UTAH GOITER SURVEY* INCLUDING EXAMINATION OF 110,000 CHILDREN

RALPH RICHARDS, M.D., F.A.C.S.

SALT LAKE CITY, UTAH

F OR many years the Utah State Board of HeaIth has been interested

in the goiter problem. It attempted

Iimited surveys as early. as 1910, but it was not unti1 192.4 that it was possible to

make a state-wide survey, which was

deemed advisable before undertaking any prophyIactic measures.

Dr. James Wallace was placed at the head of the work in 1924 and the examina-

tions were completed in 1925. SchooI children to the number of 90,000 were

examined by Dr. WaIIace and the remain-

ing 20,000 under his supervision. A pre- Iiminary articIe, covering the first 69,000

chiIdren, was pubIished. l

Four degrees of enlargement were re-

corded: (I) “Th e question mark or pre-

goitrous group,” where the neck couId

not be pronounced negative and yet the degree of enIargement was so sIight

that one might hesitate to say the indivi-

dua1 had goiter; (2) “sIight,” any enlarge- ment up to I in.; 13) “moderate,” an;; enlargement from I to 2 in.; (4) “great,

any enIargement ov.er 2 in.

The compIete report of the Utah inves-

tigation is quite Iengthy and cannot be

given in detail here. At best, we can briefly

discuss the genera1 considerations invoIved. Utah contains 84,990 square miIes, an

area one and one-haIf times that of

Michigan. The goiter survey is the Iargest numericaIIy and the most extensive geo-

graphicaIIy of any in the United States.

The tota number of schoo1 chiIdren exam- ined was I 10,086, 54,935 boys and 55,15 I

girls, representing approximateIy 25 per cent of the tota popuIation of the state.

The survey showed the average goiter

incidence to be 32 per cent. among the

boys and 54.5 per cent among the girls.

A dozen localities showed less than IO per cent goiter and in two or three of these

communities almost every case was an

imported one. In contrast to these places there were sections where every boy and

gir1 in school showed some degree of

enIargement. Again, in one district, there was a variation from 6 per cent in one

schoo1 to IOO per cent in another near by. But these schooIs were situated differentIS

from a geoIogica1 standpoint.

The examination was conducted by

inspection of each pupi in a good Iight. The thyroid gIand was paIpated and again palpated as the pupi swallowed. In these examinations, the cooperation of the Iocal

doctors was sought and in some of the Iarger centers many of the examinations were made under supervision.

An attempt was made to standardize the diagnosis as much as possibIe in order that the findings of the different examiners might be on a uniform basis and therefore comparabIe.

Furthermore, no racia1 immunity to

thyroid enIargement was found. Repre-

sentatives of practicaIIy every race that immigrates to America were examined,

in one school thirtv-six different nationali-

ties. Interest was centered on the Indians because of an opportunity afforded to examine a considerabIe number of these

peopIe living, as far as water and food supply are concerned, under conditions simiIar to the IocaI whites. Indians, as a rule, were found to be slightly Iess sus- ceptible to goiter. It was noted that male Indians had a higher incidence of thyroid enIargement than females. This pecuIiarit,v- was found to be true of the Indians whether on reservations or in the pubIic schooIs.

SampIes of drinking water from many sections of the state were examined bv Dr. J. F. McCIendon of the University ol

*Read at thr Annual &Ieeting of the American Associntion for the Study of Goiter, Dcnvvr, June 18-20, 1928.

44

XIinncsota. His results indicate a less dcflnite inverse relationship between iodine in the drinking water and the occurrence of goiter than figures from otfler parts of the cvuntry. LVith the exception of the 1lilt’orcf sample they all show-ed marked iocfine deficiency, when judged b\- the stancfarcf that proper drinking water suppf~ r-quir-ed 1;\-e parts per billion of iodine.

A sample of water from Great Saft Lake, the principle source oT the table salt used

in Utah, Fief&d severit~~ parts 0T iodine per billion of water. A11 of this iodine is lost in the process of manufacturing table salt: on account of the method used in precipitation. The following striking fact \vas noted in Kaysviffe, a town on the shore of Great Salt Lake: FormerI\- the citizens produced their table salt focaffy f1!. a process of evaporation without relining. The incidence of goiter at that time xvas veq- low-. Later, \vhen the focal method of production was abandoned and the commercial product substituted, there \V:IS a large noticeable increase of goiter. A fike increase in seteraf localities has foffowed the instaffation of improved water supplies from mountain sources repkcing foc:~f IveIls.

.-\DULT SUl<\‘EYS

in orcfer to determine approximateI)- in \f.hat percentage of children thyroid en- largement was “purely ph\-sioIogica1 and woufcf naturalf~- recede,” it \vas decided to make a survev of adults and see how the!- caompared &th the school children. Six to\vns were selected, four in the south, one about the center of popufation and one in the north. These towns lvere sur- \-e>ecf fly a house to house visitation, in order that e\.er?- adult \voufd be included; ancf onI\- half a dozen persons refused examination.

