Medical Society of the State of North Carolina. An.

Transactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) online

. (page 33 of 58)
Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 33 of 58)
Font size
QR-code for this ebook


3. Patten : Jour. Amer. Mod. Assn., 1914.

4. Dudley : The Journal Opthl. and Oto-Laryng., 1915.

5. Hare : Practical Therapeutics.

6. Bergeson : The Index of Oto-Laryngology.

7. Practical Medicine Series, 1914.

8. Bishop : Diseases of Nose, Throat, and Ear.



THE DIAGNOSTIC VALUE OF HEADACHES, GENERAL
HEADACHES, SUN PAINS, NOCTURNAL PAINS AND
LOCAL HEADACHES, TO THE GENERAL PRACTI-
TIONER.

W. p. Reaves, Greensboro, N. C.



In taking up and writing this paper I have done it more from the
standpoint of the general practitioner. In dealing with cases it is neces-
sary to treat internally or be referred for special treatment, and going-
over such a broad field, I have had to limit myself to making very definite
suggestions instead of discussing the conditions upon which these diag-
nostic points depend.

All forms of headaches are found in the region of the fifth nerve, with
few exceptions. The upper cervical nerve headaches are either general
or local. General headaches are usually due to a systemic cause, febrile
diseases, anemia, vasomotor disturbances, syphilis, nephritis, diabetes
and auto-intoxications. These are the ones that the family physician
comes in contact with every day, and should be studied very carefully
and be treated medicinally, and the results Avill be gratifying to the
physician and patient. On the other hand, local headaches, sun pains,
neuralgia, neuroses, ticdoulereaux will be equally disappointing to both
physician and patient if treated medicinally. These local headaches are
external to the cranium anterior and below the hair of the scalp, found
in people apparently in health, free from pain a part or most of the
time, not considered serious, but an inconvenience believed to be heredi-



PRACTICE OF MEDICINE. 287

tary or the result of some indiscretion of their habits. Treated by purga-
tives, tonics, or soda-fountain dope which today are making many neuras-
thenics out of our young girls !

The first question the physician should ask himself, and not the
patient : Is it from a systemic or a local cause ? Then by a process of
elimination he may classify the cause. If systemic from some acute
disease, the headache will disappear with the disease. If systemic from
any of these diseases, as diabetes, nephritis, syphilis, malaria, or intes-
tinal auto-intoxication, it will be necessary to find or eliminate the cause.
Diabetes and nephritis by urinalysis, syphilis by a "Wasserman and
clinical finding, malaria by the microscope, and auto-intoxication by the
acuity of his diagnostic ability. Every case of obscure headache should
have the blood pressure taken. I have never seen a case with a blood
pressure 30 below what it should be for his or her age that did not have
headaches, and 50 above normal is nearly always associated with head-
aches. This is the time to treat nephritis. This is the syndrome, the
blood pressure rising before any albumen is found in the urine. Save
your patient before it is too late.

Having gone into the case, eliminating systemic causes, with equal
care then check up the local causes, and the mist that has clouded the
cause of headaches will begin to clear up.

Local headaches with a local cause, with or without a periodicity, have
a diagnostic value that when properly interpreted may bring joy to the
heart of the sufferer with the thought that he may be able to work with-
out suffering and be sociable and companionable with his friends.

The character, severity, locality, and periodicity of local headaches
are worth a great deal in arriving at the cause of headaches. Frontal
headache following reading, especially in the afternoons after several
hours of study, is suggestive of eye strain, either errors of refraction or
muscle unbalance. When these troubles are corrected by an oculist the
patient usually gets relief. A sharp distinction should be drawn between
an oculist and the pseudo-doctor, optometrist and optician, that advertises
"eyes fitted without drops, cross eyes straightened without the knife."
In some States there is a law prohibiting opticians from advertising and
doing business under the title ''doctor," which is interpreted by the laity
to mean a doctor of medicine. It is a violation of the law to label oleo-
margarin as butter, yet our State permits men who have no medical
training at all to label themselves as doctors, to sell glasses and murine,
and the patients believe they are getting expert eye treatment. More
than once have I seen loss of vision from optic neuritis Avhile they were
wearing glasses and using murine, believing that they had had the best



288 NORTH CAROLIiVA MEDICAL SOCIETY.

of treatment, finding out too late that they had not had the services of a
physician at all, when the proper internal treatment would have saved
their vision.

