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to the inorganic world but prove that it holds so much importance, as we are far from the equally true in the more complex molecule of second portion of the duodenum. All of these organic matter comprising both plants and processes

processes are proteid cleavage. If you are animals. They go further and prove that the skeptical, Kjeldahl the urine of an obstructed spectrum brings this great truth from the ends

If the obstruction is in the stomach he of the universe.

may live indefinitely. If it is in the colon he

will live for months with drainage of the bowel Resume

above. Does he live if obstruction is near the There is a very broad application of the

duodenum and why? truths set forth in this paper. Every specialty have a great application of these principals


In the field of bacteriology and serology we has its phases. We observe that the new books on pediatrics are discussing intestinal acidosis We note that all bacteria pathogenic to man from an absorption of stasis products and bac

are proteid splitters, they grow on proteid culterial by-products. They outline etiology, symp

ture media best, they require proteid for their tomotology and treatment. The new books

food and as shown, select the tissues of the on Obstetrics apply these principles to involu- body that serve them best; that they may split tion of normal uterii as well as to toxic preg

that proteid best, to acquire their food and for nancy which shows a nitrogen imbalance. The

no other reason. This bacterium has 15 times bacteriologist and serologist will study its

more weight in proteid in its body than all phases carefully in the future.

other substances which lends support to the fact Proteid is builded in the fields from the soil intra and extra cellular enzyme are proteid split

that they are proteid feeders, and that their and the action of the sun's rays is stored in the wheat kernel. This same proteid is transferred

ters, for the purpose of splitting off the proteid

for its food. All bacteria seem to be alike in to the beef and stored in the cells. Man gets

this particular, that they are unable to utilize this proteid and transforms it to his cells. It proteid cleavage which they have split off the is modified and held as stock solution of serum proteid cell and are unable to again bind it into albumin and serum globulin within the body.

a usable food. It poisons them as it does man The mother's breast or mammary gland and they die after they have used the food of changes this type to that found in the mother's the media. There may yet remain much milk. How necessary it is to have a babe born cleavage proteid in this media but he cannot of its mother. The proteid of its body is very get it for his food. His own waste products similar in type to hers. Those of you who do from his own metabolism is also in the media. blood transfusions know that you select some This is not a serious thing. Man's most serious blood relative. Why? Because the recipient menaces are proteolitic enzymes and the cleais less liable to be poisoned by the foreign pro- vage by-products from any .origin. teid. The child will build this proteid of its In establishing an immunity it is not logical mother into its own more easily than it will to establish an immunity against this cleavage the proteid of a cow or goat or the proteid of proteid. This is a fact that we have lost sight some manufactured milk. In this same mother, of in our serums and leaves our immunity lackif her gland cannot build the proteid perfectly ing in efficiency. We saw that the body builded the child cannot handle it. If the mother has

the autolitic proteid cleavage into urea and exa sick attack or becomes angry, the proteid is creted it as such and that if the production was disturbed or changed and poisons the child. out of balance with this synthesis the body was The introduction of proteid serums will kill for poisoned by the cleavage product. In infection the same reason. Von Bergman has shown that we have the same problem of building these the pancreas will make a very great effort to bacterial cleavage products into elimination change the enzyme of proteid to accommodate

forms that are not irritating to the body.' But the system, that it may handle a new and is not the urea also increased in infection? strange proteid to which the body is not ac- Then wherein do they differ? In the cleavage customed.

only. There is a difference in the various Now our problem of intestinal obstruction. cleavage proteids of digestion. It requires a Von Furth shows that an inflamed bowel will different synthesis of each one in accordance absorb faster than one that is not inflamed. to the enzyme splitting it. Von Bergman saw We have the picture of inflamation, passive this and found that the pancreas would adjust congestion, moist gangrene death of millions itself to liberate an enzyme which would differ of cells, and over this area the pancreatic just a little that the various proteids in nature trypsin pouring constantly. We add bacteria to would be split and the proper cleavage proteid this and our picture is auto-digestion, autolysis, provided for the body synthisis. This is the acidosis, and the splitting of proteid by bac

function of the pancreas. Physiologists were teria. Why does the sight of obstruction have satisfied to not trace proteids beyond the bowel wall and have left its cleavage at this point. As to the treatment, the concensus of opinion In the next few steps the future will reveal among the men who have had the most experthis simplicity of all proteid chemistry.

