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wall and have left its cleavage at this point. In the next few steps the future will reveal this simplicity of all proteid chemistry.

The chemistry of proteid will explain digestion, anabolism, katabolism, autolysis, anaboceptros, immunity, and all this great nomenclature will be the great simple proteid cleavage.

PERTHES DISEASE*

C. B. FRANCISCO, M. D., Kansas City, Mo.

My object in presenting this subject is to call attention to a condition that is not particularly rare but in the past has been mistaken for tuberculosis of the hip, and many children so treated have been subjected to needless apparatus and long disability.

Juvenile Deforming Osteochondritis, the name given by Prof. George Perthes, of Tubingen, is characterized by a slight limp, mild subjective symptoms, a fairly constant limitation of abduction and a benign course with complete recovery under little or no treatment. Eighty per cent or more of the cases occuring in boys, principally between the ages of five and ten years. The condition begins when the child is in good health and is not especially concerned

with trauma.

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The pathology, according to Perthes, is a delayed ossification of the cartilage of the epiphysis and the juxta epiphyseal cartilage of

the neck and isolated area in the actabulum.

He also notes calcareous nodules or dark spots on the epiphysis. The result is that on account of the weight bearing there occurs a flattening and separating of the head into two or three parts with thickening of the neck. Recently however, many men in this country have been inclined to regard the condition as infectious in origin. The work of Dr. Kidner has been of the greatest value in stimulating efforts along the line of attempting to prove the origin of these cases to be infectious. In one of his cases he was able to grow a low grade staphlococcus from material obtained from a cavity in the neck of the femur. Dr. Freiburg points out Dr. Freiburg points out that we should look very carefully for focal infections in these cases.

As for diagnosis, according to Delitala, the X-Ray examination alone is sufficient; that the findings are distinctive and pathognomic, but one should investigate all these cases thoroughly hoping thereby to add to our knowledge.

*Read before the Medical Society of the Missouri Valley at Keokuk, Ia., March 21, 1917.

As to the treatment, the concensus of opinion among the men who have had the most experience with these cases is; that no form of fixation is indicated but that extension and massage should be used, if it is found necessary to employ measures for relief.

D. J. McChesney reports three cases from his and Dr. Sherman's clinic. Dr. Freiberg insists that he described this disease in 1905 but was unfortunate in the name that he chose, as from his description it was associated with adolescent coxa vara. In the August 26th number of the A. M. A., 1916, he reports two typical cases. In 1909 Dr. Legg reported five cases and described this identical condition but it really remained for Dr. Perthes to explore some of these joints and describe the real pathological condition.

Lodurland, in January, 1914, reported three cases under the name non-tuberculosis hip joint disease in the young, which made 21 on record. He attributed the condition to some anomaly in the upper end of the femur in the nature of a developmental disturbance, possibly abnormal ossification of the epiphysis.

Moller, in March, 1914, in the Ugeskrift, Copenhagen, under the title of Deforming Osteochondritis in the Young, collects 27 cases from the literature. According to the analysis affected than girls, ages range from 3 to 13, of this group of cases, boys are more frequently usually involving only one hip. He says the roentgenogram finding is specific and pathognomic, and that they suggest an infectious origin but that it is more probably a nutritional disturbance, particularly an interference of the blood supply to the head.

in the American Orthopedic Journal, October. Dr. Henry Ling Taylor and William Frieder, nineteen cases observed since 1910. 1915, under the title of Quiet Hip Disease, report They have that it is fairly common. come to regard the condition as an entity and

Allison and Moody in the same issue of the Orthopedic Journal report eight cases observed by them at the St. Louis Children's Hospital.

