessed no enlarged neck and head. There was a
Mazzini distinction between the rich who drank purified water and the poor who
drank water from the impure public supplies. [35] But
in the present day, Chile may be considered as a mildly goitrous place since it
gets supplied by the Aconcagua River. Feferholtz and Ortiz have stated the
occurrence of goitre in Boco. [28]
Argentina population is greatly affected
with the goitre and it produces great harm to the
individual. Use of iodised salt is now being advocated. The central region of
Argentina like San Louis and Cordoba have endemic goitre. The provinces of
argentine Republic had a 1500 mile strip which is popularly known as Spanish conquest. According to a few men, the main cause of
endemic goitre in this region attributes to the iodine deficiency in the
waters, soil and food. [31, 32] The country of Brazil has numerous cases of
endemic goitre.
NORTHERN EUROPE:
Iceland is a
non goitrous country. Till present day it had shown zero goitre cases. This is
mainly due to the excessive consumption of fish and fish products which are
rich sources of Iodine. Whenever diffuse goitre occurs here it is always
accompanied by thyrotoxicosis. 50 such cases examined
by Sigurjónsson, 30 cases were associated with graves Basedows syndrome, 10
were simple hyperthyroidism and 2 were without thyrotoxicosis. [54, 55, 56]In
Finland, Wahlberg had divided the country into four goitre belts
·
Viipuri
till the lake of Ladoga and across the Karelian
Isthmus.
·
St.
Michael towards jäppilä
·
East
of lake päijänne
·
West
of lake päijänne
Studies say that geographical location
is responsible for the incidence of goitre. These four belts were not submerged
underwater during ice age. Thus they are rich in
calcium and low in iodine. [59, 60, 61] Adlercreutz, Virtanen and Vilkki had
studied the environmental relation with goitre. Adlercreutz had studied 74
samples of water from 60 different places on Finland and stated the positive correlation between goitre occurring in
regions having low iodine content in water. [39, 40, 57, 58] Since 1850’s, Sweden has had numerous cases
of endemic goitre .However there are a few regions which are goitre free or
almost goitre free. Toxic goitre is uncommon in
Sweden, yet simple goitre is the usually occurring goitre. The existence of
iodine in milk, has reduced the incidence of goitre incidence of goitre in the
present day. The unique feature of Höjer's study is that he was able to successfully correlate the goitre occurrence with the
topographical conditions. He found that the deep valleys and foot of large
slopes were the chief sires of goitre occurrence humans were widely affected.
Domestic animals too. But Höjer never found goitrous
animals in the non-goitre occurring lands. [44- 48]
Norway in general is goitrous nation where the
incidence of occurrence is higher in females than in males. Devold and Closs
had carried out a survey in which they understood that the thyroid size increased with distance from the sea. However fish
consumption decreased the size even though the distance from the sea had
increased. [43] On the other hand Denmark is goitre free. It has only two
goitre districts Gern and Svostrup. This region had been studied by Rosenquist in comparison with the district of
Snejbjerg. [53]
Netherlands is the only country which
uses iodised water for goitre prophylaxis. In 1924, the central board of health
of the Netherlands government began their work on goitre research since the condition of goitre had worsened in the last 25
years. A group of clinical men, chemists, pathologists and biologists comprised
the commission team. [49] Pasma had done a study on the children of Friesland.
He found that 40% of the children had an enlarged
thyroid gland. He also noticed that the intellectual of these children was
lower than those who were goitre free. [50,51,52] Recent studies of Binnerts
states that , as one moves from a region of high goitre levels to a region of
mild or no goitre attacks , there is a varying
intensity in the level of iodine in the cow's milk belonging to those
respective regions. [41, 42]
EASTERN EUROPE:
Goitre is endemic in the central and
eastern region [63]. The southern region of Poland is considered to be the most the goitrous .According Heller, the goitre
incidence in central Poland had increased due to the defects in diet have
decreased quantity of iodine .Change in fertilisers also affects the goitre
rates. Initially Chilean nitrate soda with high levels
of iodine were used. Later it was replaced by synthetic nitrogen fertilisers
with no iodine content. After the cessation of kelp burning for iodine, goitre
attacks increased. Iodine vapours in the rain produced 14 tons of atmospheric
iodine. These were the findings of Heller. [65] The
post war investigation have shown that there may increase severity of goitre.