ience with these cases is; that no form of fixaThe chemistry of proteid will explain di- tion is indicated but that extension and massage gestion, anabolism, katabolism, autolysis, ana- should be used, if it is found necessary to employ boceptros, immunity, and all this great nomen- measures for relief. clature will be the great simple proteid cleavage. D. J. McChesney reports three cases from

his and Dr. Sherman's clinic. Dr. Freiberg in

sists that he described this disease in 1905 but PERTHES DISEASE*

was unfortunate in the name that he chose, as C. B. FRANCISCO, M. D., Kansas City, Mo. from his description it was associated with adol

My object in presenting this subject is to escent coxa vara. In the August 26th number call attention to a condition that is not particu- of the A. M. A., 1916, he reports two typical larly rare but in the past has been mistaken cases. In 1909 Dr. Legg reported five cases for tuberculosis of the hip, and many children

and described this identical condition but it so treated have been subjected to needless ap

really remained for Dr. Perthes to explore some paratus and long disability.

of these joints and describe the real pathologJuvenile Deforming Osteochondritis, the ical condition. name given by Prof. George Perthes, of Tubin- Lodurland, in January, 1914, reported three gen, is characterized by a slight limp, mild sub- cases under the name non-tuberculosis hip joint jective symptoms, a fairly constant limitation disease in the young, which made 21 on record. of abduction and a benign course with complete He attributed the condition to some anomaly in recovery under little or no treatment. Eighty the upper end of the femur in the nature of a per cent or more of the cases occuring in boys, developmental disturbance, possibly abnormal principally between the ages of five and ten

ossification of the epiphysis. years. The condition begins when the child is

Moller, in March, 1914, in the Ugeskrift, in good health and is not especially concerned Copenhagen, under the title of Deforming Oswith trauma.

teochondritis in the Young, collects 27 cases The symptoms are slight limp, little or no

from the literature. According to the analysis pain, some atrophy of the muscles with proba- affected than girls, ages range from 3 to 13,

of this group of cases, boys are more frequently bly one-half inch shortening, free range of motion except in abduction and rotation, which usually involving only one hip. He says the are limited.

roentgenogram finding is specific and pathog

nomic, and that they suggest an infectious origin The pathology, according to Perthes, is a delayed ossification of the cartilage of the turbance, particularly an interference of the blood

but that it is more probably a nutritional disepiphysis and the juxta epiphyseal cartilage of supply to the head. the neck and isolated area in the actabulum. He also notes calcareous nodules or dark spots in the American Orthopedic Journal, October,

Dr. Henry Ling Taylor and William Frieder, on the epiphysis. The result is that on account of the weight bearing there occurs a flattening nineteen cases observed since 1910. They have

1915, under the title of Quiet Hip Disease, report and separating of the head into two or three parts with thickening of the neck. Recently that it is fairly common.

come to regard the condition as an entity and however, many men in this country have been inclined to regard the condition as infectious Allison and Moody in the same issue of the in origin. The work of Dr. Kidner has been Orthopedic Journal report eight cases observed of the greatest value in stimulating efforts along by them at the St. Louis Children's Hospital. the line of attempting to prove the origin of

The last report of Progress in Orthopedic these cases to be infectious. In one of his cases Surgery, says that the cause of the condition is he was able to grow a low grade staphlococ- still obscure. So that one can see that there cus from material obtained from a cavity in the have been many cases observed in the different neck of the femur. Dr. Freiburg points out orthopedic clinics all over the country since the that we should look very carefully for focal in- men have had their attention called to this confections in these cases.

dition. The importance of recognition is to save As for diagnosis, according to Delitala, the

the child the disadvantage of needless apparatus. X-Ray examination alone is sufficient; that the I wish to report two cases, as follows: findings are distinctive and pathognomic, but 1st case. A boy, K. S., age 712 years. Father one should investigate all these cases thorough- and mother living and well, five brothers living ly hoping thereby to add to our knowledge. and well. Has always been a healthy child, ex

cept for bilious attacks, has had no fevers or *Read before the Medical Society of the Missouri Valley at Keokuk, Ia., March 21, 1917.

injuries : sore throat once. Present illness began

in February, 1916; the first symptom was cry- THE CAUSES AND TREATMENT OF ing out at night, and complaining of pain in left

