kept above 1 milogram per gram of thyroid. The term "endemic" means that the goiter is caused by, or in some way related to, the district where the patient lives.

The detailed correlation of the physiology and chemistry of the thyroid gland was made by Dr. David Marine and his associates at the Western Reserve University, 1905-14. In 1916 Dr. Marine was teaching, "endemic goiter is the easiest known disease to prevent."

While a student under Dr. Marine in 1916 I started a special study which resulted in the prevention of goiter in man as it is carried out in this country. We started this special research through the public schools of Akron, Ohio, in 1916, and it was continued until 1920. That experiment demonstrated conclusively, the truth of Marine's teaching: that, endemic goiter is the easiest known disease to prevent.

Early in the twenties, in coordination with State health organizations, we started searching for the most practical method of prevention; not only experimentally in a certain group of children, but throughout the whole country for everyone.

While we were in the initial stage of developing a method, we were called to West Virginia to make surveys through the schools of Charleston and Huntington. Here we found among the adolescent girls, girls from the fifth to twelfth grades, inclusive, endemic goiter, as prevalent as in our severest endemic goiter regions: Sixty percent of the school girls in these cities had a visible goiter.

At that time we did not call anything a goiter where it could be questioned. It was a visible goiter, one that could be seen across the schoolroom.

The older physicians asked me why the sudden progressive development of goiter in that section of the country, when previous to 1900 goiter was virtually unknown throughout the whole Kanawa River Valley in West Virginia.

That was a real challenge as to why the sudden change, with a rapid development of endemic goiter. By the cooperation of the State health department, the Federal health worker in that section and the College of West Virginia, both the medical school and the agricultural college, we learned this simple truth: The only change in food was a change of salt. Previous to 1900 they used salt mined in the Kanawa River Valley, which was remembered by many as a coarse brownish salt. It was in 1898 that a new process of refining by recrystallization was developed, and a pure, fine white table salt was put on the barket in this State about 1900. Their coarse brownish salt could not compete with the fine white table salt that was being produced and shipped in from Ohio and Michigan. They immediately, i. e., about 1900, ceased using their local salt and started using the refined salt, and thereby denied themselves of their only source of food iodine.

We obtained samples of the salt that they had previously used and still manufactured and used for agricultural purposes only and it contained iodine in the amount of, 1 to 10 thousand parts of salt. That amount is what we are now using in iodized salt.

Here in the Kanawa River Valley the inhabitants had unknowingly carried to completion a scientifically controlled experiment-for generations they had prevented endemic goiter by the use of their locally produced salt which contained iodine 1 to 10,000 parts of salt.

About 1900 the whole community switched to a refined, white table salt which contained no iodine and within 25 years their valley was classified as one of the severe endemic goiter districts in this country.

In 1924 Dr. Olin, who was State health commissioner of Michigan; Dr. Slemmons, who was city health commissioner of Grand Rapids; and myself discussed our problem with the salt manufacturers in Detroit and Chicago and they agreed to manufacture an iodized salt, 1 to 10,000.

First, in order to be sure the average would be 1 to 10,000, the first iodized salt was made to contain 1 to 5,000; but that does not concern our work here, because this experiment lasted only a few years.

The Wholesalers Grocers' Association agreed to handle only iodized salt for table use in Michigan, insofar as it was possible. They also agreed to bear half the added expense. The State health officials, and the Salt Producers' Association agreed that it would be better to have no law or regulation that they produce iodized salt, or that iodized salt must be used. Such a regulation would give the few opponents of Public Health an opportunity to complain about compulsory medication. Therefore, there was no law, but complete cooperation continued, and beginning May 1, 1924, iodized salt was introduced throughout the State of Michigan.

At that time, the incidence of goiter throughout Michigan was established as 38.6 percent. In 1923-24 we had examined every school child in four counties in a line diagonally across the State and used the average as that of Michigan.