Those goitre free individuals who move to this region, have greater tendency to
acquire goitre .The mountain regions of Carpathian in Romania is said to be goitrous. Along with iodised salt, iodine
tablets are also administered. Studies by Campeanu and Danielopolu reveal the
distressing cases of goitre and cretinism. [62, 64]. Bulgaria having a high
population was affected by goitre in 1958, leaving
thirty two provinces affected with twelve of them majorly suffering. Most of the endemic region are to the
mountainous slopes. Ticholov had investigated the adults and school children of
Teteven in 1926 and 1947. In the former year, only 10% of the population was affected. By 1947 the rate had increased by
20%, leaving 80% of the children affected. [67]
Yugoslavia shows extremity in goitre
attacks. It's a serious life threat to these people and causes chronic ill
health with lowered output. In Albania, thyroid
disease is called Berat. Schneider and Ganss had conducted a survey in small
areas near each other. In Hisardzik, a small mountain village, numerous goitre
cases were found. Next they examined Kacevo, which was completely goitre free.
A miles away from this place was Kosatica. Higher
places of this region where non goitrous whereas the low lying regions showed a
few goitre cases. Both Schneider and Ganss gave a clear understanding about the
local geology and topography. It is clear from their study that's goitre is seen mostly in the valleys and not plateaus. However
the valleys which are covered by soft rich soil do not favour goitre, when
compared to the steep valleys with poor soil. [66]
CENTRAL AND SOUTHERN EUROPE:
Austria concentrated a lot in administering the potassium iodide in rock salt.
According to Kriebernig, the nation showed increased rate of goitre attacks
after war, and it was also seen occurring in new borns [69]. A study was also
made on people who moved from the goitre free areas
into the goitrous nations. Schreckels had studied 2220 people in Salzburg and
found that nearly 40% of them were affected. The prevalence among these people
increased more with time. [71] In Hungary, the west central part of the nation,
away from the lake showed that the children of the
region were goitre victims. But the shore of the lake area, was completely non
goitrous. [73] Iodised salt had been introduced in the year 1948. However
marked improvement was seen in the west and north of the country. [72]
In the land of Czechoslovakia, Dolecek
had found a number of stress related goitres. [68] Vomela has studied eastern
Moravia in detail. 80-90% of the inhabitants in the mountains were affected. In
general, hypothyroidism was the cause. On the other hand,
the Moravian plains had people having other side effects like tachycardia,
exophthalmos and some symptoms of hyperthyroidism. [74] In Germany, post war
studies had been performed by Widdowson and McCance. They found that there was
an enlargement in the thyroid gland of the children
in the municipal orphanages at Duisburg. [75] Another study done by Ligdas was
that initially the German used to consume 12 kg of fish per annum. But after
war they hardly ate any fish, which increased the goitre attacks. [70]
WESTERN EUROPE:
Lands of Belgium have reduced goitre
cases. Clinquart observed that drinking water in Belgium has a lot of iodine
and that is the main reason for a goitre free land. [79] During the war, Brull
had noticed that there was a change in the incidence
of thyroid disease. The intensity of thyroid enlargement had dropped. [78] This
had also been confirmed by another person, Bastenie who studied a group of
people at St. Pierre hospital. [76] In England and Wales, children used to wear
a piece of black velvet around their neck to prevent
them from getting a goitre. This was a mythical practice followed in those
days. [80] Berry was the first man to describe the geographical distribution of
goitre in England. [77] Research by the Medical Research council had mentioned that the soft water containing iodine
can produce adequate results in reducing the amount of goitre. However hard
water with the same content of iodine shows no marked reduction in goitre
levels. This is the main reason why Scotland has low
levels of goitre since soft water is present here and England is affected
largely due to the presence of hard water. [83] A recent study by Keddie on the
distribution of deaf mutism proved that deaf mutism was not directly associated
with goitre occurrence. [81] Mayet and Rochaix
noticed that the goitre prevalence in France has not altered since the last
century. [82, 84]
AFRICA:
Numerous goitre historians have provided
enough data to understand the goitre distribution of the continent. Isador, a famous goitre historian had explained the endemic
goitre in the land Africa. He stated that goitre attacks were ink keen to Egypt
and the Roman North Africa until the 19th or 20th century. [91] The region of
Algeria has shown various belts with differing
intensities of the disease. The attacks in Algeria are quite severe. Though it
doesn’t cause death of an individual, it hampers their normal life routines.
