The swelling and the salt
A mystery lay beneath the soil of the Upper Midwest.
By Jake Ruffer
A call sounded throughout the United States in 1918. The call for men, people, warm bodies — soldiers, to fight in World War I.
It echoed back in lots of different ways. One of the strangest reverberations came from Michigan, where the physician Simon Levin had been tasked, as medical chairman of Houghton County Draft Board number two, with evaluating the health of young men in the state’s upper peninsula.
The Swedish-born Levin had grown up in the upper-peninsula town of Michigamme, then earned his medical degree from the University of Michigan. At the time of his survey for the military, he was in the middle of a 20-year stint as a surgeon at the Calumet and Hecla Mining Company in Lake Linden. He was in his own neck of the woods — a Michigander, through and through.
He still wasn’t prepared for what he found.
Levin examined 583 draftees that year. In some towns, it seemed as if every person had a giant lump hanging from their neck.
He found that more than 30 percent had these lumps protruding from the fronts of their necks, some of them larger than baseballs.
The medical condition was known as a goiter: a swelling of the thyroid gland. Most of these cases were “simple” goiters in which the entire gland was swollen evenly as opposed to producing bumps or nodes. Many of the men also had “toxic” goiters, meaning their thyroid was producing too much hormone and they had hyperthyroidism. This condition disqualified them from military draft or enlistment, and so did goiters that were just concerningly large.
A goiter alone doesn’t necessarily mean that a person has hyperthyroidism, which is a condition that can cause severe weight loss and irregularities in heartbeat. On its own, a goiter is a cosmetic issue — just something the afflicted has to live with in the mirror. In the worst cases, goiter and thyroid issues can cause physical deformity or dwarfism, and impaired cognitive development (what the medical field in the early 20th century referred to as “cretinism”). The condition isn’t fatal, but it has a significant impact on the quality of one’s life.
Suspecting that the 30-percent figure from his draft results meant bad news for the rest of the state, Levin ventured out to collect more data.
As he expanded his test population past the otherwise-healthy young men of draft age, the percentage of goiter, like the ailment it represented, swelled. In 1919, after a survey of 1,783 people living in the upper peninsula, Levin concluded that the incidence of goiter in northern Michigan was about 64 percent.
• • •
Goiter wasn’t just Michigan’s problem. Most of the Great Lakes states were battling pervasive issues with the lumps. In Europe, some countries were shot through with it. Mark Twain once quipped, to some notoriety, that the only things to see in Switzerland were Mont Blanc and goiters. That was in 1880, and the problem went back further.
If so many people had been living with this problem for so long, why hadn’t anyone fixed it yet? Some scientists had tried to rid their patients of goiter — and gotten strikingly close.
In the ancient world, physicians had noticed that applications of seaweed tended to reduce goiter. But centuries passed before modern science took up the problem.
During the Napoleonic wars of the early 19th century, the French chemist Bernard Courtois discovered an abundance of iodine in seaweed while trying to make gunpowder.
Then the Swiss physician Jean-Francois Coindet, recalling the connection between seaweed and goiter, administered iodine to his goiter patients. The treatment showed promise, but Coindet’s doses were too high. He ended up giving some of his patients iodine poisoning, which caused nausea, diarrhea and vomiting.
But there was something about iodine worth exploring further.
Twenty years later another chemist, the Parisian Jean-Baptiste Bossingault, suggested using salt with iodine in it. Except he didn’t quite say it that way. Bossingault had simply noticed that goiter was a regional problem, and had gone so far as to test transplanting salt from goiter-free regions to affected regions. His approach had some positive effects on populations in the Andes mountains while he was working out of Bogotà, Colombia, but the high incidence of goiter in mountainous areas led him astray.
Connecting goiter to altitude wasn’t all wrong. But it wasn’t altitude itself that depleted the iodine in the soil or water of a region.
Michigan, Ohio and parts of other Great Lakes states likely lost their iodine when the Laurentide Ice Sheet receded over 20,000 years ago, scraping soil from the surface. The result became a kind of goiter puzzle for scientists to work through in the nineteenth century.
After reducing some of the goiter in Andean regions, Bossingault hypothesized that the disease had something to do with the level of oxygen in the drinking water and that it was somehow depleted by high altitudes. Or something like that. It just couldn’t be iodine.
Maybe Bossingault would have taken a harder look at iodine if it was more popular. In its medical infancy, the applications of iodine were somewhat mishandled by the scientific community. No one had refined the administration process for iodine treatment of goiter — especially not by the time Coindet started giving it to people in the form of a tincture.
Iodine’s history in medicine made it an unattractive possible solution — to anything, at the time, and that included goiter. Even before Coindet’s blunderings, scientists had already begun to label iodine as a poison.
• • •
David Marine had to think for a minute.
