Doctor's Review: Medicine on the Move

July 28, 2014
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Goiters be gone

Getting rid of these loathsome lumps has been a bumpy road

Ancient art and science tell us that the unsightly goiter has been around for as long as we've had tools to record our histories. From the texts of ancient China (around 2700 BCE) to Indian Ayurvedic documents dating to 1400, we've known that big necks have meant big problems. Even Cleopatra has been depicted as having a goiter in one artifact.

These days, doctors in developed countries recognize these enlargements at the front of the neck as being symptomatic of a thyroid disorder, since iodized salt has eliminated endemic goiters. In centuries past, however, the mysterious condition was difficult to treat. Uncomfortable and socially isolating, the lumps were sometimes seen as an indicator of poverty, disproportionately affecting those who couldn't afford the fresh produce whose minerals prevented the condition. In many parts of the world, goiters unfortunately remain prevalent and are a serious public-health concern.


BUMPY ROAD TO RECOVERY


Goiters are now known to be caused by lack of iodine, thyroid conditions and autoimmune diseases. Though they're seen as more of a nuisance today, since they're relatively easy to treat, living with a goiter used to be quite difficult. Once they reached a certain size, the lumps caused sufferers to have difficulty breathing and swallowing. Though surgery is sometimes the answer in serious cases, it's a relatively modern option. In centuries past, physicians and scientists were left scrambling to treat them through trial and error.

The ancient Chinese were probably the first to find a relatively good treatment for goiters. As long ago as 1600 they realized that large doses of seaweed and burnt sponge managed the neck swellings nicely. It worked so well in fact, that news spread westward.

In Roman times, Aurelius Celcus (25 BCE-50 CE) provided us with the first clinical description of the goiter, which he called bronchocele -- a tumor he advised be lanced, cut out or burned away with acid. But it was author and naturalist Pliny the Elder (23-79) who, like the Chinese, recommended using burnt seaweed to treat neck swelling epidemics in the Swiss Alps region. He believed the condition was caused by drinking dirty water.

The dirty water theory held sway for centuries and it was a belief that harked back to ancient Greece, where goiters were thought to be the result of drinking water from melted snow. In a way, they were right to look at water quality, since iodine does leach into the drinking water in regions where the soil contains the mineral. A century or so after Pliny, Galen (129-200 CE) is known to have used spongia usta, sea sponge burnt down to powder form. Though nobody understood how kelp and sea stuff cured these neck bumps, the practice of healing (or at least managing) goiters with seaweed was well established by the Middle Ages, with surgery also occasionally employed by a few brave physicians.

Though physicians in China around the end of the 15th century were also treating goiters with the dried glands of pigs, that prescient physician Paracelsus (1493-1541) had another idea. He pointed out for the first time that there appeared to be a link between goiters and lack of minerals. Though he believed the missing culprit was iron sulphide, he did note that it seemed to run in families. It surely did, though geography and not heredity was the likely culprit.


PURPLE HAZE


The next step in curing endemic goiter came when iodine was discovered in 1811, when a Frenchman by the name of Bernard Courtois (1777-1838) stumbled upon it quite unexpectedly. Courtois wasn't a physician or a healer, and he was actually looking for a way to kill people -- not cure them -- when he found it. While manufacturing gunpowder for Napoleon's army, Courtois, having run out of the willow ashes needed to create sodium carbonate (a key component in saltpeter, one of gunpowder's main ingredients), began burning seaweed and using those ashes instead. After adding a little too much sulfuric acid while destroying the byproducts of the chemical process used to isolate the sodium carbonate, a purple puff of vapor appeared before hardening into mysterious violet crystals. Courtois was too poor to give up his day job to devote time to analyzing his discovery. Within a few years, however, Humphrey Davy (1778-1829), an English chemist, proved that the substance Courtois had isolated was an element belonging to the halogen family and named it iodine.

Over the next few decades, physicians began to connect the dots. In 1821, the Swiss doctor Jean François Coindet reasoned that the newly discovered iodine might be the ingredient responsible for seaweed's medicinal effect on goiters. Naturally, he had to test his hypothesis -- on 150 hapless goiter sufferers to the tune of 250 milligrams of iodine a day, pretty much poison considering that the RDA for iodine is 150 micrograms! Despite the overkill, the treatment worked and physicians began to take note, especially when French physician Jean Lugol (1786-1851) developed his famous iodine solution in 1829. It was easier and safer to administer, and just happened to work as a surgical antiseptic as well.

Unfortunately, in their enthusiasm for the simplicity and effectiveness of the iodine cure, some 19th-century physicians went a little too far. Indeed, the widespread application of high amounts of iodine led to problems at the other end of the spectrum -- iodism. Iodine poisoning was an unfortunate side effect of goiter treatment. Burning in the mouth and throat, soreness of the teeth and gums, increased salivation, coughing and skin lesions seemed like a high price to pay for a pretty neck. Eventually, dosages were reduced to an effective balance.

Despite the advances, goiters remained a serious public health concern in the early 20th century, since they were still endemic to regions where the soil was lacking in key minerals. Without iodine in the soil, it never enters the food chain and therefore never enters the human body. In England, where the lack of iodine in the diet caused legions of bumpy-necked Brits, the condition became known as Derbyshire Neck. In the US, the Northwest also suffered from an overly goitered populace, as did the Great Lakes region, which came unflatteringly to be known as the "Goiter Belt." The problem required immediate attention, since otherwise able-bodied men were being excused from military duty around the time of the First World War because of their goiters. The search for a cure went into high gear. But if only there were a way to prevent them instead...


SALT OF THE EARTH


The solution, though obvious now, was to figure out a way for everybody to have access to the mineral through diet. David Marine (1880-1976), a well-regarded pathologist from Johns Hopkins with an interest in goiters, revived an old idea belonging to French chemist Jean Baptiste Boussingault. He'd noticed in the 1830s that goiters were nonexistent in areas where people used crude sea salt (naturally rich in iodine) and that replacing sea salt with refined salt might be the answer. Boussingault believed that iodine cured goiters, though he didn't understand that a lack of the mineral was their de facto cause to begin with.

Marine recognized that pretty much everyone has some amount of table salt in their diets, and since the amount of iodine needed to prevent goiters would be so minuscule, it seemed the perfect solution. After successful experiments feeding iodized salt to goiter-prone schoolgirls, the State of Michigan became interested. Dr David Murray Cowie (1872-1940), a professor of pediatrics at the University of Michigan, teamed up with American salt manufacturers in 1924. They introduced the first "functional food" by successfully iodizing salt to prevent goiters, effectively eliminating that and all other symptoms of iodine deficiency. It was as a public health triumph.

Marine and Cowie also made the world a smarter place; iodine deficiency in pregnant women is now known to cause mental retardation. In developing countries, where iodine deficiency disorders (IDD) are still a huge problem, it's estimated that 38 million babies are born every year with cretinism and impaired mental faculties. There's a huge push now from public health authorities and food manufacturers around the world to follow suit by providing iodized salt to the masses, cooperating to ensure that people get the basic vitamins and minerals they need.

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