Sergent was the first to trace the goitrous localities of Algeria [93]. Later a
study done by Bernard, Vergoz and Boulard, found that
the endemic zone is not only confined to those areas discovered by Sergent, but
extends to other places as well. [95] In the olden days, goitre was called
Hansla in Morocco. There were two studies done by Manuel Amaro and Alonso Romeo on Jaled and Ahamed respectively to
get a better understanding of the goitre conditions. In Jaled, 72 hamlets were
studied. Nearly 18 cases of simple goitre were identified. The root cause for
goitre occurrence was the consumption of turnips,
which lacked iodine in it. Moreover this place was situated on the mountain
top, away from the sea. [92] In Ahamed, Alonso studied 19 townships where he
found cases of hypo and hyperthyroidism. [85]
Madeira shows low risk rates of goitre
whereas the Santa Cruz shows increased goitre
prevalence [90]. Gambia shows reduced goitre occurrence. It lies in the upper
river district where granite formation begins. However its occurrence had been
described clearly by Todd. [86] Haubold found goitre prevalence in the mountains of Bavaria and stated that it was
mainly due to decreased vitamin A and carotene content in the diet. [89] In
Ghana, goitre is referred to as * colloid looking * and it has been associated
with fluorosis. Wilson had identified goitre along
the river bank of Volta. [96] In Nigeria, goitre had been discovered first in a
man staying in Giata. When researched in detail it was found that many of the
locals were affected, but those staying on the valley region where normal. All the goitre sites
are associated with the granite location of the pre - Cambrian basement
complex. They may also be linked to
waters which drain these granite rocks. However the exact incidence of goitre
in Nigeria is unknown. [94] Omar and Dolbey, had discovered that down the river Nile, farmers had been suffering from
goitre. However at the time the prevalence of hyperthyroidism among this
population was scarce. But the rich Egyptians were affected since they adopted
a European diet lifestyle. [88] Dean had examined a
children in Uganda and found only one child with an enlarged thyroid. [87]
ASIA:
The first study had been done by
Bramely. He confined his research work to Nepal. He tried to study the goitre
incidence in this region. He discovered another fact that there massive variations among populations of the Himalayas
living twin close proximity. One village showed 2 % of the disease whereas the
neighbouring village showed 30% of the disease. Bramely had suggested the use
of neck bands and iodine ointments. This was reduce
the swelling of the goitre affected patients. [103] According to Saka, the city
of Istanbul, was completely goitre free although a few thyrotoxicosis cases
existed. [106] McCarossin estimated that nearly 5 million people of the Indian
population are goitre victims. He affirms that the
number may still be the same till today. [101] Ramalingaswami had reviewed many
statistical evidence and concluded that goitre rates in Indian haven't changed
a bit. [104] The etiological factors causing goitre are
1)
Pollution
2)
Lime
rich water and soil
3)
Poverty
4)
Improper
diet
5)
Iodine
deficiency [99,100,102]
Raymond had discovered that in the Chin
Hills of Burma, the women were more susceptible to goitre than the men. It was
seen mainly during puberty and pregnancy. The water
of this region was very pure and had good iodine content. However due to
decrease vitamin A in their diet, goitre was seen. [105]. Kawaishi had
discovered that iodine deficiency was not the only cause of goitre to occur on
the people of Taiwan. It was due to the massive cases
of hypercalcaemia seen the in the Taiwanese natives. Thus goitre was caused as
a result of the defect in calcium metabolism. This was the latest findings [98] Greenwald had proved that goitre cases
in Philippines was seen as early as the 18th century.