Sun pains should be Avritten sinusitis, coming on after rising in the
morning at a certain hour and going off before sundown at a certain
hour. This periodicity of the day and hour with localized pain, although
it may become general pain, is almost pathognomonic of chronic sinus
trouble. The other forms that have a less typical periodicity are often
seen in what are called sick headaches.

These cases are often sequelas of an abscess tooth involving the maxil-
lary, or grippe involving one or all of the sinuses. When one or more
fail to make a spontaneous cure, and the patient is left with what he
calls catarrh, and finally when he is forced to seek surgical relief, he
wants to pay you in part in atomizers that he has accumulated in treat-
ing his catarrh.

Within the last few years instruments and technique for operation
upon the maxillary, frontal, ethmoid and sphenoid sinuses have been so
perfected that one or all of the sinuses on one side can be operated on
under local anesthesia at one sitting, and by keeping the patient near the
surgeon for a few hours the nose can be left unpacked, which aids drain-
ing in a field that has pus. The bleeding is an advantage, by depleting
the operated field, w^ashing away infection and pus. To pack aids absorp-
tion of pus, causes inflammation, and multiplies the after-pain of the
operation. More than 95 per cent of sinus cases can be operated upon in
this way.

'Now compare this method with the old external operations that were
formerly done'by the general surgeon, scarring the patient for life, often
leaving an ethmoiditis or sphenoiditis back of a frontal or maxillary
that would reinfect the operated field, which now explains the many
failures of relief, not to mention that the patient had to take a general
anesthetic and stay in a hospital for about a week. When this is ex-
plained to a patient, many will submit to the operation, when before they
would rather suffer the pain than to take an anesthetic, lose the necessary
time after the operation, and have a scar on the face for life.

Nocturnal or night headaches have some diagnostic significance. First,
they practically eliminate sinus trouble, Avith the exception of acute
sinusitis that has day pains, and the day pains always predominate the
night pains. The old chronic sinusitis that has developed a neurosis
overshadows the sinus trouble, and the patient may have sick headaches
at night, but without the sinus periodicity. Night headaches are often



PRACTICE OF MEDICINE. 289

found in sypliilitics, and some mistake them for sinus trouble, wliieli
should not be done if they are free from pain during the day.

Pressure headaches are caused by a deviation or abnormal anatomical
condition of the nose. The child may fall on the floor and mash its nose
flat and dislocate the septum, as the athlete on the football ground.
These conditions block one or both of the nares, and may by the con-
tinued pressure produce a neurosis of some nerve that is the cause
of a neuralgia every time the person deviates from his normal habits.
The cure is to remove the pressure and restore normal breathing. Neu-
roses are often sequelfe to chronic catarrhal or hypertrophied conditions
in the nose, the results of nasal obstruction, especially adenoids in chil-
dren — in short, adenoids in children and catarrh in adults.

Every case of hay fever should be carefully examined to eliminate any
pressure or neurosis in the nose or sinus trouble. Asthmatics are usually
nasal sufferers. At our last meeting I reported eight cases relieved or
improved by nasal operations. One of the cases still has attacks, but
they are less frequent and less severe. One other, although nares are
clear, as she had a double ethmoidectomy, has had a return, after several
months relief, in all its severity. This return and severity are attributed
to a tubercular involvement of the lungs.

Headaches in women during menstruation, especiall}^ if associated
vpith dysmenorrhea, may not be a true uterine or ovarian headache,
especially when these organs are normal in every way. Most all mucous
membrane becomes congested at this period, especially in the nose at the
point known as the "genital spot" on the septum and middle turbinates.
Should these points have become sensitive or neurotic from pressure or
by hypertrophy, then the congestion and psychic condition acting upon
these hypersensitive points often cause a headache that precedes the
painful menstruation, and the proper treatment in the nose prevents
both headache and the dysmenorrhea.

RESUME.

The character, location, and periodicity of headaches ■ are of much
value when elicited and studied in a systematic way — systemic causes
• eliminated, local causes analyzed.

The physician should ask himself these questions as he interprets the
history of the patient :

First. Has the patient headaches characteristic of eye strain ?

