THE CRETINIC DEGENERATION 445 



burden of supporting large state communal and private institutions for 

 their care. Many of the less afflicted are withheld through their mental 

 or physical deficiencies from productive vocations. Again, many large 

 commercial companies refuse to employ those rejected by military exam- 

 iners with the result that such young men are often forced into vocations 

 beneath their actual ability, thus again entailing economic loss. The 

 sociologic and economic burden imposed upon a community or state by 

 such a prevalent disease is enormous. The loss to the military of numerous 

 recruits due to this disease is of grave significance in countries where the 

 disease is common and severe. 



Endemiological 



Endemicity is a characteristic feature of the disease. There is great 

 variation in the intensity with which the inhabitants of various countries, 

 districts, and even villages, are affected. Certain countries, such as the 

 United States, may have large areas free from endemic goiter and cretin- 

 ism. On the other hand, the disease may elsewhere exhibit such great 

 intensity that practically none of the inhabitants of an endemic area may 

 entirely escape. Endemic goiter may be regarded as the lightest clinical 

 expression of the disease. In many affected regions, cretinism, deaf- 

 mutism and goiter heart may be quite absent. Where the disease presents 

 its maximal intensity nearly all the inhabitants are goitrous and the 

 severer clinical forms are found always, however, in much less numbers 

 than merely goitrous individuals. Adjacent villages in endemic areas 

 may present great differences in this regard. In one, only goiters may 

 be encountered ; in another but a short distance away, cretins also may be 

 found. 



A very slow ebb and flow of the endemic may be observable. Usually 

 the lack of precise data renders it difficult to follow such fluctuations in 

 severity, which develop over a long period of years. In this regard, 

 Baillarger's extensive statistics are of great value. This writer found 

 that during a period of 50 years ending 1865 that in the 60 departments 

 of France, the incidence of endemic goiter increased in 26 departments, 

 decreased in 17 and remained in statu quo throughout the remainder. 

 It seems as if a period of maximum intensity leads to a certain degree of 

 auto-immunization which tends to check further development and brings 

 about a gradual recession. Indeed, an endemic area may become practi- 

 cally free of the disease, with only a few cases of goiter persisting. This 

 may be induced by hygienic measures, particularly the introduction of a 

 pure drinking water supply. 



Endemics of cretinic degeneration are much more frequent in rural 