Of these focafities, Farmington, Oak City-, Pro\?dence and Cedar City were chosen because a high percentage of goiter hat1 been found among the schoo1 popufn- tion; Delta and Mifford, holvever, kvert chosen because the incidence WAS low-. Tficse t\\o to\vns are comparati\ efy nehv.

Details v,.ere taken regarding the length of residence in the town of the adults examined, and the comparative t’rcedom from thyroid enlargement among those who had fix-cd in the region for some time. The water supply of this focalit~ is from weffs 200 to $00 feet deep.

The details gathered further shoved that in a goitrous area like Utah thel-e is ver)’ little less enlargement of the t h>-r-oid gland among the adult population than a1nong

the school population and that the number of cases that are only “temporary-” in cflifdren is very smaff and that of a11 those \vho develop enfargements when chifdrcn, not more than about 20 per cent of these enlargements, among the males and IO per cent among the females, disappear spontaneously.

PROPHYLAXIS

A large amount of proph! lactic work has been done in the schoofs. The State Board of Health has urged the use of chocolate tablets containing IO mg. of iodine, one tablet to be taken once a week for the fort?: weeks of the school J-ear. Through the cooperation of the superintendents and teachers, in one year, more than I,ZOO,OOO of these tahfets were administered to the pupils. Alany more have been administered which ha1.e not been reported to the State Roard of Heafth. Besides this man>. parents, following the idea1 methocf, ha\-e taken their chiftfren to their o\vn physicians t’or prophylaxis or treatment.

In the foregoing summary of the Utah goiter sur\.ey it has been pornted out that the thyroid gland enlargement in children, among a11 races of people, may be t;)und in a11 sections of the state, with marked local \.nrintions of incidence and that the occurrence of goiter among ;itlufts is not much less than among children. It has also been sholvn that there is a lack of cv)rrefa- tion between the percentage of icodine in the samples of drinking water t’rom differ- ent localities and in the pre\~aknce ot goiter in these same communities.

There is another interesting :Ispect of the Utah problem xvhich \vas not. co\,ered in

46 American Journnl of Surgery Richards-Utah Goiter Survev JULY, 1<>2r)

any detai1 in the State survey. It has to do with the geoIogica1 features of the inter- mountain region, which differ from every other section of the United States. Prac- ticaIIy the whole of America is drained by water sheds which discharge their burdens into streams which flow into the ocean. In the arid region between the Uinta moun- tains on the east and the Sierra Nevada mountains on the west invoIving the western haIf of Utah, smaII contiguous sections of Wyoming, Idaho and Oregon, nearIy a11 of Nevada, a Iarge part of eastern an d southern CaIifornia and extending into Mexico, is a Iand area caIIed the Great Basin which has no outlet to the ocean. AI1 the streams of this region fIow into saline lakes or evaporate.

In the Quaternary geoIogica1 period, Canada and the northern half of the United States were covered by four miIIion square miIes of ice, during the so-caIIed Ice Period. This sheet did not co\-er the section west of the Rocky Mountains. At that time the precipitation was much more abundant than at present. There was more water falling than was evaporat- ing and it gathered in the various depres- sions in the bottom of the Great Basin, forming numerous Iakes of which we stili h . ave evrdence. In Utah this water accumu- Iated to the depth of a thousand feet and formed a lake called Lake BonneviIIe, the size of Lake Michigan, at which point it stayed for a long period, etching into the mountain sides a Iine of wave-wrought cliffs and depositing under the water edge the disintegrated rock in the form of a IeveI shelf of sand and gravel. That this IeveI was maintained for a long time is evi- denced bs- the fact that this underwater sheIf had time to build itseIf severa hundred yards wide in places. This IeveI known as’ the Bonneville Shore Lme persists to the present dav and can be traced aIong the mountiin sides for hundreds of miles.

The outlet of this Iake was at the north an d was through a rather Ioose formation through which the discharging waters cut

a channel, four hundred feet deep, to be halted by a hard Iimestone Iedge which heId the waters at this stage Iong enough to buiId another deliniteIy defined shoreIine which is caIIed the Provo Shore Line. At this time precipitation diminished to the point where it was insufhcicnt to keep the Iake fuI1. Then the water receded rapidI) and Ieft two remnants of Lake BonnevilIe, Great Salt Lake on the north and Sevier Lake on the south.

At the point where the Iake faiied to empty itseIf the character of the water began to change; the soIubIe mineraIs from its drainage area were brought down to the Iake and remained in soIution. Through the ages those mineraIs became more con- centrated as there were more coming in each year and the lake water was getting smaIIer in amount. This process did not Ieave its mark unti1 the dessication and concentration reached the Iower IeveIs of the Iake bottom and then the chemicals were deposited. This process is stiII going on.

