CONCLUSIONS

From our own experience and from a study of the results of others, we believe present vital capacity standards to be incapable of clearly differentiating normal persons from those with early heart disease or pulmonary tuberculosis. In the more advanced cases the differentiation increases, but by this time definite physical signs are usually present. The procedure thus affords little aid in those cases in which the diagnosis is most difficult. This deficiency may be due in part to the fact that none of the standards at present in use take into consideration all the factors known to influence the vital capacity. Chief among such factors is age, which may exercise an even more profound influence than height, weight or surface area. No reliable results can therefore be expected from any standard which fails to take account of the age of the patient.

Even after taking into consideration age, obesity and race, we may still expect normal persons to exhibit extremely wide variations from the theoretical normal. We therefore feel that more value is to be derived from the comparison of periodic vital capacity readings in the same individual than by the application of any standards at present in use.

Consequently we have studied 12 cases of pneumonia with a view to ascertaining the clinical value of such determinations. Although the series is too small to permit of any final conclusions being drawn therefrom, yet it has seemed to us to indicate the following uses for the spirometer in this disease. (a) As an adjunct to the usual clinical pulse, temperature and respiration record, the vital capacity graph assists in visualizing the course of the disease. (b) After the crisis, a failure of the vital capacity to increase rapidly and steadily may point towards a complication, while

the presence of such an increase argues against the latter. (c) Frequent accurate vital capacity readings before and after operation for empyema are apparently valuable in indicating the

success or failure of the operation. (d) An extremely low vital capacity may assist in differentiating pneumonia from diseases which do not lead to such a marked reduction.

(1) HUTCHINSON, J.: Med. Chir. Trans., 1846, xxix, 137.

(2) DREYER G.: Lancet, August 9, 1919, cxcvii, Vol. ii, 227.

(3) LUNDSGAARD, C., and VAN SLYKE, D. D.: Jour. Exper. Med., January, 1918, xxvii, 65.

(4) WEST, H. F.: Arch. Int. Med., March, 1920, xxv, 306.

(5) BOWEN, B. D.: Arch. Int. Med., April, 1923, xxxi, 579.

(6) MYERS, J. A., and Cady, L. H.: Amer.

Rev. Tuberc., March, 1924, ix, 57. (7) PRATT, J. H.: Amer. Jour. Med. Sc., December, 1922, clxiv, 819.

(8) WILSON, M. G., AND EDWARDS, D. J.: Amer. Jour. Dis. Child., November, 1921, xxii, 443.

(9) FOSTER, J. H., AND HSIEH, P. L.: Arch. Int. Med., September, 1923, xxxii, 335. (10) HEWLETT, A. W., AND JACKSON, N. R.: Arch. Int. Med., April, 1922, xxix, 515. (11) PEABODY, F. W., AND WENTWORTH, J. A. Arch. Int. Med., September, 1917, xx, 443.

(12) MYERS, J. A., AND MYERS, F. L.: Journal-Lancet, October 15, 1922, xlii, 519.

(13) MYERS, J. A.: Journal-Lancet, May 1, 1921, xli, 252.

(14) Arnold, F. B.: Ueber die Athmungsgrösse des Menschen. Heidelberg,

1855.

(15) GARVIN, A., LUNDSGAARD, C., AND VAN SLYKE, D. D.: Jour. Exper. Med., January, 1918, xxvii, 87. (16) MCCLURE, C. W., AND PEABODY, F. W.: Jour. Amer. Med. Assoc., December 8, 1917, lxix, 1954.

(17) CAMERON, C.: Tubercle, May, 1922, iii, 353.

(18) DREYER, G., AND BURRELL, L. S. T.: Lancet, June 5, 1920, cxcviii, Vol. i, 1212.

(19) MYERS, J. A.: Amer. Rev. Tuberc., October, 1922, vi, 702.

(20) MYERS, J. A.: Arch. Int. Med., November, 1922, xxx, 648.

(21) SHEPARD, W. P.: Arch. Int. Med., February, 1924, xxxiii, 185.

INTRODUCTION AND HISTORICAL

S

REPORTS

OME time ago the author made a survey of cases in certain hospitals in St. Louis with a view of ascertaining the frequency of occurrence of diseases of known hereditary tendency (Davenport, 1911). From the data thus obtained goiter was found to be the most prevalent. This fact seemed to indicate a relatively marked incidence of goiter in this region.

The following investigation was consequently undertaken with the object of determining the prevalence of goiter throughout the city of St. Louis, together with a comparison with the incidence of goiter in Chicago, a city in which the incidence of goiter has been more extensively studied.

St. Louis is situated in a region which has not been considered a goiter district and the suggestion arose that should the data be supported by the results of the more extensive study, possibly similar factors are operative to make goiter endemic in the St. Louis region as well as that of the Great Lakes.

