SOME CASES OF GENERAL INTEREST, IN

VOLVING THE HEAD.

By A. W. STIRLING, M.D., ATLANTA.

It strikes me forcibly that as this is not a gathering of eye or throat specialists, who compose only a minority of our membership, and as the object of our meeting is mutual assistance, I shall do better to bring any special knowledge I may have into the realm of general medicine rather than speak to you on some highly technical subject separate from your daily thoughts and experience. For this reason I have decided to take up a few familiar complaints affecting parts about the head and neck, as they occur to me, and remind you that a superficial diagnosis in these, as in other diseases, sometimes entails much suffering on the patient, as well as brings chagrin upon his doctor, illustrating this truth by examples within my knowledge.

A subject, which presents many pitfalls, is that most common of complaints, headache or neuralgia, which I shall here consider together. There are many causes of headache besides cold or rheumatism and unwise eating and drinking. That I need not say. But some of them are sometimes forgotten. Take for example the following case:

An unmarried lady, age forty-seven, had been suffering for a week from excessive pain in the right side of the face, extending into the eye and ear. She had been seen at least once daily by one of the best-known physicians of the State, who declared her trouble to be neu

ralgia, and besides prescribing other drugs had been compelled to use hypodermics of morphia. After a week of what she described as great agony, she came under my care, with the sanction of the medical attendant. There was nothing in the eye or the ear to cause the pain, but there was a history of a little yellow discharge from the right nostril. There was none when I saw her, nor could I get any by changing her posture. I used transillumination, and found the right side of the face distinctly darker than the left, in the region of the maxillary antrum. I then punctured the antrum through the nose, and washed out a quantity of thick yellow pus. The pain immediately disappeared, and the patient did not return for five days, when the pain had again become troublesome. The antrum was then opened freely through a tooth socket and washed out at intervals with complete and lasting relief.

This case illustrates the fact that antral suppuration may not discharge into the nose in sufficient quantity to draw of necessity the attention to it of a good surgeon, and also that the radiation of the pain may point to the involvement of any neighboring locality rather than the one affected. In fact, the pain of antral suppuration is more often felt in the forehead than in the jaw.

I might quote other cases. I shall take one more,

this time a chronic case. She was also an unmarried lady, age forty one. She complained of headaches whenever she was exposed to draughts or cold, and of some "catarrh" of the nose and throat, for which she had been treated by washes, etc., for years, by the best doctors of the city from which she came. Since the age of twelve her complaint had been confined to the right side, until two months previously, when the left had also become affected. When I first saw her, besides pain in the

temples, eyes and the root of the nose, she complained of a greenish discharge from the nostrils, which she could herself smell. By the process already indicated, suppuration in both maxillary antra was diagnosed, pus was washed out of them, and tubes were worn for a time with very satisfactory results.

This is an example of a class of cases of which I have seen a number. Her antral trouble seems to have been set up by an acute fever-dengue, she says-and to have continued through nearly thirty years, sometimes unobserved, and at others, after exposure to cold, excited into prominence. I believe it to be a by no means uncommon matter that an acute coryza, simple or secondary to a specific fever, such as grippe, is continued into the antrum (what can one expect when people will blow their noses) and that such an acute catarrh, instead of completely clearing up, lies semi-dormant till the next cold rouses it up again, and so on through a series of years. The antrum, like a bottle, has its mouth at the top, and if that once becomes firmly corked, then, of course, follow the pains of pressure. The contents may become infected, and if the abscess comes to be opened, those in the vicinity may be treated to one of the most offensive odors which the much-suffering surgeon has at times to endure. A cold in the head, then, is not the insignificant thing which it is too often thought to be. There are other sinuses besides the maxillary opening into the nose, and the severe headache of acute coryza is probably frequently a symptom of a passing inflammation of the frontal sinuses, or it may be the ethnoidal or sphenoidal. But these are far from being always passing inflammations. They may prove lasting and most

troublesome.

In these days, it is almost unnecessary to mention the frequency with which headaches disappear on the cor

rection of errors of refraction, errors which may be so slight that the patient has often no idea that they have any connection with the eyes. I read a paper on this subject last year before the Savannah meeting of this Society, and therefore shall let it pass now.

But to one other subject, on which I read my first paper before the Society, I wish to refer for a moment, by quoting the following recent cases:

A married lady, age forty-eight, suffered for years from headaches. She then discovered that with her right eye she could see only to the temporal sides. She was then referred to my care, from a Georgia city, when the following was the condition of her eyes: The right had one-twentieth normal vision when looking at things downward or outward, but it was totally blind to the nasal and upper sides. The left, with correcting glasses, had full normal vision. The right was very hard, the left was distinctly hard. She had old glaucoma in the right, and glaucoma beginning in the left. A double iridectomy was performed, but the best that one could. expect for the right eye was that the operation would prevent further retrogression. This was a case in which a diagnosis of glaucoma might easily have been made by a physician knowing the mere rudiments of eye work, had this disease been remembered as a not infrequent cause of headaches.

The following is another case: A widow, sixty-five years old, had been rheumatic for thirty years. Four years before I saw her she is said to have caught cold in her eyes, causing pain in that neighborhood, and indistinct vision. By the advice of two doctors she had for weeks used atropin drops. When I saw her she had not even perception of light in either eye, and was doomed to total blindness for the rest of her life. And yet her eyes had

a stony hardness, and a very little knowledge of the

symptoms of glaucoma on the part of her medical advisers would have in all probability saved her vision. When will able men learn that atropin should never be used in the eye, unless they know for certain that it is indicated? I should like to lay down the law: When in doubt avoid atropin.

I regret that I could quote a number of cases in my own experience in which the vision has been destroyed on account of a lack of knowledge on this easy subject. I opened a book which I published a few years ago on Glaucoma (Glaucoma, Its Symptoms, Varieties, Pathology and Treatment. Jones Parker, St. Louis, Mo.,) with the following words: "Glaucoma

is a subject of great interest to the ophthalmologist, an interest which ought to be shared by all practitioners of medicine, because, unfortunately its symptoms so closely simulate other diseases, that it is by no means an uncommon thing that their true origin is overlooked, with the unhappy result that valuable time is wasted, or improper remedies applied."

I still endorse these words, and cannot too strongly express my feeling, that every medical student, before leaving college, should be asked the differential diagnosis of glaucoma.

Allow me to quote one more case in illustration: A married lady, age sixty-two, was sent to me from another city of this State. For three months her doctor had been treating her left eye for iritis-with atropin, of courseblistering her, and giving her internal remedies. And yet it is not very hard to remember that glaucoma dilates the pupil, while iritis contracts it, not to mention the hardness of the glaucomatous eye compared to one with iritis. When I saw her the eye was as typically glaucomatous as an eye ever was; every symptom was there, and especially noticeable was its stony hardness. That