[97]
CONCLUSION:
The key factor is that iodine can help
reduce the intensity of goitres. The geographical locations which include
mountainous regions are distant from the sources of salt containing iodine.
Thus people living at higher altitude tend to be more
susceptible to the goitre attacks. The best remedy is the use of iodinated salt
or iodine tablets. Many governments of the world have made the use iodinated
salt mandatory.
REFERENCES:
1) Boussingault JB. Recherche sur la cause qui produit le goître dans la
cordillčre de la Nouvelle Grenade [Research on the cause of goitre in the
cordillera of Nueva Granada]. Annales de Chimie et de Physique, 1831, 48:41–69.
2) Delange F. Administration of iodized oil
during pregnancy: A summary of the published
evidence. Bulletin of the World Health Organization, 1996, 74:101–108.
3) F.C. Kelly, W.W. Snedden; Prevalence and
geographical distribution of endemic goitre; Bull. Wld Hlth Org, 1958, 18,
5-173.
4) F.W. Clements; Health significance of endemic goitre and related conditions
5) Stanbury JB et al. Iodine-induced
hyperthyroidism: occurrence and epidemiology. Thyroid, 1998, 8:83–100.
6) Todd CH. Hyperthyroidism and other
thyroid disorders. A practical handbook for recognition and management. Harare, World Health Organization, International
Council for Control of Iodine Deficiency Disorders, 1999 (WHO/AFRO/NUT/99.1).
7) WHO. National strategy for overcoming
micronutrient malnutrition. Report to the Direct General, 45th World Health
Assembly. Geneva, World Health Organization, 1992
(WHA 45.33).
8) Wolff J. Iodide goiter and the
pharmacologic effects of excess iodide. American Journal of Medicine, 1969,
47:101–124.
9) World Summit for Children – Mid Decade
Goal: Iodine Deficiency Disorders. UNICEF–WHO Joint
Committee on Health Policy. Geneva, United Nations Children’s Fund, World
Health Organization, 1994 (JCHPSS/94/2.7).
10) Binning, G. (1935) Canada. Med. Ass. J.,
32, 533
11) Binning, G. (1939) Canada. Publ. Hlth
J., 30, 393
12) Borjas, E. A. and Scrimshaw, N. S. (1954) Amer. J. publ. Hlth, 4, 1411
13) Borjas, E. A. (1955) Rev. Med.
hondurenia, 23, 957
14) De Girolami, E. and Fallas Diaz, M.
(1954) Rev. Biol. trop. (S. Jose), 2, 1
15) Garcia C., E. (1941) Rev. mid. C. Rica,
4, 558
16) Richardson, J. (1823) Narrative of a journey to the shores of the polar sea, by John Franklin,
London, pp. 118-119
17) Rowntree, L. G. (1944) J. clin. Endocr.
4, 545
18) Mendez, J.etal. (1953)Fed.Proc. 12,423
19) Scrimshaw, N. S. et al. (1953) Lancet,
2, 166
20) Stacpoole, H. H. (1953) Bul. Wld Hlth
Org., 9, 283
21) Vivian, R. P. et al. (1948) Canad. med.
Ass. J., 59, 505
22) Bengoa, J. M. (1946) Medicina social en
el medio rural Venezolano, Caracas, pp. 109-123
23) Boussingault, J. B. (1833) Ann. Chim.
Phys., 54, 163
24) Boussingault, J. B. (1831) Ann. Chim.
Phys., 48, 41
25) Burga H., B. (1938) Reforma me'd., 24,
967, 972, 986
26) Burga H., B. (1956) El Comercio (Lima),
April 21
27) Crotti, A. (1938) Diseases of the
thyroid, parathyroids and thymus, 3rd. London,
28) Feferholtz, J. and Ortiz, A. (1951) Rev.
mid. Chile, 79, 22
29) Humboldt, A.
von (1824) J. Physiol. exp. path., 4, 109
30) Monge, C. (1921) Cr6n. mid. Periu, 38,
31) Mazzocco, P. (1929) Rev. Soc. argent.