Second. Has the patient headaches characteristic of sinus trouble ?

Third. Has the patient headaches at night and not during the day?
That tends to eliminate sinus trouble.
19



290 NORTH CAROLINA MEDICAL SOCIETY.

Fourth, Has the patient headaches with obstructive breathing charac-
teristic of pressure with or without a neurosis ?

Fifth. If the patient has hay fever it should be imperative to have the
nose examined to eliminate a neurosis or a pathological condition before
pumping vaccines into his system.

Sixth. The very complex chain of reflexes in headaches associated
with dysmenori'hea should be carefully studied, as the patient's health
and happiness depend upon both the gynecologist and the rhinologist.

Dr. p. R. Hardee, Stem : I do not wish to discuss this paper, but I
want to ask Dr. Reaves a question. The information that I want to
get is in regard to the blood pressure. I notice Dr. Reaves in his paper
spoke about giving medicine to relieve the high blood pressure, and I
would like, for my own information, to hear something about this. I
find that that is a hard thing to control, and I would like to know what
remedies Dr. Reaves finds best in holding the blood pressure down.

Dr. Reaves (in reply to Dr. Hardee) : That is a question I inten-
tionally avoided, because I am not sure of my therapeutics ; but what
I have tried to do, first, is to increase elimination. You would treat it
almost as a nephritis. Of course, you would restrict meat diet. High
tension nerves in daily work mean high blood pressure. The only thing
that has done my patients good is bichloride, one grain to the ounce of
a saturated solution of potassium iodide, ten drops after meals. Some-
times they run it up to twenty and thirty. It's the only thing from
which I have gotten any permanent result. This is what I generally
give, letting them take it for a month. I have had some patients on it
from three to six months, and the blood pressure would gradually come
back. It has been as high as 170, and has dropped to normal in the
cases with no albumen in the urine. Cases that have a blood pressure
less than 200 without albumen I have gotten results from. In one case
a sufferer from headaches got relief for a time from glasses. His blood
pressure when I saw him was 170 or 180. He weighed 200 pounds,
and his height was 6 feet 2. I put him on one grain of bichloride to an
ounce of saturated solution of potassium iodide, ten drops after meals.
He came back in about six weeks, stuck his head in the door, and said
he was glad he had found something else besides glasses to cure head-
ache. In blood pressure that is not the result of arterio-sclerosis, with
the urine free from albumen, you have to deal with an auto-intoxication,
and in potassium iodide and mercury you have a remedy that will in-
crease the elimination through every emunctory of the body.

In a few cases with an idiosyncrasy for iodides other remedies will
have to be used.



PKACTICE OF MEDICINE. 291

Dr. Hardee : Dr. Reaves purposely evaded what to me is the gist of
his paper, for I have not found it an easy matter to prescribe a remedy
which will relieve high blood pressure for a considerable length of time
without being injurious to the patient. I am very much interested to
know that Dr. Reaves relieved this case of high blood pressure with
bichloride of mercury and iodide of potash, remedies which if indexed
as being vasomotor sedatives I am not cognizant of, and am certain
that bichloride is not so indexed. That Dr. Reaves obtained such prompt
and permanent results in this particular case with these remedies, which
are a specific for some other trouble, leads one to believe that the doctor
was treating primarily the patient's blood, for spirochajta, and not
treating the blood pressure per se, knowing that when this irritant was
eliminated nature would not only relieve the high blood pressure, but
the pain also, for syphilis has long since been recognized as being a
cause of high blood pressure, and we all know it causes pain.

A case of high blood pressure in a maiden lady 65 years old has given
me a good bit of trouble for two years. When called to see this patient
the first time, on my arrival her companions informed me that she had
just had a very hard fit. I^ever having had an opportunity to test the
blood pressure before an epileptic fit, I decided to test it in this case
after the paroxysm, while in the comatose state, and found it 180. I
at first suspected kidney trouble as cause of this condition, but found the
urine negative; then, believing that I had a case of epilepsy, caused,
probably, by arterio-sclerosis at base of brain, I decided to try and pre-
vent the epileptic paroxysms by maintaining a low blood pressure. Ac-
cordingly I prescribed for this patient a mixture of JSTorwood's tincture
V.V. and tincture aconite root. By giving about 4 doses a day it has
controlled this patient's pressure very well. She soon learned by certain
indescribable symptoms when an extra dose is necessary. On a few occa-
sions when, from some cause I know not what, this failed to relieve, I
have given nitroglycerin, 1-110 grain every thirty minutes. This has
never failed to give relief until an increased dose of the aconite and Y.V.
gets its effect.