On reexamination in 1928 the percentage of goiter had decreased to 9 percent. Yet, since the use of idoized salt started in 1924, an occasional complaint was being sent to the State department of health about some harmful effect, for example, a surgeon in northern Michigan wrote and informed us how iodized salt had produced an unusually severe toxic goiter in one of his patients. The resurvey by the State took us to the Upper Peninsula, the home of the patient who had been injured by the use of iodized salt. While there I obtained the patient's name and visited them, and according to their own statements the doctor had treated her for a severe exophthalmic goiter in April 1924, but iodized salt was not put on the market until May 1924. Much criticism and reports of harmful effects were heard, but not one case was ever found to be justified. For example, one such mythical objection, about which you may often hear, is a lady, who has to take her salt celler with her in her bag when she goes out to eat for fear the restaurant might serve iodized salt. There are a few dermotologists who say they have had one or more patients who are allergic to iodine. Some think they have seen cases of acne which are aggravated by the use of iodized salt. Yet there is not, to my knowledge, any real evidence of allergy to a necessary food element such as iron, calcium, phosphorus, or iodine in amounts needed for normal metabolism, nor has there been published in medical literature, to my knowledge, reports showing scientifically controlled experiments by any dermatologists or dermatological clinics to show harmful effects of iodine in the amounts obtained from iodized salt. Dr. Grange started the use of iodized salt in Switzerland in 1840 and continued its use as well as teaching this health measure for 18 years. In 1858 Dr. deRilliet, of Geneva, wrote an article in which he described four people, who had

sometime used iodized salt and later developed symptoms of toxic goiter. His article was very critical, and yet, it was so unscientific compared to what we now know that it was perfectly absurd. However, the authorities of Geneva passed a ruling forbidding the use of iodized salt. It took 100 years to overcome the critical errors in Dr. de Rilliet's criticisms and to appreciate the importance of this great public health measure that Dr. Grange taught from 1840 to 1858.

My conclusions here are based on years of study of the physiology and chemistry of the thyroid gland; the examination and reexamination of several hundred thousand children. We had 200,000 children card-indexed in the State of Michigan, and over 100,000 indexed from the studies in Ohio.

In 1935 and 1936 we reexamined the children throughout the same counties in Michigan, and found that the incidence of goiter had gone down to approximately 8 percent. During the depression in some localities bag salt was being used instead of iodized salt because it is a few cents cheaper. As a matter of fact, the best example we ever found was where the department of relief was assisting the people in Calumet. Calumet is in the copper-mining territory of northern Michigan, and approximately two-thirds of the families in this community were on relief. They got only bag salt, and from 1930 to 1935, those on bag salt, or noniodized salt, developed goiter to as high a percentage as before iodized salt was introduced. That is, children not using iodized salt 60 percent had goiter, and in the same community those who had remained on iodized salt only 3 percent had goiter.

So, quite accidently we had before us the opportunity to study thousands of children who had been on iodized salt for several years and then they stopped it, and in the course of 3 to 5 years there was exactly the same percentage of goiter that you had found before the use of iodized salt. Including the cities where many were on relief and who used bag salt, or noniodized salt, still the percentage of goiter throughout Michigan was down to 8 percent.

There is one thing we have learned: Unless the State health department and the Public Health Association through its goiter study committee continues to make other campaigns reeducating each generation, there will be a tendency on the part of many people to use just ordinary salt, as they call it.

Last year a survey throughout our city was made by myself, assisted by friends. We would go into the grocery stores and ask the clerk, "should I use iodized salt?" and invariably they would answer, "why do you want to be medicating yourself?"

The conspicuous labeling "iodized salt" in large letters on the package frequently creates the impression that this is a medicated salt. It seems to invite a return of the old worn-out phrase "enforced medication." The simple truth is, iodine is one of our necessary food elements, and if we do not get it in sufficient amounts in our food and drink we will develop endemic goiter, and endemic goiter is the first step on the road to cretinism and feeble-mindedness.

In a survey through the Detroit public schools, 1928-31, it was found that one-tenth of the feeble-mindedness and mental deficiency is due to thyroid deficiency of the mother during pregnancy. This is a most significant part of the endemic goiter problem. Therefore, we prevent not only a goiter, but malformation and lack of development of body

and mind, the result of thyroid deficiency during congenital life. The severest forms are cretinism and Mongolian idiocy, while the lesser forms are infantilism, sterility, and mental deficiency.

It would not be fair if I did not reiterate again that since 1923 and 1924 the salt producers' associations have consistently asked that there be no law enforcing them to iodize salt. They have been perfectly willing to make iodized salt and have cooperated consistently with this health measure. No one could have done more. Without their cooperation the problem could not have been carried so far, so accurately, and so efficiently. They have always agreed that the way this public-health measure was developed it was not compulsory medication.

The Michigan State Department of Health did all of the education. on iodized salt and the prevention of goiter. The salt companies agreed not to make any advertisement of it. The wholesale grocers agreed to assume half the cost and asked for no return. The health department wrote the placards that were put in each school, the articles for the newspapers, and also used the radio programs to teach the simple fact that goiter is a food-deficiency disease and that this food deficiency could best be met by the use of iodized salt.