The last report of Progress in Orthopedic Surgery, says that the cause of the condition is still obscure. So that one can see that there have been many cases observed in the different orthopedic clinics all over the country since the men have had their attention called to this condition. The importance of recognition is to save the child the disadvantage of needless apparatus. I wish to report two cases, as follows:

1st case. A boy, K. S., age 71⁄2 years. Father and mother living and well, five brothers living and well. Has always been a healthy child, except for bilious attacks, has had no fevers or injuries sore throat once. Present illness began

in February, 1916; the first symptom was crying out at night, and complaining of pain in left hip, but never complained during the day. He developed a limp which has continued but not increased. Seven months later he was brought to Mercy Hospital more particularly on account of a digestive upset that he was having at that time, but on account of the limp he was referred to my service. He was well developed and nourished, all joints negative, except left hip, which presented free motion in flexion, extension and adduction, but rotation and abduction moderately limited. His temperature was 103. He had a coated tongue and foul breath. He was admitted referred to medical service for general treatment and sent to Dr. Bacon for X-ray. The picture showed rather typical flattening of head and thickening of neck, justifying the diagnosis of Perthes disease. His Von Perquet and Wassermann were negative. His general condition. cleared up in a few days, plaster of paris spica was applied and the child sent home. He wore the plaster for four weeks and then was allowed to go without protection. He was kept under close observation, and the mother instructed very carefully about his diet, and told to report any change in his hip condition. He has been free from pain for past six months and his general condition is good. He still has moderate limp.

2nd Case. R. H., boy 9 years old. Referred by Dr. C. W. Off, of Higginsville, Missouri. Father and mother living and well. One brother living and well. Patient has had children's diseases, but no fevers or injuries. Present illness began November, 1915, when he began complaining of pain in hip on first awakening in the morning, which would soon disappear. At this time Dr. Off was unable to find any trouble in the hip joint, however, in January, 1916, an X-ray made by Dr. McCandless showed considerable change in the head and neck, and meanwhile the child had developed a limp. An extension brace was applied and all pain immediately subsided. However, he was brought in to me in August, 1916, when another picture was taken and the conclusion arrived at, that the condition was a Perthes. He continued to wear

his brace for a time, but is now going without. apparatus and is free from pain.

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THE CAUSES AND TREATMENT OF
HEADACHE*

G. WILSE ROBINSON, M. D.
Kansas City, Mo.

I make no apology for using a part of the time of this Society in a discussion of the subject of headaches. Some may be of the opinion that our time could be spent to better advantage in the discussion of a subject of greater rarity. that bulks larger on the horizon of medicine. Headache may occur as an independent affection and may continue so throughout the greater part of life. There may be no appreciable effect upon the health or life of the individual. · .It also occurs as one of the commonest symptoms of the most diverse forms of disease. In no case should the complaint of headache. be treated with indifference by the physician. A very careful examination should be made of all persons consulting a physician with the complaint of headache. At the very beginning of a discussion of this subject there should be a clear understanding of the question, in which portions of the central and peripheral nervous systems can headache originate. All headaches are perceived through the trigeminus and sensory branches of the upper cervical nerves through the distribution to the dura. The arachnoid has no nerve supply, and the piamater is probably supplied only by sympathetic branches, the brain substance has no sensory nerves. The dura is supplied as far back as the tentorium cerebelli by the trigeminus. The dura of the anterior part of the cranial vault and of the anterior fossa by the meningeal nerves arising from the superior maxillary division of the trigeminus before it leaves the cranial cavity. The anterior fossa of the skull is also partly enervated by the anterior and posterior ethmoidal branches of the ophthalmic nerve. The tentorial nerve which leaves the ophthalmic nerve in the sinus cavernosus, supplies the tentorium cerebelli. The middle portion of the cranial vault is supplied by the recurrent branch of the third division of the Fifth nerve. This branch arises below the Foramen-ovale and enters the cranium through the foramen spinosum. The dura of the posterior fossa is supplied by the tentorial nerves and by the meningeal and recurrent branches of the vagus running upward through the jugular foramen. According to Edinger, the posterior meningeal or recurrent sensory nerves arise from the sympathetic, hypoglossal, and vagus. Auerbach says it is highly probable that in the production of headaches the sensory endings of the sympathetic running in the vessel walls to many parts of the dura play an important

*Read before the Medical Society of the Missouri Valley at Lincoln, Neb., September 21, 1917.