Biol., 5, 440, 463, 486
32) Mazzocco, P. and Arias Aranda, C. (1929)
Rev. Soc. argent. Biol., 5, 472
33) Roche, M. et al. (1957) J. clin. Endocr., 17, 99
34) Roche, M. et al. (1956) Proc. Soc. exp.
Biol. (N.Y.), 91, 661
35) Romero, H. (1943) Rev. chil. Hig., 5,
423
36) Salazar N., S. T. (1952) Bocio endemico
en el Periu, Lima, pp. 1-143
37) Sdnchez, C. R. and Paredes, J. E. (1933)
An. Univ. centr. Ecuador, 50, 585
38) SocarrAs,J.F.(1942)An.Econ.Estadist.colomb.,5,65
39) Adlercreutz, E. (1928) Acta med. scand.,
69, 1, 187, 325
40) Adlercreutz, E.(1928) Orientierende
Untersuchungiuberdie Verbreitungdes Kropfes in Finnland undiberderen Zusammen
hangmitdem Jodvorkommenim Wasser, Stockholm
41) Binnerts, W. T. (1954) Nature (Lond.),
174, 973
42) Binnerts, W. T. (1956) Het jodiumgehalte
van melk, Amsterdam (Thesis)
43) Devold, 0. and Closs, K. (1941) Nord.
Med., 10, 1694
44) Hojer, J. A. (1931) Hygeia (Stockh.),
93, 577
45) Hojer, J. A. (1931) Schweiz. med. Wschr., 61, 265
46) Hojer, J. A. (1931) Svenska LikSallsk.
Handl. (Acta Soc. Med. Suecan.), 57, 1
47) Hojer, J. A. (1931) Z. Hyg. InfektKr.,
112, 370
48) Hojer, J. A. (1934) Bull. Of. int. Hyg.
publ., 26, 241
49) Josephus Jita, N. M. et al. (1932) Het
kropvraagstuk in Nederland. Uitgegeven door den
voorzitter van den gezondheidsraad, The Hague
50) Pasma,F.(1947)Deendemischekropemhaargevolgenindenz.o.hoekvanFriesland,
Wolvega
51) Pasma, F. (1951) T.N.O.-Nieuws, 6, 143
52) Pasma, F. (1955) T.N.O.-Nieuws, 10, 429
53) Rosenquist, K.(1943)Om
struma problem et paagrundlagafenunders gelseitre Danske landsogne (The goitre
problem elucidated through studies in three rural districts in Denmark),
Copenhagen
54) Sigurjonsson, J. (1938) Virchow’s Arch.
Path. Anat., 301, 91
55) Sigurjonsson, J. (1940) Studies on the human thyroid in Iceland, Reykjavik
56) Sigurjonsson, J. (1950) Amer.J.Path.
26,1103
57) Vilkki, P. (1956) Ann. Acad. Sci. Fenn.,
Series A, I. Chemica, No. 71
58) Virtanen, A. I. and Virtanen, E. (1940)
Acta med. Scand., 105, 268
59) Wahlberg, J. (1938) Acta med. scand., Suppl. 94
60) Wahlberg, J. (1938) In: Transactions of
the Third International Goiter Conference and the American Association for the
Study of Goiter, p. 71
61) Wahlberg, J. (1939) Nord. Med., 4, 3045
62) Campeanu, L. (1924) Problema guzei
vicretinizmului in Romania, Cluj 264. Danielopolu, D.
(1934) Bull. Of. int. Hyg. publ., 26, 1601
63) Czyzewski, K. and Falkiewicz, A. (1952)
Pol.Tyg.lek. 7,1106
64) Danielopolu, D. and Nicolaie, D. (1936)
Bull. Of. int. Hyg. publ., 28, 288
65) Heller, J. (1951) Postepy Hig. Med. dosw., 4, 44
66) Schneider, P. and Ganss, 0. (1941) Z.