There have been numerous reports made on the incidence of goiter in different regions of the United States of which probably the most complete is that published by Love and Davenport in 1920, from the office of the Surgeon-General of the Army, in their statistical study of the physical conditions of the drafted men and in which is shown the approximate incidence of goiter among men coming from all regions of the United States. They found the greatest incidence to be in the men coming from the Northwest and the region of Wisconsin and Michigan. In these localities 9 to 26 men in 1000 had goiter. The states showing the next highest incidence of cases were in the central and north central regions including Illinois, Iowa, Colorado, Minnesota, Indiana and Ohio where goiter was found in 4.5 to 9 men in 1000. Missouri occurred in the third group which included California, South Dakota, Tennessee and Virginia with an incidence of 1.5 to 4.5 men in 1000. The general incidence for Missouri was 4.4 affected men in 1000 and 6.89 affected men in 1000 for Illinois.

In the following discussion we may also direct attention to the results of a

number of other investigators who have made a study of various regions of the country.

Simon Levin (1921) examined people from Houghton County, Michigan, and in this unselected group he found 1146 goiters in 1783 persons. He investigated the histories of these

cases for the localization of the disease in families and he found that in the case of 22.2 per cent of the patients the fathers had goiters; in 85.4 per cent the mothers were affected and in 67.6 per cent of the cases the children showed the disease.

George Dock (1895) made a brief survey of several districts of Michigan, through his own observations and those of other physicians to whom he sent question blanks. From the report he received there seemed to be 3.9 cases of goiter in 1000 people in the region of Calumet, Michigan. The same was true of the districts around Central Mine and Adrian, Michigan. A physician at Gaylord reports onefourth of the population to be affected. Dock believed that the greatest incidence of goiter in Michigan was to be found in the northern peninsula. This statement was substantiated by the report of Levin on the examinations of recruits from the Upper Peninsula of Michigan where 98,665 cases of goiter were found, or 30 per cent of the drafted men from Houghton County, Michigan, were reported to be affected.

Edward Jones (1918) of Atlanta, Georgia, studied the incidence of goiter in that region and concluded that it was 5 to 10 times less common there than in the Great Lakes region.

Hrdlicka (1916) observed the presonce of goiter among the Sioux Indians

who live along the Missouri River in North and South Dakota and found 61.4 cases in 1000 Indians in that region. The incidence of goiter for the Indian population as a whole was about 3 cases in 1000. Hrdlicka did not consider goiter a tribal disease since other groups of the tribe living away from the river show an incidence like that of the Indian population as a whole. However, the Indians in the goitrous region live in good hygienic conditions and showed no great incidence of other diseases. It was pointed out that they get their water supply from the Missouri River.

Blankinship (1920) collected data on goiter from several state universities and from Wellesley College, which was arranged by Canavan. Sixteen per cent of the students who came from the west to Wellesley College had goiter. At the University of California Blankinship found 17.6 per cent of the students were affected, and 19.8 per cent of those at the University of Washington showed goiter. The report from the University of Wisconsin indicated 28.6 per cent of the students affected. Blankinship states that in Wisconsin the mortality records for 1921 showed 0.24 per cent of the deaths due to goiter.

Taylor (1922) examined 1425 girls from twelve to twenty-two years of age. He found a large percentage had enlarged thyroids as is shown in table 1. These girls were students coming from 16 different states.

Guilder (1923) reported on the examination of 609 women at the University of Illinois, all of whom are residents of Illinois and members of the class of 1924. She found 276 cases

in endemic regions of Ohio which have recently been investigated. The only references which might apply to St. Louis are those made in the Army Report and that by Hrdlicka. Hrdlicka has noted the high incidence of goiter among the Indians in South Dakota and pointed out that only those who get their water supply from the Missouri River seem to be affected. The same factor may be influential in the incidence of goiter in St. Louis.

PRESENT INVESTIGATIONS

The present survey was based on records from the health departments, mortality records, school hygiene committees and hospital cases found in Chicago and St. Louis as giving accurate evidence of a large proportion of the goiter cases in these two regions. From these records and the Army Report the incidence of goiter in Chicago and St. Louis was estimated.

The hospital records of patients with goiter represent only a small group of the population who are affected. However, the hospital records give definite data, such as the age, race, sex and characteristics of goiter patients which can be held as typical of the affected persons in that region. The family histories of many of these patients were studied to determine the importance of heredity as an etiological factor.

INCIDENCE BASED ON HOSPITAL
RECORDS

Records of goiter cases reported in 1922 in St. Louis were collected from the seven largest hospitals and one dispensary and proportioned to the total admissions to the institution for