During the past 2 years the goiter study committee tried to have all table salt iodized, and at the same time omit the conspicuous labeling, "iodized salt." There would be no such thing as iodized salt, but all table salt would contain iodine in quantity sufficient to meet the body requirements of this food element.

We have tried to accomplish this through the Department of Foods and Drugs, and after careful study it was decided that the Food, Drug, and Cosmetic Act did not have the authority to change or to redefine table salt. The Salt Manufacturers' Association were willing to cooperate and to join together to make all salt iodized and say nothing about it, but again there was danger of being held liable for collusion under the antitrust laws.

We have found no way by which we can carry on this public-health measure and to prevent goiter permanents, not only for our lifetime, but have it go on indefinitely, preventing goiter and cretinism and feeble-mindedness. Therefore, we find it necessary to come to Congress to ask a change on our law whereby through the Department of Food and Drugs it is possible to redefine table salt; to have it include iodine. There are men here who have worked with me. One is an eminent surgeon from Henry Ford Hospital, Dr. Brush. He and Dr. McClure have watched the gradual decline in the number of goiter patients coming to surgery in the Henry Ford Hospital, from 1920 to the present time. They stated recently that they have barely enough goiter patients in their hospital to teach the surgical residents. All of this in a period of 25 years. Dr. Towsley, who is from the Department of Pediatrics, University of Michigan, has been on the goiter committee for years, and in 1935 and 1936 helped to make the resurveys throughout the four counties of Michigan.

I will not take more time. If there are any questions, I will be more than glad to answer them. I would like to have you hear from these men who have studied endemic goiter from the standpoint of surgery and the possibility of harm from the use of iodized salt. They have watched the results of this prophylactic measure in one of the severe endemic-goiter districts over a period of 20 years.

Mr. HALE. Are there any questions by members of the committee? Mr. MILLER. Yes, Mr. Chairman.

Mr. HALE. Mr. Miller.

Mr. MILLER. I just have one or two questions, Doctor. You referred to the statement as the possibility of harm. What is the possibility of getting to much iodine?

Ďr. KIMBALL. I have never seen a case of harm from the use of iodized salt. Ordinarily when you go to a physician and he prescribes iodine for treatment, you get lugols; that is a saturated aqueous solution of iodine, and you would get as much iodine in the first dose as you get in 1 year from iodized salt. From iodine in large doses, you might develop a rash, or if you had a long-standing goiter, or a tumorous goiter, it might become toxic; but that is not true with the amount of iodine obtained from iodized salt. A special survey throughout four counties of Michigan was made by the State department of health with the assistance of the county medical society of each county. These goiter study clinics were advertised thoroughly and every goiter patient found was restudied for any and every possible bad effect of iodized salt. A total of 1,200 goiter patients, all using iodized salt were studied, and not one had suffered any bad effects from the use of this food iodine.

Mr. MILLER. I can see the value of it in that part of the country where there is a shortage of iodine, but what about the parts of the country where they use a lot of sea food and get their iodides from that source?

Dr. KIMBALL. People do not always stay in one part of the country anymore. They move around. Just this last year I treated a young lady formerly of New York City who had never used iodized salt, she came to Cleveland, married, and became pregnant, and during pregnancy developed a goiter.

Mr. MILLER. We have got a lot of people in New England who have never been out of New England. Perhaps it is unfortunate for them but they stay there. And, I was just wondering if there is any possibility of getting too much of this substance in your system, assuming it is used by some of these people along the shore who practically live on fish.

Dr. KIMBALL. The amount that they would get could not be too much.

Mr. MILLER. What would be the cost, Doctor?

Dr. KIMBALL. There has never been an increase in cost so far. Iodine does cost money. When we started to produce iodized salt a pound of potassium iodine cost $4.50, and that was a real expense to be added to the comparatively low cost of salt; however, the salt manufacturers assumed half the cost and our wholesale grocers the other half, and it did not cost the retail man one cent more. That is what I mean by cooperation. The price of iodized salt may some time have to be raised, but even at that, a few cents more per year would be much less expensive than to try to prevent it by medication, or going to your physician.

Mr. MILLER. I take it you would not be here if your answer to this question were not yes, but I assume that you have come to the conclusion that this is important enough to the health of the Nation, throughout the 48 States, to justify Congress enacting specific legislation on the subject?