The year was 1905, and the 25-year-old bespectacled farm boy from Whitleysburg, Maryland, had just landed in Cleveland, freshly decorated with his new medical degree from Johns Hopkins University. He was to be the resident pathologist at the Lakeside Hospital in the Case Western Reserve University system. On his first day, he was asked what type of research he wanted to do alongside his regular responsibilities. He hadn’t given it any thought.
But, come to think of it, there was something that had bugged him on his walk to Lakeside that morning. The dogs he saw in the area around the hospital had large, swollen lumps on their throats.
“I would like to study the case of goiter,” he said.
The young Marine, who had attended Johns Hopkins to study zoology before switching to medicine, looked more closely at the dogs. He talked to sheep farmers who were seeing swollen goiters in their livestock. When he fed the animals iodine, their swellings often seemed to go away and he thought they also became livelier.
In the mind of Marine, the viability of iodine gained some traction. Another goitrous population was fish, and that’s where he went next.
In October 1909, Marine brought Dr. Carl H. Lenhart, a surgeon at Lakeside, to a trout hatchery in the Pennsylvania mountains. Through November, they observed the fish and their goiters as they added iodine to some of the hatchery tanks, and kept others for controls.
The experiment was a success (the pair actually had a rare condition named after themselves — “Marine-Lenhart syndrome” — that had to do with carcinoma, the primary focus of the experiment. That name was later superseded by the term “Graves disease”). Iodine appeared to cure trout goiter with high reliability.
What made Marine’s and Lenhart’s experiment so useful, besides its success and general validation of iodine as an important element to the thyroid, was how little iodine they gave the fish. The researchers added only four cubic centimeters of sodium iodide to the water each day. Only one gram of that entire solution was actually iodine. It was still effective.
Take four grams, or 2,000 milligrams, dropped into a tank full of water and 15 fish. Compare that to Coindet’s method of giving a single person up to 350 milligrams of iodine in tincture each day. No wonder he was poisoning his patients. Coindet himself, after his own studies, suggested iodine could still be the solution to goiter if its administration was medically supervised.
Marine was a 10-year veteran of the medical field by the time he turned his exploratory focus to human goiters. To some, that would have seemed like enough medical supervision. For the school board of Cleveland, though, it wasn’t good enough. When Marine raised the idea to the board and the parents of the community that they should let him give iodine (which was still widely considered a poison) to their teenage daughters, he got a firm “no.”
Still, he believed he was onto something. His work with trout had been substantial and reassuring enough that the next step, it seemed, would be to test the efficacy of iodine on human subjects. He was focusing on school children between the fifth and twelfth grades because of their developing thyroids (goiters usually only appear in adults over the age of 30, but in the goiter belt they were a problem of puberty akin to acne) and girls because of the four times higher incidence of goiter in females. Teenage girls in Cleveland were very likely to develop goiters; if Marine could experiment on a large enough group of goiter-belt schoolgirls, he would have his answer about iodine — and so would the world.
In 1915 he and his partner O. P. Kimball ventured some 40 miles south to the city of Akron. The school board there was more open-minded, and decided that the pair could run their experiment on students of the Akron public schools.
Marine, Kimball and the schools’ medical inspection director gave students a letter for their parents about submitting to a medical experinment. It reminded parents of the health risks of goiter while warning that their daughters’ “just pride is wounded” by large lumps on the sides of their necks.
The letter instructed parents to give “three grains of Iodide of Soda taken in a glass of water once a day for ten school days in the fall and again in the spring” to “prevent goiter.”
Two groups of more than two thousand participants each were formed. One control group of girls whose parents wouldn’t allow the testing would go without the iodine treatment, and the other group would take the iodide as prescribed.
When the study started, more than half the girls had some evidence of goiter already. Over the next two years Marine and Kimball watched as more and more of the girls in the control group developed thyroid issues and swollen goiters. By the test’s conclusion, almost a quarter of the girls who received no iodine treatment had developed goiters.
And the 2,190 girls who took iodine? Only five had goiters at the end of the treatment.
In October 1917 Marine and Kimball published their study “Prevention of simple goiter in man,” an exposition of the first successful attempt at curing goiter in an entire population of people.
Simon Levin made his discovery during the draft of the following year. He proved there was a problem, and Marine proved iodine was the solution. After carefully progressing from dogs to fish to people, he had finally waded through all of the suspicion built up by scientists before him and figured out the truth. And yet the public still didn’t rush to be treated. It would take one last push to put Marine’s work to use.
• • •
In June of 1922, the Michigan State Medical Society held a symposium on thyroid issues.
During the deliberations, one man stepped up to speak with a deep-rooted intent to rid his state of goiter. His kind eyes swiveled around to his colleagues, and his arguments flowed out from beneath a little gray mustache.
Dr. David Murray Cowie, a Canadian graduate of the University of Michigan’s medical school, wanted to set the goiter problem on his own shoulders. At the age of 50, Cowie had just been named Michigan’s first ever professor of pediatrics. In the wake of Levin’s draft-inspired survey, the scope of the goiter problem had been established, and in the wake of Marine’s research Cowie could see a solution forming. Seeing it as an issue that pervaded the nascent field of pediatrics, he wanted to spearhead that solution.