Great SaIt Lake, during the Iast sevent)-- five years, has varied as much as 9 feet in its average depth, because of the irregu- Iarity of seasona precipitation and evaporation. At its Iow point it has left great stretches of richIy mineralized depos- its on the shaIIow at the edge of the lake. The waters of the Iake itseIf contain 13 to 18 per cent sodium chIoride, according to the season; 2 per cent phosphates: nu- merous other chemicals in smaIIer amounts and seventy parts per biIIion of iodine, a higher percentage than any of the ocean anaIyses.

Sevier Lake, the southern remnant of Lake Bonneville, is going through the same fluctuations as Great SaIt Lake and has Ieft, during its desiccation and shrinkage, a flat desert country to the north richly impregnated with mineraIs which in agri- cuIture are designated under the generic term “aIkaIi” which indicates a11 those chemicaIs which in sufficient concentration prevent the growth of vegetation.

In order that we may study the possibIe relationship of the Lake Bonneville phe- nomenon to the distribution of goiter. x1-e

XI.\\ ?,FKIES VOL. VII, No. I Richards-Utah Goiter Sur\-e) American Journal 01 Su,::t rv 47

may gIance at a map of the State of Utah

and see that the mountainous regions on

and ab0L.e the BonneviIle shore lines show

:I high percentage of goiter, bvhile the towns in the desert country, representing the Io\\.est part of the oId Iake bottom, show a

lo\\- percentage. A map of blillard county illustrates these sharpI\- contrasting con-

ditions within a smal1 llrea; therefore we

shall use this county for illustration because it has been twice surveyed in detail, by the

State Board of HeaIth-in 1924 and by the writer in 1923.

On the east side of Millard County, situated on the level bench Iand above the

Pro\.0 shore Iine, are six olcl mountain towns, Leamington, Oak City, Holden,

Fillmore, AIeadow ancl Kanosh, which

she\\, an a\-erage of 73 per cent goiter among the school children. The drinking

rvater supply- of this group is derived from

the adjacent mountains and is Iow in iodine. Oak City had 0.017 parts of iodine per billion. Her goiter percentage in 1923 \vas 90 and in 1924, after a l-ear of pro-

phylazis, it was 82. The people of this

district live IargeIy on the IocaIIy grown

produce, cultivated on the soil washed do\vn from the same mountains mhich furnish the drinking and irrigation water.

Here the problem seems to be compara-

ti\.el,v simple because nnaI\:ses of the drink- ing \vater give the clue to the total iodine

as represented in drinking lvater, irriga-

tion lvater, soil and food. T\tenty to forty miIes away, on the lake

bottom desert is another group of old

tcmm, HinckIeg, Oasis and Desert,

kvhich ha\-e an average of about IO per

cent goiter. Near them is the town of

Delta which is comparntivel~~ new and oft‘crs an opportunity to contrast the old inhabitants with the new, to show what

effect desert dwelling has upon those recruit cd largely from the goiter districts.

The school figures of Delta showed 22 per cent th>-roid enlargement. A residence duration sur\-eJ- of the pupils showed that children living there fi\ye years or Ionger hntl only I I per cent goiter.

The ground waters of this area have

been thoroughly studied by the United

States Geologica Survey. The drinking water is obtained from artesian weIls which tap severa water bearing strata at differ-

ent depths. These strata are suppIied from a catchment area above the Provo shore line twenty to forty miles away.

This accounts for the fact that the drink-

ing water analysis from two artesian IeveIs showed .029 and .08 parts per billion of

iodine. It is immediately apparent that the amount of iodine in the drinking water does not expIain the fact that there is a

small amount of goiter on the desert and a

Iarge amount in the nearb). mountains. The irrigation lvater in the desert is

entirely different from the drinking water. It comes from the Sexier River which

travels 300 miIes through all sorts of forma-

tions before being spread upon the land. In looking for another source of iodine a chemical investigation wil1 be pursued until the r-ale of irrigation water is understood.

S&l is the next possible factor influenc-

ing goiter. Fifteen hundred soil :samples

from this section have been analyzed in detail, with the exception of iodine deter-

mination. The IocaI station of the Depart- ment of Agriculture is now prepared to investigate iodine. This promises to be an

extremely interesting study because of the high alkali content of the soils.

Food anaIyses ha\re not been made with the exception of a few specimens of wheat from Oak City examined by Forbes and his associates of the Ohio Experiment Station. A trace of iodine was found in

I sample. This brief discussion of the Lake Bonne-

\,iIIe reIationship to goiter is in the nature of a preliminaq- report onI?. There seems to .be suflicient evidence to justify the hypothesis that: The soi and irrigation water as contributors to the food chemis- try ma\? be the sources of sufficient nddi- tional ‘iodine to account for the smaI1 amount of goiter in the desert country-. At the completion of the irrigation ancl soil analgsis a ful1 report will be made.