HEADACHE* hip, but never complained during the day. He

G. WILSE ROBINSON, M. D. developed a limp which has continued but not

Kansas City, Mo. increased. Seven months later he was brought to Mercy Hospital more particularly on account I make no apology for using a part of the of a digestive upset that he was having at that time of this Society in a discussion of the subtime, but on account of the limp he was referred ject of headaches.

ject of headaches. Some may be of the opinion to my service. He was well developed and nour- that our time could be spent to better advantage ished, all joints negative, except left hip, which in the discussion of a subject of greater rarity. presented free motion in flexion, extension and that bulks larger on the horizon of medicine. adduction, but rotation and abduction moderate- Headache may occur as an independent affecly limited. His temperature was 103. He had a tion and may continue so throughout the greater coated tongue and foul breath. He was admitted

part of life.

There may be no appreciable referred to medical service for general treatment effect upon the health or life of the individual. and sent to Dr. Bacon for X-ray. The picture . It also occurs as one of the commonest sympshowed rather typical flattening of head and toms of the most diverse forms of disease. thickening of neck, justifying the diagnosis of In no case should the complaint of headache Perthes disease. His Von Perquet and Wasser- be treated with indifference by the physician. mann were negative. His general condition A very careful examination should be made of cleared up in a few days, plaster of paris spica all persons consulting a physician with the comwas applied and the child sent home. He wore plaint of headache. At the very beginning of the plaster for four weeks and then was allowed a discussion of this subject there should be a to go without protection. He was kept under clear understanding of the question, in which close observation, and the mother instructed very portions of the central and peripheral nervous carefully about his diet, and told to report any systems can headache originate. All headchange in his hip condition. He has been free aches are perceived through the trigeminus and from pain for past six months and his general sensory branches of the upper cervical nerves condition is good. He still has moderate limp. through the distribution to the dura. The ar

2nd Case. R. H., boy 9 years old. Re- achnoid has no nerve supply, and the piamater ferred by Dr. C. W. Off, of Higginsville, Mis- is probably supplied only by sympathetic souri. Father and mother living and well. One branches, the brain substance has no sensory brother living and well. Patient has had chil

The dura is supplied as far back as dren's diseases, but no fevers or injuries. Pres

the tentorium cerebelli by the trigeminus. The ent illness began November, 1915, when he began dura of the anterior part of the cranial vault complaining of pain in hip on first awakening and of the anterior fossa by the meningeal in the morning, which would soon disappear. nerves arising from the superior maxillary At this time Dr. Off was unable to find any

division of the trigeminus before it leaves the trouble in the hip joint, however, in January, cranial cavity. The anterior fossa of the skull 1916, an X-ray made by Dr. McCandless showed is also partly enervated by the anterior and considerable change in the head and neck, and posterior ethmoidal branches of the ophthalmic meanwhile the child had developed a limp. An nerve. The tentorial nerve which leaves the extension brace was applied and all pain imme- ophthalmic nerve in the sinus cavernosus, supdiately subsided. However, he was brought in plies the tentorium cerebelli. The middle porto me in August, 1916, when another picture was

tion of the cranial vault is supplied by the taken and the conclusion arrived at, that the recurrent branch of the third division of the condition was a Perthes. He continued to wear

Fifth nerve.

This branch arises below the his brace for a time, but is now going without. Foramen-ovale and enters the cranium through apparatus and is free from pain.

the foramen spinosum. The dura of the posterior

fossa is supplied by the tentorial nerves and Distinctive Bottles for Poison - A recent by the meningeal and recurrent branches of the bulletin issued from the Surgeon General's office

vagus running upward through the jugular forat Washington states that every year, on an

amen. According to Edinger, the posterior average, five thousand people take poison acci- meningeal or recurrent sensory nerves arise dentally. To prevent these mistakes a bottle has

from the sympathetic, hypoglossal, and vagus. been invented which has the skull and cross

Auerbach says it is highly probable that in bones molded deep in the glass, so that when the

the production of headaches the sensory endings bottle is taken up in the dark it can be easily of the sympathetic running in the vessel walls distinguished by the sense of touch. If the label to many parts of the dura play an important from such a bottle is lost the fact that it contans poison will still be obvious.