The treatment outlined above has been reasonably satisfactory in con-
trolling the pressure, and I think in preventing epileptic paroxysms also.
At any rate, her life has been tolerable. I do not believe this treatment
has had the injurious effect which the bromides w^ould have produced.



CONSERVATION OF VISION.



ECONOMICS OF THE PEEVENTION OF BLINDNESS, AND
THE STATE SCHOOL FOR THE BLIND.



John E. Ray, Superintendent North Carolina State School for the

Blind, Raleigh.



Mr. President and Members of the State Medical Society:

I am not UBmindful of the compliment conferred and tlie courtesy
extended me in this permission to speak in your presence upon a most
vital topic. I shall seek to not impose upon your patience, nor to abuse
the privilege accorded me. I am deeply grateful to you.

The subject assigned me is a very broad one, and I shall hope to touch
merely upon a few of the most important phases. And let me, in the
beginning, disabuse your minds of any thought that I come to instruct
you experts. I come as a layman, after forty years association with the
blind, with a message which I wish to lay upon your hearts, and to "stir
up your pure minds by way of remembrance."

"Economics of the Prevention of Blindness, and the State School for
the Blind."-

There are three words which we hear very frequently these latter
days — "efficiency,'" in matters of education ; " profi.ciency ," in the me-
chanical and industrial world, and "prevention'' in the sanitary and
medical world. I am to deal meagerly with this last. I quake at the
task. But since you have dealt so graciously with me these past few
years, I presume.

Upon the old proverb, "An ounce of prevention is worth a pound of
cure," I base my remarks. You know how much more easy it is to pre-
vent than to cure. After blindness has occurred, the cure, in most in-
stances, is impossible. Hence the seriousness of the proposition before
us, and the immense importance of prevention.

And let me remind you that there are cases of blindness which should
never have occurred, and would not, if proper preventive measures had
been employed at the right time. The most prolific causes of blindness
are heredity, atrophy, trachoma (in some sections of our country), acci-
dent, and ophthalmia neonatorum — baby sore eyes. Of the last two I
shall speak more particularly.

And let me inject just here one brief remark. I have read only re-
cently from the pen of a very distinguished specialist, and with no little



CONSERVATIOIS' OF VISIOX. 293

relief, that it has been discovered that the gonococcus is not alone respon-
sible for this dreadful disease. On the other hand, another germ — there
may be more — will produce the direful results. I confess to considerable
relief, but to no less apprehension. I^ay, more. Does not the situation
call for greater care ?

There are approximately 100,000 blind persons in the United States.
Of this number, the blindness of fully 25 per cent is due to ophthalmia
neonatorum ! How appalling ! In K^orth Carolina there are more than
1,600 blind persons of all ages. The records of the State School for the
Blind for the past two years show an enrollment of 388 students. Of
these, 87 are congenital, SO causes unknown, 79 from ophthalmia neona-
torum, and 33 from accident. This means that more than 20 per cent are
blind from ophthalmia neonatorum, and nearly 10 per cent from acci-
dent — approximately 30 per cent of all from preventable causes. Think
of 30,000 needlessly Mind persons in our I^ation, and more than 450 of
them in our own State ! And when we remember that a little care on the
part of the parents in keeping from their children sharp-pointed instru-
ments and explosives would have prevented most of the accidents, and
just a little cleanliness before and after the birth of the babies, the
administration of a few drops of a 1 per cent solution of silver nitrate
in both eyes of the newly born child, requiring not more than ten minutes,
and costing less than 10 cents, would have preserved the sight of practi-
cally all the others, is it not 'pathetic, not to say criminal? Who is to
blame ?

You all know that the prophylactic is to be had in well arranged par-
cels, hermetically sealed and guaranteed for several months. If it is not
used within the prescribed time, it may be returned and replaced by a
fresh supply.