role. It is a well established fact that the dura of the base of the skull is more richly supplied than that of the vault with sensory nerves. Headaches arising from tumors at the base of the brain are more severe and lasting than those caused by tumors situated on the vertex of the brain. Irritation of the associated ganglia and roots, as well as that of the peripheral nerves, obtain in headaches. The pain is projected from the irritated root or ganglia into the area of distribution of the nerve involved. Headaches are classified by Auerbach under four general headings: (A) The more independent forms of headaches, such as migraine, neurasthenic headache, and nodular or induration headaches. (B) Headaches associated with diseases of individual organs; first, headaches in brain disease; second, diseases associated with disorders of special senses; third, headaches in diseases of the diggestive tract; fourth, headaches in diseases of the kidneys. (C) Headache in general diseases, the infectious diseases, acute and chronic intoxication, and constitutional diseases. (D) combination of different forms of headache, the so-called habitual headaches. Some of the more common combinations are nodular headaches associated with severe hystero-neurasthenia and migraine; severe pain or exhaustion as the result of nodular headache; the combination of migraine and nodular headaches; the combination of chlorosis and nodular headaches; the combination of nephritis, suppurative otitis media, and nodular headaches, migraine, neurasthenia, frontal sinus suppuration, and supra-orbital neuralgia.

Migraine is generally recognized as the commonest of all forms of headaches. It bears a close relationship to epilepsy. It occurs periodically, and migraine in early youth may in later life be manifest as epilepsy or may be transmitted as epilepsy to the offspring. The headache of migraine most closely resembles that of brain tumor of any other form of headache. It presents many of the characteristics of a pressure headache; namely, the intense gnawing character of the pain, disturbances of vision, speech and hearing,together with vomiting which is doubtless due to the irritation of the recurrent branches of the vagus, and in many cases a distinct papilloedema of the fundus oculi may be observed. The most important etiological factor is, perhaps, the inherited predisposition to the attack. Various theories have been advanced concerning the etiology of migraine. As previously stated, the headache of migraine is accompanied by many symptoms of increased intra-cranial pressure. Reichardt has established that a difference between the capacity of the skull and the weight of the brain of ten per cent is the normal average. If the difference be less than this, the brain and

its membranes have in such case insufficient play for the numerous possibilities which may lead to an increased blood supply. It is obvious that a person having a difference of less than ten per cent would, as a result of even a normal variation in the intra-cranial circulation, be disposed to manifest symptoms of increased intracranial pressure. The shape of the skull is a family characteristic that is quite constantly transmitted through one generation to another. I am of the opinion that all persons having migraine have less than normal average of ten per cent difference between skull or cranial capacity, and cranial contents. During the attack of migraine the intra-cranial circulation is increased; there is also an increase of cerebrospinal fluid as indicated by an increased fluid pressure. The exciting causes of the attack are those things which tend to increase the intra-cranial blood supply and cause an increased secretion of cerebro-spinal fluid. Some of the more common exciting causes are emotional disturbance, mental over-exertion, alcohol and sexual excesses; gastro-intestinal disorders resulting from over-eating, and constipation are also causes of some importance. Intoxications

of all sorts stimulate over-secretion of cerebrospinal fluid, and act as exciting causes of the attacks of migraine.

The prophylactic treatment would be the avoidance of those things which cause the attacks, or, in other words, living a life of temperate and regular habits. Medicinal treatment is of some importance. Bromides have been used with some success between the attacks. I do not recommend them. During the attack those remedies should be given which tend to lessen the intra-cranial blood supply. Sodium salicylate, pyramidon, and antipyrine are perhaps the best. Some cases are benefited by comparatively large doses of ergot. Lumbar puncture, withdrawal of sixteen to thirty c. c. of cerebrospinal fluid gives striking relief in some cases.

Next to migraine the neurasthenic headache stands as the headache of the greatest frequency. In the majority of cases there is no actual pain, but a sense of constriction and heaviness of the head. A sense of pressure is usually located in the frontal region, or a feeling of constriction may include the entire head, the sensation arising as though the skull was squeezed in a vice, or as though the inside was filled with lead.

