the right side, unable to smell with the right nostril, and wholly blind with the right eye. He could not then tell light from darkness, nor did he flinch when the finger was brought close to his eye. There were no morbid ophthalmoscopic appearances. Unfortunately he became so unruly and dirty that it became necessary to discharge him, and he was thus lost sight of, not much better than when admitted.

Hysterical contracture will also be found sometimes in girls of eleven or twelve. Quite lately, a case of this kind has been under my care. It was speedily cured by keeping the affected arm firmly bound to the side, and compelling the use of the other.

Headache is very common in children, from six years old and upward, and it arises from all sorts of causes. It is usually frontal and associated with sickness; sometimes it is one-sided, over one or other frontal eminence, and occasionally disturbance of vision accompanies it, as in the megrim of older patients.

Causes and Diagnosis.—It is not easy to distinguish between the different forms of headache. Most commonly the child is said to be subject to sick-headache; but, when the case is investigated-in one the ailment may be due to anæmia; in another to indigestion or constipation; in another it is the trait of a child of rheumatic parentage; in another, the result of hypermetropia. To arrive at an opinion in any case, it is well first of all to examine the eyes by the ophthalmoscope so as to eliminate the last-named condition. A large number of children are hypermetropic, and when they begin to tax their eyes for reading the strain upon the power of accommodation becomes excessive, and frontal headache arises, which may or may not be associated with internal strabismus. The headache is usually a supraorbital one, and the letters run one into the other as the child reads. It is not unimportant to add that these cases

are often distinctly worse when the health is deteriorated from any cause. The strabismus may, indeed, only be noticeable at such times-like the decayed tooth, which, though always decayed, aches only now and again, in response to impairment of the general health. In another large group

of cases, the children are badly nourished and anæmic. The relation of gastric disturbances to headache is more open to question; for it is certain that in many, perhaps most, cases of megrim, the stomach and brain react upon each other, and food will unquestionably excite an attack of headache, as a worm or other intestinal irritant will excite a convulsion. Headache is sometimes troublesome in girls at puberty, and is associated with catamenial irregularity and backwardness. The headache of brain disease is likely to be occipital, unless it be due to meningitis, when it is general.

Symptoms.-Sick-headaches usually manifest some periodicity, though it may be but an irregular one. They are oftentimes attributed to food, and they are associated with vomiting. The headache is frontal, often of throbbing character about the temples. The head is hot, and there is often some intolerance of light, or some hyper-sensitiveness of hearing. The victim is the subject of a terrible malaise, and for the time being only wishes to be let alone, and longs for sleep. The tongue is usually clean, the temperature normal, and the pulse not quickened. The duration of sickheadache is variable. It generally subsides in sleep, and lasts but a few hours. Occasionally the vomiting is severe and repeated, and the child is out of sorts for some days. The anæmic headache is less localized, more continuous, and perhaps less often associated with sickness. In most cases of headache the bowels are irregular.

Diagnosis. The ailment being a common one, there is some risk of overlooking the headache of organic disease.

It will be well, therefore, to remember that bad headache sometimes ushers in typhoid fever-one of the common diseases of childhood-and that the headache of meningitis is usually associated with pyrexia and constipation, as well as its own more special symptoms. The hypermetrophic headache may be suspected if there be hypermetropia, and the anæmic, rheumatic, and other forms must be diagnosed by reference to the appearance of the child, its past history, its family history, etc.

Treatment. Headaches are usually troublesome, for several reasons. They are common, are not thought much of, and their excitants are not therefore avoided as they might be; moreover, they are not immediately amenable to remedies-in many cases they hardly appear to be influenced at all-and the child slowly "grows out of them." The hypermetropic headache must be treated by the ophthalmic surgeon (not by the spectacle-maker), who will see that any anomalies of refraction or in the shape of the eyeball are properly corrected by carefully adjusted spectacles. Apart from this special form, all headaches are likely to be rendered less frequent by the prolonged use of such drugs as arsenic and iron, but they must be given for some weeks continuously if they are to produce much effect. In the headache of girls at puberty, perhaps iron, permanganate of potassium, and bromide of ammonium are most useful. For the attack itself, bromide of potassium may be given; it is sometimes successful in relieving the throbbing forms of sick-headache. Guarana and tonga are sometimes useful, although not easily administered. Guarana may be administered as an elixir (Martindale), the tincture of guarana being mixed with equal parts of simple elixir (F. 44), and half a teaspoonful or a teaspoonful given, in water, for a dose. But, upon the whole, sleep is the best restorative, and arsenic the most reliable tonic for keeping the attacks at bay.

CHAPTER XLI.

cases.

IDIOCY AND CRETINISM.

Idiocy is met with at any age, from a few weeks after birth onwards. Imbecility is a condition of many grades. In some there is but slight departure from the healthy condition; some are for long unable to walk or talk; the worst cases have no natural sense of any kind. Twice only have I seen anything in the nature of cretinism amongst my own Of nineteen cases, five were uncomplicated. In one there was a peculiar condition, which I could only denominate speech idiocy. The child, aged five, seemed fairly intelligent, although mischievous. She appeared to understand in a measure what was said to her, but her utterances in return were quite unintelligible. Two were deaf mutes; five were more or less amaurotic (only one of these had had fits); one had white optic discs; one retinitis pigmentosa; one a peculiar stippled condition of choroid (? choroiditis); and the other two were amaurotic, without visible change in the fundus oculi; four others had had fits; and two were cretins.

Idiocy may be either congenital or acquired. The congenital cases are likely to be microcephalic. Acquired idiocy is common after convulsions. It is in many cases impossible to say whether the two forms are alike due to some cerebral lesion or whether the one is dependent upon malformation rather than disease; but in some cases the history of sudden convulsion, one or many, is precise, as also that progressive impairment of intellect has followed. Idiocy may be compassed in a variety of ways at this early

age, in some by lesions which deprive the child of important channels for the acquisition of knowledge and experience, such as sight and hearing, in others by damage to the cerebral cortex; but the frequency with which convulsions are spoken of as an initial symptom seems not unlikely to point to meningeal or inter-arachnoid hemorrhage, and subsequent pachymeningitic changes, as a common method of causation. Other cases there are, called by Dr. Langdon Down" developmental," where the disease comes to children who have at first evidenced an average intelligence, at the period of the first or second dentition or at puberty. Such children develop up to a point, and as a result, perhaps, of a fit, or some greatly impaired nutrition, such as may show itself by chorea, they become imbecile, and the brain undergoes no further development.

Cases of this kind, and congenital idiocy probably, find a predisposing cause in consanguineous marriages and in alcoholic excess in either parent. The developmental form is possibly sometimes to be attributed to masturbation.

Cretinism, as commonly seen, is a disease which is endemic in certain parts of certain countries. In Europe, it abounds in Styria and the Tyrol, and it is not uncommon in the Swiss valleys, Savoy, and Piedmont. It is occasionally seen in England, in the dales of Derbyshire and Yorkshire; but in this country it is more generally known as a sporadic affection. Happily it is not common. Those who have charge of large asylums for idiots see most of it, and Dr. Fletcher Beach, of Darenth Asylum, has published some interesting cases. Dr. Hilton Fagge was the first in this country to call attention to sporadic cretinism, in a very valuable paper in the "Transactions of the Royal MedicoChirurgical Society."

It is a curious and interesting disease, so strangely contradictory is it in its external form; for in many respects