“It would be a simple way of solving the goiter problem,” he told his audience.
He meant salt.
Cowie’s persuasive abilities earned him a spot as chairman of the society’s Iodized Salt Committee. His committee’s oddly specific name declared its entire goal: they wanted to get iodine into Michigan’s table salt to cure goiter. They had a pretty good idea this would work — though not entirely because of Marine and Kimball’s study.
Medical communities in the U.S. and Switzerland had resumed their dialogue after World War I. The Swiss, possibly motivated to avoid more ridicule like Mark Twain’s, were quicker to take findings from research and produce real-world changes. Earlier in the same year as the Michigan thyroid symposium, the surgeon Hans Eggenberger successfully petitioned the Swiss government to allow the distribution of iodized salt. It was working.
Seeing the Swiss sodium iodide solution being put to good use led Cowie to shop that idea to many of his fellow society members and public health leaders.
The road was long and winding. Cowie, known by his university colleagues and students as “Tic-Tac-Toe” for his methodical step-by-step ways of teaching, ran his plans past chemist William J. Hale, lawyer Clyde Holmes, D. B. Doremus of the Michigan Salt Producers Association, and countless other scientists and medical pundits of the day.
Holmes recommended the committee abandon one of its pursuits, which was after a state bill requiring iodine in salt. It would complicate things — better to keep the effort away from legislation. Oddly enough, these men saw little help or interference from any governing bodies; even the FDA. Founded by the Pure Food and Drug Act of 1906, the FDA (at the time just the “Food Administration”) was only halfway through its second decade of operations and was getting its hands into issues involving vitamins and the general nutrition of widely-consumed food products. It didn’t give Cowie a hand with the salt, but it didn’t stand in the way, either.
Doremus, one of the “salt men” (his words), made himself useful to Cowie’s endeavor. Cowie came to him with a plan that involved setting aside a supply of salt to be iodized and sent to the goiter belt. By Doremus’s assessment, that would have been way too expensive. Michigan salt factories would produce only iodized salt to keep costs down, and they would do it by adding the iodine seamlessly into a production step that already existed. He even made sure that animal-grade salt was iodized to solve the livestock problem that David Marine had observed in his early days at Lakeside Hospital.
All together, they decided it would be best to add sodium iodide so that it would be 0.1% of the table salt that came out of factories serving the state.
• • •
Charles Moore sat in his office in Saint Clair, Michigan, holding a piece of paper.
“I am desirous of getting in communication with the proper person in your company with whom to take up the question of the Iodization of all salt used as food in Michigan,” it read.
Moore, the co-founder and 37-year president of the Diamond Crystal Salt Company, looked the letter over amid the November chill.
Very sincerely yours,
DMC/DET.
It was Dr. David Murray Cowie, writing as chair of his committee. Moore and the company had their response prepared two days later.
The two parties corresponded throughout the winter and met March 7 of the following year. The final message from Diamond Crystal in April said they could have the new salt ready to go within three weeks.
On May 1, 1924, Michiganders walked into supermarkets and grocery stores across the state. They perused the shelves, ambled up and down the aisles and some remembered they were almost out of salt.
The Diamond Crystal Salt Company’s slogan attempted to evoke purity: “The salt that’s all salt.” On May Day, the hefty cylinders of Diamond Crystal table salt that shoppers grabbed were a little more than just salt. They were among the first commercially available containers of salt that were supplemented with iodine in the form of sodium iodide.
After many decades of suffering in the region, several scientists and salt-producers had banded together and figured it out. The only opposition came from the USDA’s Bureau of Chemistry, which submitted that the new salt containers should bear a skull and crossbones denoting “poison.” That idea was later withdrawn.
Within ten years of salt’s first iodized appearance, some counties in Michigan saw only 10 percent of the goiter incidence that they had before 1924.
We’re still eating iodized table salt today, but medical organizations and journals don’t hail it as much of a miracle any more.
“Cut salt — it won’t affect your iodine intake,” wrote Harvard Health Publishing in 2011.
The results of a 1974 FDA study suggest iodine could even be a bit of a problem between seafood, food dyes and other sources.
About two billion people around the world still suffer from iodine deficiency, according to a 2015 study by the UK Iodine Group. Fifty million of those cases result in “clinical manifestations,” or physical complications that require treatment — like the goiter, or hyperthyroidism. Iodine deficiency disorders now occur mostly in developing countries that don’t have the benefit of the public health feat the U.S. experienced.
The salt solution only helped people in affected regions. In the U.S., the effects of rampant sodium consumption have surpassed those of iodine deficiency. But it’s only because of Marine, Cowie and the salt companies of the 1920s that the world of public health can shift its attention from those thyroid issues.
One hundred years later, the “goiter belt” is a distant memory.