The etiology of neurasthenic headache is the etiology of neurasthenia. Our conventional neurasthenia is that of a condition of prolonged fatigue or exhaustion resulting from various adverse influences. Of much importance in its production are the infectious diseases, and local infection such as those about the mouth and tonsils. A disharmony between the production

and elimination of fatigue toxins due to overproduction or faulty elimination, or both, results in general systemic intoxication, favoring the production of neurasthenia. These toxins, These toxins, as well as those elaborated in the system as the result of infection, are capable of doing considerable damage to the dural nerves, and of producing those disagreeable sensations known as neurasthenic headache. Also as a result of a fatigue of the sympathetic nervous system, there is a tendency to engorgement and dilatation of the dural arteries and veins. This condition tends to resolve in pressure upon the sensory nerves of the sympathetic, and sensations of a disagreeable and painful character may be perceived by the patient as a result. There is also in this condition a tendency to an abnormal accumulation of cerebro-spinal fluid for two reasons. In the first place, the toxic influences upon the choroidal plexus tends to cause an over-secretion of cerebro-spinal fluid. In the second place, the engorgement of the veins delays the absorption of the fluid secreted. The result of this increased intra-cranial pressure upon the dural nerves is to cause pain and a sense of fullness in the head. A lumbar puncture in many such cases demonstrates an increased fluid pressure, and withdrawal of fluid results usually in a decrease of the headache, and in some cases gives most decided relief. The general treatment of the headache is that of the treatment of the condition, and the best results are obtained by rest in bed, careful at-tention to nutrition and elimination, and, above all, the administration of large quantities of water, three to five quarts daily. Investigation usually reveals the fact that these patients do not drink much water. If forced to drink sufficient water, the matter of elimination is easily adjusted.

Nodular or Induration Headache: This form of headache is of common occurance but not frequently recognized. In the majority of cases it occurs in women of middle or advanced age who in their youth have been free of the more severe forms of headache. As a rule the pain of nodular headache is persistent, severe, and disabling, involving the whole head, usually beginning in the occiput or neck, radiating to the frontal region, and not infrequently to the shoulders and arms. It has a tendency to continue during the night, and may be more severe in the recumbent position; it is not accompanied by nausea or vomiting, nor has it the periodicity of migraine; exposure to sudden changes of temperature are apparently important exciting etiological factors. Eddinger suggests that the localized chill incident to washing the hair is a common cause. The patients may, by the disabling effects of the long continued pain, be

reduced to a neurasthenic state, but in such cases the pain over a considerable period of time precedes the neurasthenia. The history will suggest to the physician that the headache is not migraine nor neurasthenic in character. A careful palpation of the scalp reveals changes that are charac-. teristic; small nodules ranging in size from a millet seed to a bean are found in the subcutaneous tissue in the occipital fascia and the fascia. of the nape of the neck, at times also the upper part of the back and sides of the neck as far as the shoulders. These are tender to the touch and may be very irregular in outline. Nodules are also found in the tendon of the occipitofrontalis muscle and in the parietal subcutaneous tissues. The pain in its greatest intensity is referred intracranially through the medium of the meningeal branches of the trigeminus. Especially in the region of the insertion of the larger cervical muscles and the occipitofrontalis there may be felt rather hard, raised infiltrations giving the impression of callosities. They are usually tender to the touch and may attain to the size of a hazel nut or almond. The trapezius, sternocleido-mastoid, and scalenus posticus and splenius are the muscles most frequently concerned. These nodules can be outlined to a better advantage if the muscles be relaxed during the period of examination. Numerous theories have been advanced as to the pathogenesis of this condition. It has been suggested that the nodules are the result of a chronic, indurated inflammation of the subcutaneous and muscle tissues. Other theories are that the indurations in the muscles are due to a myositis fibrosa. Auerbach has suggested that the nodules be due to locally dilated lymph vessels with extravasated lymph. Some hold that they are rheumatic or gouty nodules. Microscopical examination of excised nodules indicates that they are fibrinous in character, but the why of their origin has not been definitely settled..