*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 its membranes have in such case insufficient of the base of the skull is more richly supplied play for the numerous possibilities which may than that of the vault with sensory nerves. lead to an increased blood supply. It is obvious Headaches arising from tumors at the base of that a person having a difference of less than the brain are more severe and lasting than ten per cent would, as a result of even a normal those caused by tumors situated on the vertex variation in the intra-cranial circulation, be disof the brain. Irritation of the associated gang- posed to manifest symptoms of increased intralia and roots, as well as that of the peripheral cranial pressure. The shape of the skull is a nerves, obtain in headaches. The pain is pro- family characteristic that is quite constantly jected from the irritated root or ganglia into transmitted through one generation to another. the area of distribution of the nerve involved. I am of the opinion that all persons having

Headaches are classified by Auerbach under migraine have less than normal average of ten four general headings: (A) The more inde- per cent difference between skull or cranial pendent forms of headaches, such as migraine, capacity, and cranial contents. During the atneurastheniç headache, and nodular or indura- tack of migraine the intra-cranial circulation is tion headaches. (B) Headaches associated with increased; there is also an increase of cerebrodiseases of individual organs; 'first, headaches spinal fluid as indicated by an increased fluid in brain disease; second, diseases associated pressure. The exciting causes of the attack with disorders of special senses; third, head- are those things which tend to increase the aches in diseases of the diggestive tract; fourth, intra-cranial blood supply and cause an inheadaches in diseases of the kidneys. (C) Head- creased secretion of cerebro-spinal fluid. Some ache in general diseases, the infectious dis- of the more common exciting causes are emoeases, acute and chronic intoxication, and con- tional disturbance, mental over-exertion, alcohol stitutional diseases.' (D) combination of dif- and sexual excesses; gastro-intestinal disorders ferent forms of headache, the so-called habitual resulting from over-eating, and constipation are headaches. Some of the more common com- also causes of some importance. Intoxications binations are nodular headaches associated with of all sorts stimulate over-secretion of cerebrosevere hystero-neurasthenia and migraine; spinal fluid, and act as exciting causes of the severe pain or exhaustion as the result of nodu- attacks of migraine. lar headache; the combination of migraine and The prophylactic treatment would be the nodular headaches; the combination of chloro- avoidance of those things which cause the atsis and nodular headaches; the combination of tacks, or, in other words, living a life of tempernephritis, suppurative otitis media, and nodular ate and regular habits. Medicinal treatment is of headaches, migraine, neurasthenia, frontal sinus some importance. Bromides have been used suppuration, and supra-orbital neuralgia.

with some success between the attacks. I do Migraine is generally recognized as the not recommend them. During the attack those commonest of all forms of headaches. It bears remedies should be given which tend to lessen a close relationship to epilepsy. It occurs per- the intra-cranial blood supply. Sodium salicyiodically, and migraine in early youth may in late, pyramidon, and antipyrine are perhaps the later life be manifest as epilepsy or may be

best. Some cases are benefited by comparatransmitted as epilepsy to the offspring. The tively large doses of ergot. Lumbar puncture, headache of migraine most closely resembles withdrawal of sixteen to thirty c. c. of cerebrothat of brain tumor of any other form of head- spinal fluid gives striking relief in some cases. ache. It presents many of the characteristics Next to migraine the neurasthenic headof a pressure headache; namely, the intense ache stands as the headache of the greatest gnawing character of the pain, disturbances of frequency. In the majority of cases there is vision, speech and hearing, together with vomit- no actual pain, but a sense of constriction and ing which is doubtless due to the irritation of heaviness of the head. A sense of pressure is the recurrent branches of the vagus, and in usually located in the frontal region, or a feelmany cases a distinct papilloedema of the fundus ing of constriction may include the entire head, oculi may be observed. The most important the sensation arising as tủough the skull was etiological factor is, perhaps, the inherited pre- squeezed in a vice, or as though the inside was disposition to the attack. Various theories filled with lead. have been advanced concerning the etiology of

The etiology of neurasthenic headache is the migraine. As previously stated, the headache etiology of neurasthenia. Our conventional of migraine is accompanied by many symptoms neurasthenia is that of a condition of prolonged of increased intra-cranial pressure.' Reichardt fatigue or exhaustion resulting from various has established that a difference between the adverse influences. Of much importance in its capacity of the skull and the weight of the production are the infectious diseases, and local brain of ten per cent is the normal average. If infection such as those about the mouth and the difference be less than this, the brain and tonsils. A disharmony between the production

