1. The element iodine is found in nature only in combination with other elements, such as NaI, sodium iodide, or NaIO, sodium iodate. It occurs as a free element only transiently in chemical or biochemical reactions. The reader is asked to bear in mind that iodine may refer to any of these forms.

2. I have synthetized my presentation for this section and for the remainder of this chapter from the following sources. The WHO works by Clements (1961) and Dunn and Medeiros-Neto (1974) gave me my original understanding, which was complemented by further reading in Pitt-Rivers (1961), Netter (1965), Acta Endocrinológica (1973), Stanbury (1969, 1978), Utiger (1979), Tepperman (1980), Thompson and Thompson (1980), Medvei (1982), Matovinovic (1983), Krenning and Hennemann (1983), Fisher (1983), and Harrison's . My understanding of what was known in the early days of prophylaxis comes from the Schweizer Kropfkommission (1928), Carrasco Cadenas (1934 a ), Plummer (1936), and Salter (1940).

3. The seaweed believed to have such a virtue was known in Asturian as ocle, in Castilian as ocla or sargazo .

4. La Canilona is a cleft in the Asturian coastal cliffs where seaweed, because of heavy currents, tends in stormy water to accumulate. Asturians have long harvested seaweed as a cash crop from this and other dangerous coastal sites, cured it, and—ignorant of its final uses—sold it to merchants transporting it to distant industries.

5. Commercial feed in the United States is supplemented with calcium iodate (Purina labels, for example, state this clearly); commercial feed in Spain, even under the Purina label, was at the time of this investigation not supplemented. Other feed grown on the Spanish plains is naturally rich in iodide (César Cifuentes, pers. comm.). Livestock passes iodide into the human food chain by way of milk and meat or indirectly when livestock manure is dropped onto cropland.

6. UIE is a rate measurable as micrograms of iodide per gram of creatinine excreted per day. Creatinine is a normal metabolic waste.

7. The term cretinism may come from Swiss patois creitin (L. Christianum), referring to popular usage, which holds that these creatures, though idiotic and deformed, are nevertheless human and therefore potentially Christian ( OED ). Other etymological works suggest roots in early forms of the word "creature," in its sense of innocence or dependence.

8. Iodine deficiency was not so severe as to make cretinism endemic.

9. Hunziker (1924), Plummer (1936), American Public Health and Hygeia articles spanning 1922-1937, and Morton's Salt advertisements all testify to the broad diffusion of this information.

10. I have gained the impression in Escobines, where nowadays only females manifest goitrousness in the higher grades, that in this village cretinism and deaf-mutism affect mostly males. Since male embryos are not known to be more vulnerable to maternal iodine deficiency than female embryos, I speculate that Escobines females born deaf or deficient have a harder time surviving infancy or childhood.

11. MIT is monoiodotyrosene, and DIT is diiodotyrosene. One of each kind are joined to make T3, the more potent of the hormones; two DITs are joined to make T4.

12. The Manihot, Brassica, and Crucifera plant families are high in goitrogens.

13. Unlike cabbage or cassava, the goitrogenicity of these nuts is not well known, probably because, relative to other foods, they are viewed as insignificant in human diets.

14. Only later was it statistically shown that the crisis would have occurred spontaneously without supplementation, though perhaps not in so accelerated a fashion.

15. Very old women in the mountain community of Río Aller not far from Escobines spoke with resentment of just such peremptory intervention. To achieve the desired cosmetic effect, such women were thyroidectomized on a rustic table in the local schoolhouse.

16. Iodine can be conveyed by injecting iodized oil, Lipiodol, an additive product that became available only after mid-century. Public health authorities have injected remote populations with it, those in New Guinea and in the Andes, for example, where safe and sufficient levels of dietary iodine could not be assured. Lipiodol affords protection for a span of from three to five years. Injections have also been found useful in less remote areas, as in Asturias, where, in 1983 at the inception of the campaign to eradicate goiter and cretinism, iodized salt had still not appeared on the market. A cheaper, oral form of iodized oil suspension promises soon to supplant the injected form (Francisco Escobar del Rey, pers. comm.). Basil S. Hetzel gives a fuller account of the development and use of iodized oil (1989, see pp. 58-67 and 111-116).

17. It did not, for example, seem plausible to Severo Ochoa, the Asturian-born recipient of the Nobel Prize in physiology, nor to his compatriot Grande Covián, a nutritional physiologist of international stature, that Asturians could still, in 1980, given the declining incidence of goiter, be experiencing iodine deficiency (pers. comms.).

18. RAI procedures became available in Asturias in the 1960s and were reported as novel procedures by Suárez-Lledó (1962). A more detailed chronology is given in chap. 7.

19. The thyroid disorders possibly resulting from the fallout of nuclear devices—such as those that befell the people of Eniwetok in the Pacific

or the "Downwinders" of Utah and Nevada (Ball 1986)—lie outside of this consideration.

20. CONN and The Merck Manual in Spanish translation, which were the most common desk references of Asturian country physicians, reflect the overwhelming diagnostic/curative emphasis that fills the stage vacated by prevention.

21. Propylthiouracil is one example of an antithyroid agent.

22. Pharmacologic doses of iodine have an altogether different effect than do physiological doses.

23. Toxic coma is sometimes classified, for example, as a psychiatric disorder, ignoring its possible origin in complications of simple goiter.

24. The particular manifestation of defect in the cretin—whether of bone growth retardation, of incoordination, of sexual or thyroidal agenesis, or of sensory and neural loss resulting in deaf-mutism or in reduced intellectual function—depends on the timing and intensity of hormone deficiency both early in utero and in early postnatal life.