THE CRETINIC DEGENERATION 469 



It is probable that in endemic areas other growth and developmental 

 dystrophies such as true nanism, infantilism, mongolism are frequently 

 mistaken for cretinic degeneration. The differentiation of these conditions 

 has been already detailed. (See Diagnosis of Hypothyroidism. ) 



Treatment 



Prophylaxis. In view of the increased importance recently attached 

 to the toxemic and bacterial causation of the cretinic degeneration, new 

 impetus should be given to the prevention of the disease by means of hygi- 

 enic measures. It is indeed remarkable that hitherto no general attention 

 has been given by public and private health authorities to such prophylaxis 

 in this widespread disease. Excellent proof has long been afforded of the 

 value of the preventive treatment. Though rather refractive to therapeutic 

 measures, endemic goiter and cretinism will, in all probability, be soon gen- 

 erally regarded as preventable diseases. The chemical composition of the 

 water is chiefly of importance as affecting its general hygienic qualities. 

 The main point to be observed is the avoidance of surface contamination, 

 particularly fecal. In view of recent experiments already quoted, it is 

 recommended to boil or chlorinate a dubious water supply. It is an estab- 

 lished fact that certain natural waters prevent or alleviate cretinic degener- 

 ation, especially goiter. Such waters are bacteriologically pure and have a 

 high iodin content. 



The experimental production of goiter and cretinism by the alimentary 

 introduction of fecal material from affected individuals, also by bacteria, 

 (McCarrison) emphasize the important role probably played by soil con- 

 tamination in producing the disease. This writer therefore advises the 

 strictest care as to sewage disposal in endemic areas, including the removal 

 of stables and barnyards from the vicinity of houses, the filling in of cess- 

 pools, introduction of sanitary plumbing, as well as greater attention to 

 personal hygiene. It would seem that about the same measures so well 

 applied in stamping out a typhoid fever epidemic might be instituted. 

 Removal from an endemic area often effectually prevents an outbreak of 

 the disease. It may be kept in mind that patients who have been appar- 

 ently cured still remain prone to a recurrence of the disease, particularly 

 on a return to endemic areas. 



Many examples of the therapeutic effect of the introduction of a pure 

 water supply are cited in the literature. One of the most striking is de- 

 scribed by E. Bircher. In the village of Asp, there were in 1863 among 

 the population 34 per cent goitrous, 15 per cent deaf-mutes and 8 per cent 

 cretins. In 1907, the upper part of the village obtained a new and pure 

 water supply, while in the lower the old system remained. In 1910 the 

 statistics gave the following results. Upper village 6.4 per cent goiter dis- 



