446 KELSON W. JANNEY 



districts. Its severer clinical forms are rarely met with in large cities 

 though its lighter expressions are common in Vienna, Innsbruck, Berne 

 and Beyrouth, also certain cities of India. 



New regions may become affected within a reasonably short time. 

 McCarrison%) describes an interesting epidemic in Nagar, India, intro- 

 duced through the arrival of a goitrous family. By slow development in 

 seven or eight years thereafter 31 individuals of a total population of 1,500 

 had acquired the disease. The source of infection was traced to a spring of 

 drinking water. In Brazil goiter did not exist previously to 1830 in 

 certain Districts (Natividad, Bio Grande do Sul) in which the disease is 

 now endemic (Crotti). There are many other localities where changes 

 in the endemic can be verified. A decrease in endemic goiter has been 

 observed in certain parts of Switzerland, the Khinelands, the Harz, Fran- 

 coma, Thuringia in Germany ; in the Pyrenees in Spain ; in Ferrara, Bara 

 and parts of northern Italy ; also in some sections of Sicily. Goiter and 

 cretinism have disappeared from the Rhenish Island of Niederworth where 

 formerly nearly all inhabitants were affected. In the valley regions near 

 Granada, Spain, goiter began to appear in the early part of the last cen- 

 tury and has greatly increased (Crotti). Ewald, Roesch, Kutschera, et al. 

 cite other examples of fluctuations of the endemic. 



Newcomers into an infected area are usually more susceptible than 

 the older inhabitants. Removal from an affected area usually leads to 

 diminution or disappearance of the symptoms. Frequently healthy chil- 

 dren will again be born to goitrous parents, even to those who bore cretins 

 while living in an endemic region. During the early period of the endemic, 

 variations are apt to occur in the size of the goiters. 



Epidemiological 



It is questionable whether "goiter epidemics" ever occur except in 

 endemic areas. Probably such exacerbations of the disease are best re- 

 garded as rapid endemiological fluctuations due to unusual conditions such 

 as the sudden introduction of large numbers of new and susceptible indi- 

 viduals in a badly affected community, particularly when the added etio- 

 logical factor of unhygienic surroundings is present in addition. These 

 outbreaks often take place in institutions such as boarding schools, prisons 

 and military barracks, where crowding, intimate personal contact, unsani- 

 tary water supply and sewage disposal becomes etiologically important. 



Crotti recounts a particularly interesting epidemic development of 

 goiter among tho sailors during Captain Cook's voyage of exploration in 

 1772, reported by the ship's surgeon, Forster. While their vessel lay 

 among icebergs, the crew used bits of ice therefrom for drinking purposes. 

 Such of the sailors who partook of the ice developed goiter, the remainder 