Hyg. InfektKr., 123, 302
67) Ticholov, K. (1947) Med. Let., 39, 978
68) Dolecek, R. (1952) eas. Lek. ces., 91,
149
69) Kriebernig, E. (1950) Wien. klin.
Wschr., 62, 105
70) Ligdas, E. (1953) Dtsch. GesundhWes., 8,
1025
71) Schreckels, J. (1949) Wien. klin.
Wschr., 61, 456
72) Sos, J. and Szabo, G. (1955)
Nepegeszsegugy, 36,201
73) Straub, J. (1930) Z. Hyg. InfektKr.,
111, 472
74) Vomela, S. (1932) Ann. Med., 32, 461
75) Widdowson, E. M. and McCance, R. A.
(1954) Studies on the nutritive value of bread and on
the effect of variations in the extraction rate of flour on the growth of
undernourished children, London (Spec. Rep. Ser. med. Res. Coun. (Lond.), No.
287)
76) Bastenie, P. A. (1947) Lancet, 1, 789
77) Berry, J. (1901) Diseases of the thyroid gland and their surgical treatment, London, pp. 57-65
78) Brull, L. (1942) Bul.Acad.Mid.Belg.
6thseries,7,23
79) Clinquart (1926) Bull. Acad. Mid. Belg.,
5th series, 6, 505
80) Inglis, J. (1838) Treatiseon English
bronchocele, with a few remarks on the use of iodine
and its compounds, London
81) Keddie, J.A.G. (1954) Deaf-mutesin
Scotland, Edinburgh (Department of Health for Scotland)
82) Mayet, L. (1900) Arch. gen. Med., new
series, 4, 179
83) 83)
Murray, M.M.etal. (1948) Thyroid enlargement and of the changes related
to the mineral content of drinking water (with a note
on goitre prophylaxis), London (Medical Research Council Memorandum No. 18
84) Rochaix, A. (1938) Rev. Hyg. Police
sanit., 60, 401
85) Alonso Romeo, V. (1946) Med. colon. 7,
343
86) Bouilliez, M. (and Todd, J.-L.) (1916) Bull. Soc. Path. exot., 9, 143
87) Dean, R. F. A. (1954) J. trop. Med.
Hjyg., 57, 283
88) Dolbey, R. V. and Omar, M. (1924)
Lancet, 2, 549
89) Haubold, H. (1955) Der Kropf, eine
Mangelerkrankung, Stuttgart-Plieningen
90) Hirsch, A. (1860-64) Handbuch der
historisch-geographischen Pathologie, Erlangen
91) Greenwald, I. (1949) Bull.Hist.Med.
23,155
92) Manuel Amaro, J. (1945) Med. colon. 5,
487
93) Sergent, E. (1912) Bull. Soc. Path.
exot. 5, 122
94) Tonkin, T. J. (1905) Brit. med. J, 396
95) Vergoz, C., Boulard, C. and Bernard, P.
(1955) Algandrie med., 59, 697
96) Wilson, D.C.etal. (1954)Trans. Roy.
SOC. Trop. Med. Hyg. 48,481
97) Greenwald, I.(1952) Bull.Hist.Med.,26,263
98) Kawaishi, K. (1940) Taiwan Igakkai Zassi,
39, 1667
99) McCarrison, R. et al. (1927) Indian J.
med. Res., 15, 207
100) McCarrison, R. (1906) Lancet, 1, 1110
101) McCarrison, R. (1917) The thyroid gland,
London
102) McClelland, J. (1835) Trans. med. phys.
Soc. Calcutta, 7, 145
103) Mountford J Bramley, 'Some account of
the bronchocele, or goitre of Nipal, and of the Cis, and Trans-Himalayan regions',
Trans. med. Physical
Soc.,Calcutta,1833,6:181-264.
104) Ramalingaswami, V. (1953) Bull. Wld Hlth
Org., 9, 275
105) Raymond, R.L. (1940) Report on the goiter and general medical survey, Chin Hills, January to April 1940
106) Saka, 0. (1938) Virchows Arch. Path. Anat., 302, 228