and elimination of fatigue toxins due to over- reduced to a neurasthenic state, but in such cases production or faulty elimination, or both, re- the pain over a considerable period of time presults in general systemic intoxication, favoring cedes the neurasthenia. The history will suggest the production of neurasthenia. These toxins, to the physician that the headache is not migraine as well as those elaborated in the system as the nor neurasthenic in character. A careful palparesult of infection, are capable of doing con- tion of the scalp reveals changes that are charac-. siderable damage to the dural nerves, and ofteristic; small nodules ranging in size from a producing those disagreeable sensations known millet seed to a bean are found in the subcutanas neurasthenic headache. Also as a result of a eous tissue in the occipital fascia and the fascia fatigue of the sympathetic nervous system, of the nape of the neck, at times also the upper there is a tendency to engorgement and dilata- part of the back and sides of the neck as far as tion of the dural arteries and veins. This con- the shoulders. These are tender to the touch and dition tends to resolve in pressure upon the may be very irregular in outline. Nodules are sensory nerves of the sympathetic, and sensa- also found in the tendon of the occipitofrontalis tions of a disagreeable and painful character muscle and in the parietal subcutaneous tissues. may be perceived by the patient as a result. The pain in its greatest intensity is referred There is also in this condition a tendency to an intracranially through the medium of the menabnormal accumulation of cerebro-spinal fluid ingeal branches of the trigeminus. Especially for two reasons. In the first place, the toxic in the region of the insertion of the larger cerinfluences upon the choroidal plexus tends to vical muscles and the occipitofrontalis there may cause an over-secretion of cerebro-spinal fluid. be felt rather hard, raised infiltrations giving In the second place, the engorgement of the the impression of callosities. They are usually veins delays the absorption of the fluid secreted. tender to the touch and may attain to the size The result of this increased intra-cranial pres- of a hazel nut or almond. The trapezius, sternosure upon the dural nerves is to cause pain cleido-mastoid, and scalenus posticus and splenand a sense of fullness in the head. A lumbar ius are the muscles most frequently concerned. puncture in many such cases demonstrates an in- These nodules can be outlined to a better advancreased fluid pressure, and withdrawal of fluid tage if the muscles be relaxed during the period results usually in a decrease of the headache, of examination. Numerous theories have been and in some cases gives most decided relief. advanced as to the pathogenesis of this condiThe general treatment of the headache is that tion. It has been suggested that the nodules of the treatment of the condition, and the best are the result of a chronic, indurated inflamresults are obtained by rest in bed, careful at- - mation of the subcutaneous and muscle tissues. tention to nutrition and elimination, and, above Other theories are that the indurations in the all, the administration of large quantities of

muscles are due to a myositis fibrosa. Auerbach water, three to five quarts daily. Investigation has suggested that the nodules be due to locally usually reveals the fact that these patients do dilated lymph vessels with extravasated lymph. not drink much water. If forced to drink suffi- Some hold that they are rheumatic or gouty cient water, the matter of elimination is easily nodules. Microscopical examination of excised adjusted.

nodules indicates that they are fibrinous in char

acter, but the why of their origin has not been Nodular or Induration Headache: This form definitely settled. of headache is of common occurance but not frequently recognized. In the majority of cases Therapeutics: That the pain of nodular it occurs in women of middle or advanced age headache does not yield to ordinary internal medwho in their youth have been free of the more ication, rest in bed, attention to diet, and correcsevere forms of headache. As a rule the pain tion of disorders of internal organs, and so forth, of nodular headache is persistent, severe, and is a well established fact. The most successful disabling, involving the whole head, usually be- treatment is the manual massage of the nodular ginning in the occiput or neck, radiating to the areas. At first this treatment should be adminisfrontal region, and not infrequently to the shoul- tered daily and should extend over a period of fifders and arms. It has a tendency to continue teen or twenty minutes. As improvement is obduring the night, and may be more severe in the tained the treatment may be given on alternate recumbent position; it is not accompanied by days. Hot compresses applied to the tender and nausea or vomiting, nor has it the periodicity painful areas are also helpful, but cold has the of migraine; exposure to sudden changes of opposite effect. If tender spots be found over the temperature are apparently important exciting scapulae from which pain radiates into the neck etiological factors. Eddinger suggests that the or shoulders, much relief may be given by inlocalized chill incident to washing the hair is a serting a needle down to the bone, first injecting common cause. The patients may, by the dis- a few drops of five per cent novocaine solution, abling effects of the long continued pain, be followed by a few drops of ninety per cent

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