Therapeutics: That the pain of nodular headache does not yield to ordinary internal medication, rest in bed, attention to diet, and correction of disorders of internal organs, and so forth, is a well established fact. The most successful treatment is the manual massage of the nodular areas. At first this treatment should be administered daily and should extend over a period of fifteen or twenty minutes. As improvement is obtained the treatment may be given on alternate days. Hot compresses applied to the tender and painful areas are also helpful, but cold has the opposite effect. If tender spots be found over the scapulae from which pain radiates into the neck or shoulders, much relief may be given by inserting a needle down to the bone, first injecting a few drops of five per cent novocaine solution, followed by a few drops of ninety per cent

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normal, in either the primary or secondary type, gives the greatest degree of relief. If the primary type be due to over-activity of the choroid plexus, administration of extract of thyroid gland usually lessens the secretion, and in this manner controls the headache. In pachymeningitis interna hemorrhagica which is usually secondary to alcoholism, headache is a very annoying symptom. Headache, coma, transitory paralyses, which are the most common symptom of this condition, are due in great measure to increased intra-cranial pressure, and lumbar puncture gives most immediate and satisfactory relief of the headache in many cases.

Headache Associated with Diseases of Individual Organs-Of the various organs diseases of which have headache as a symptom there are no diseases known that have headache so constantly associated as the diseases of the brain. Headache is a most constant symptom of intracranial tumor, and every protracted case of headache should arouse suspicion of an intracranial tumor. The pain is described as dull, boring, or gnawing, and always referred to the interior of the skull. Patients have a feeling as though the head was about to burst. It is not so intense with children who have more elastic skulls. The pain begins moderately and increases as the intracranial pressure increases. Some cases may be intermittent and subside for a period of even several months. Pressure of a tumor or the displaced intracranial structures upon the nerves of the trigemina, are responsible for the pain. Relief may be given the patient by doing lumbar puncture, withdrawing from ten to sixty c. c.'s of cerebro-spinal fluid. Removal of this fluid helps to restore the proper ratio between the size of the skull and the intra-cranial contents. In some cases the freedom from pain following puncture extends over a considerable period of time. When the tumor is growing rapidly or the fluid reaccumulates quickly, the relief is of short duration. A decompression operation or, an attempt to remove the tumor gives relief of longer duration. Headache is an early symptom in brain abscess, it is not so prolonged nor so obstinate as the headache of brain tumor, nor is it so severe. If a positive diagnosis be made and the abscess located, operation should be done at once, but if for any reason there is cause for delaying the cranial operation, temporary relief may be had by lumbar puncture.

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Intra-cranial Syphilis-Headache may be a very early symptom in paresis and other forms of cerebro-spinal syphilis. It is most severe in gummatous basal meningitis, but is present in meningitis of the convexity and in meningoencephalitis associated with meningo-myelitis. It may be periodical with nocturnal aggravation. It is the result of the action of the syphilitic toxins as well as an increased intra-cranial pressure, and to pressure upon the dural nerves. Lumbar puncture gives temporary relief, but intensive and prompt anti-luetic treatment should be administered. In cerebral arterio-sclerosis we commonly expect headache as a symptom. Pain is the result of the changes occuring in the vaso-motor nerves of the atheromatous arteries, and to irritation of the dural nerves by the distended arteries secondary to the frequently occuring associated cardiac hypertrophy. Relief can be given by careful regulation of habits. diet, rest in the recumbent position, administration of iodides, stimulation of the excretory organs, and such other measures as will tend to reduce the usually increased blood pressure. In many of these cases lumbar puncture done once a week over a considerable period of time has proven very beneficial. In the headaches of the various types of meningitis other than syphilitic, most important of which are the cerebro-spinal and the tubercular types, headache has both a chemical and mechanical etiology, and most beneficial results are obtained by withdrawal of cerebro-spinal fluid. Any disorder of the thoracic organs leading to passive hyperaemia of the brain may be a cause of headache. Any constricting band about the neck, such as the too tight collar or neck band of the shirt may for the same reason produce the same condition. Treatment of this form of headache is the treatment of the underlying cause.

The most characteristic type of headache of hysteria is the so-called clavus hystericus, or hysterical nail. The patient describes the pain as similar to the driving of a nail into the skull. Pain is usually limited to the convexity of the skull, and but a small area seems to be affected.

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