to some natures as this may be, is it really desirable? Possibly only in a training-school large enough to form a little world in itself, is it wise even here? Is it expedient from the point of view of the profession?

Keenness, gentleness and strength, patience, hard work, accuracy and attention to detail, powers of observation, kindness and unselfishness, consideration, and understanding—all these we need as nurses, but we need them also as tennisplayers or partakers in sport of any kind, as musicians or singers, actors or artists, needlewomen, literary students-in short, as human beings.

Nurses devoted, patient, conscientious and whole-hearted let us be, seeking not our own but another's good. Women let us also be, responsive, alert, intelligent, every ready to assimilate new impressions and to see wider points of view, alive to the beauty and richness of the world around us and to the infinitely varied manifestations of life.-The Hospital.

THE CANADIAN MEDICAL PROTECTIVE ASSOCIATION Organized in 1901, at the Winnipeg meeting of the Canadian Medical Association. Incorporated by Act of Dominion Parliament, February, 1913. OBJECTS-Defends its members against cases of alleged malpractice. Annual fee three dollars, half rates from July 1st. Qualifications for membership: All members of the Canadian Medical Association in good standing, may be enrolled upon the payment of the annual fee. All other regularly qualified practitioners may join by having their application approved by any two members of the Canadian Medical Protective Association. Blank application forms and other information upon request. Address all correspondence to the Secretary-Treasurer.

UNIVERSITY OF MICHIGAN IRRADIES

and Review

Vol. XLV. TORONTO, FEBRUARY, 1920

Original Communications

HEADACHES OF OCULAR ORIGIN *

BY DR. W. W. WRIGHT.

No. 2

A considerable proportion of cases sent to the ophthalmologist are referred to him on account of headache in order to determine whether the ocular apparatus is an etiological factor therein. Few symptoms are of more importance and moreover there are few conditions that will more largely tax his diagnostic and therapeutic resources.

There is no doubt that there is a strong inclination on the part of those who have adopted some particular branch of medical study as a so-called specialty to look at any symptom from the somewhat narrow point of view of that particular branch. For this reason and if we are to be of the greatest service to our patients I feel that the ophthalmologist as well as the physician should have a general working knowledge of headache.

When one reads the advertisements in the press or even as some one has aptly called them "those loose and semi-hysteric accounts" that crop up in medical literature one is apt to think of every headache as due to eyestrain and its uniform treatment a pair of glasses. This is of course far from the mark. Nevertheless I think it is a fact that some abnormal condition of the ocular apparatus is the commonest cause of frequent headaches. It is said by one authority that of all forms of headache probably not less than 40 per cent. are due to the ocular element while of all bilateral frontal headaches 75 per cent. are due to that

cause.

In the remarks that follow I do not propose to consider as a headache those pains that arise from inflammation of the anterior part of the eye as e.g., iritis. The pain here, some

*Read at meeting of Academy of Medicine, December 9, 1919.

times so severe as to keep the patient awake throughout the night, is located in the eve and radiates from there to the surrounding parts especially to the forehead. In these cases the accompanying injection, the photophobia and tearing etc., at once direct one to the eye as the source of the trouble.

There are many points in a carefully taken history that will be for or against the eye as an etiological factor. Let us consider these. First as to the location, headache from eye strain is most frequently frontal, next in order of frequency deep orbital, then fronto-occipital, then temporal. Purely occipital headache is seldom due to the eyes. Again it is nearly always bilateral, although frequently more severe on one side than the other and although it is stated that the severer pain is found on the side of the worse eye, this is, in my experience, by no means necessarily the case as I have repeatedly found it the other way. The headache of eye-strain is seldom severe or accompanied by nausea or vomiting. Probably the most generally useful diagnostic point is the fact that these headaches usually follow prolonged and continuous use of the eyes, particularly for near work, such as reading, writing, sewing, fine painting, the use of the typewriter, typesetter and numerous other modern machines which demand a maximum of close attention. This point has been particularly brought home to me since examining the vocational students of the Department of Soldiers Civil Re-establishment. Out of the two hundred odd vocational courses the vast majority of the men referred for headache have come from the vocations demanding much use of the eyes for near work such as plan reading and estimating, the various technical courses, shoe repairing, the business college course and above all the machine operator. In this connection also it was very interesting to note the lack of headache in the Army. Many men found that after a time they were able to get along very comfortably without their glasses which in civil life they had found a necessity.

In other cases again much use of the eyes for distant vision will bring on a headache. Here motion especially of a panoramic nature seems to be the essential factor e.g., an ocular headache is often the result of a shopping expedition, a crowd, a railway or motor journey or an evening at the theatre especially at the movies. In fact it is quite a sign of the times the number of people that complain either of not being able to read the explanations thrown on the screen or complain of a headache whenever they go to the movies.

Now if we accept this excessive use of the eyes as a necessary factor in headache from eye-strain it explains certain other characteristics. It is practically always a day headache. It does not keep the patient awake at night and he seldom wakes with it in the morning because when the use of the eyes is discontinued the reflex pain stops.

Observation of the eyes will frequently help to point to eye-strain as the cause of the headache. There is often some blepharitis or congestion of the palpebral and bulbar conjunctiva or there may be a tendency to photophobia or watering. On the other hand, it must not be forgotten that photophobia may be a marked reflex symptom of headache from other causes.

All these clinical points are of importance because inasmuch as the proportion of normal eyes is small, in the presence of headache one cannot always judge from the local findings alone whether one is dealing with a patient in whom an unstable nervous system is reacting to an otherwise insignificant irritant. in the form of a slight ocular defect. In a definite case however our ultimate diagnosis depends mostly on a thorough and careful examination of the refraction and of the muscular apparatus both intra and extra ocular. This examination should also of course for obvious reasons include an examination of the fundus.

The conditions that cause eye-strain are errors of refraction, anomalies of accommodation and convergence and disturbances of muscular equilibrium, the so-called heterophorias.. Of the errors of refraction, hypermetropia and astigmatism are the great offenders. Simple myopia on the other hand seldom causes headache as the patient can see well near at hand and cannot by any effort see well in the distance. The same is true of the very high degrees of hypermetropia and astigmatismtheir disability is too great to overcome and so they do not try. Of the heterophorias the most troublesome are hyperphoria and exophoria, the latter frequently combined with weakness of

convergence.

How do these conditions cause headache? We know that the ciliary, recti and oblique muscles endeavor to bring about effective vision under all conditions and that in abnormal refractive and muscular conditions there is an extra and prolonged effort on their part which causes certain symptoms prominent among which is headache. It is supposed that these extra efforts irritate the third nerve nuclei and reflexly the nuclei of the trigeminus. This theory fails to explain a number of points,