Would it be unreasonable to ask the next General Assembly to provide
all county and city health officers and midwives with the prophylactic
free of charge ? And will not the members of the State Medical Society
do all in their power to require all persons practicing obstetrics in our
State to administer this prophylactic, or something else equally effective ?
Such laws have been enacted recently in the States of Indiana, Kansas,
ISTew Hampshire, I^ew York, Rhode Island, South Dakota, Tennessee,
California, Connecticut, Illinois, Kentucky, and possibly others. In
most of these States the birth of every child must be rej^orted to the State
Board of Health within thirty-six hours, and in some of them the physi-
cians, or midwives, are required to answer the questions : "1. Did you
administer the prophylactic ? 2. If not, why not ?"



294 NORTH CAROLINA MEDICAL SOCIETY,

The law in 'New York is very stringent, requiring all midwives to be
licensed, and refusing to license any one who has not "attended 15
maternity cases and nursed 15 lying-in patients, under the supervision
of a physician" ; and even then they are allowed to be in "attendance
upon normal cases only, and nursing of mother and child."

The results have been most satisfactory. At the Sloan Maternity Hos-
pital of New York City, where preventive methods are employed, "out
of 4,000 births, during a period of six years, not one case of infant oj^h-
thalmia has developed." In Michigan 19 cases were averted last year,
and in Missouri 167 cases of eye trouble were cared for.

Through the good services of Drs. Carr, Kent, Capehart, and others,
a bill was passed by the recent General Assembly of our State entitled
"An act to prevent blindness in infancy," and is now upon our statute
books. It is a very decided step in the right direction, and I commend it
to your consideration and support.

I have not yet touched the first word of my subject — the "economics"
of the situation. You are all aware that it is very expensive to properly
educate and train the blind. The United States Commissioner of Educa-
tion, Dr. Claxton, tells us in his recent report to the Government that the
average "per capita cost of instruction and maintenance" of the 64 pub-
lic schools for the blind in our country "was a little more than $328."
("Tell it not in Gath, publish it not in the streets of Askelon," but the
legislatures of our State have appropriated less than $200 per capita for
the "instruction and maintenance" of our blind students for the past
eight years — in fact, less per capita than was given eighteen years ago !)

Taking this $328 per capita as a basis, you can see that it costs the
State of J^orth Carolina at least $25,000 annually to "instruct and main-
tain" the needlessly hlind children in the school. In the course of ten
years this amounts to a quarter of a million dollars ! And this takes no
account of the scores of such children in the State who never enter the
school, for there are more than 200 blind children of school age within
our borders who have never entered the school ! And there are many,
many more who are now too old to be admitted who will be a care and
an expense upon their relatives, or their respective counties, so long as
they live. It is impossible to calculate to Avhat this amounts. Is it not
worth considering ?

Others think it worth while to prevent, and the United Steel Corpora-
tion spends a half million dollars annually for devices to prevent acci-
dents to the eyes of its employees. The Eussell Sage Foundation, too,
is spending thousands of dollars annually in this work of prevention.



CONSERA'ATION OF VISION-. 295

This enterprise is pretty well organized in tlie northern and some of the
mid-western States, but North Carolina is the only southern State Avhich
has given much attention to the subject.

Some ten years ago one person began to study the situation, thinking
little of its importance at first, because of the homogeneous and rural
character of our population. He was soon amazed to find that the mea-
ger information furnished in the application blanks filed for the admis-
sion of students into the State School for the Blind showed 15 per cent
of blindness from ophthalmia neonatorum. As more attention was given
to the subject a much more appalling condition was manifest. He began
to raise his voice at public gatherings and to write through the State
press, calling attention to what existed. He has been amply rewarded
by the hearty support accorded by the medical profession and the en-
couragement extended almost unanimously by the editors of our Com-
monwealth. The physicians in the General Assembly the last three ses-
sions have wrought manfully for legal measures to aid in the work of
prevention. Special mention is due Drs. Kent, Carr, Macon, and others
who have been most active in this movement. Is the time not ripe for
aggressive work for prevention ?

The problem before our school now is to do the best that can be done
for those already blind. The one pleasing phase of our work is that 85
per cent of the graduates of the school are self-supporting, self-respecting,
independent citizens, making a comfortable living for themselves and



Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 33 of 58)