nausea. The doses are increased now more rapidly to get the constitutional effect, and to note then the effect on the spasm. 19th. One hundred and twelve drops 4 i. d. No nausea; spasm strong yet; weakness in legs felt ten minutes after drug is taken; arms also weak, with slight numbness in arms and legs for an hour. 23d. One hundred and forty drops in the morning was followed by a chill; one hundred and forty-five drops at noon produced no symptoms; one hundred and fifty drops at night made legs and arms very weak. 24th. One hundred and sixty drops were taken at nine and eleven A. M. and three P. M. and were followed by no more constitutional symptoms than the smaller doses. 25th. No conium taken. The muscular spasm was unchanged. She can hold her head straight about thirty seconds. Small clonic spasms are felt in the muscles, then a rest; the spasms and the interval of repose are each of about five seconds duration. Head can readily be brought to a good position without aid of hands. Conium treatment stopped as improvement was slight. The intensity of the muscular spasm has been diminished a little, but her improved hygienic conditions rendered possible by the brace might have done this. No dangerous or even serious constitutional symptoms were observed from these enormous doses. Injections of an aqueous solution of sulphate of atropine were now made once a day into the muscles affected, and into the painful points. Each point of injection was a little tender for a day, so different muscles were attacked on successive days. The splenius and trapezius and the upper part of the sterno mastoid being especially selected as the spasms seemed most intense in these muscles. Deep injections were made many times into the deep rotators also. The quantity injected was steadily increased. 25th. Four drops of a solution, gr. i to 3 i, were injected. 28th. Six drops; slight flushing of the face and dryness of the mouth for two hours-slight headache also; patient a little nervous. December 6th. after the injection. spondent. Twelve drops; spasm is less immediately 8th. Eight drops of a double strength solution (gr. ii to 3i) as large injections are painful. Eyes much affected. Bones ache. Has much better control of head after the injection. Walked round and round the room with head straight. Dryness persists five or six hours; patient could not read for the same length of time. Ioth. Eleven drops; dreadfully depressed. Though the spasm is less, she cannot shake off the feeling of despondency. 12th. Six and one-half drops of double strength solution (gr. iv to 3i). Very despondent, dreams a great deal. Cannot keep awake; cannot read; dryness intolerable. Spasm about nil after injection, but eight hours later returns and seems unchanged. Nausea seven hours after injection. Last dose-gr. 1-18 atropine. 15th. The feeling of depression has passed off, but the spasm has returned with almost its original force. The patient so dreads the despondent feeling produced that she refuses to go on with the drug, and I do not feel justified in urging it, since the effect on the spasm is so transient. For several hours after the injection the spasm almost disappeared. The effect of atropine is evidently much greater on this disease than that of conium, but unfortunately was not permanent in this case. My second case is as recorded below. Especial care was taken in both these cases to get a fresh supply of the conium in a large quantity, to keep the bottle sealed, and for this patient's sole use. In this way we avoided decreasing the doses for safety when a new prescription was filled. In one case, however, this precaution (adopted always for the first dose) proved useful, see August 16th. M. P., twenty-one years, July 31st, 1893. First noted a stiffness of the neck four and one-half months ago. There is pain just below occiput-at times severe. She is anemic. Eye-balls are slightly prominent, but there are no symptoms of exopthalmos. Patient does not seem to be of a nervous temperament. She has been treated by liniments and had galvanism several times. This hypercorrected the position of her head, but was very painful, and the relief was not permanent. She now carries her head thrust forward, somewhat extended, and with chin rotated to the left. There is no disease of the spine, or other apparent irritating cause. Rotation to right is limited by spasm. Flexion, extension and rotation to left are quite free, but not quite normal. September 6th, 1893. Fl. ext. conium, four drops t. i. d. 13th. Fl. ext. conium, five drops t. i. d. No December 8th. Spinal assistant brace and chin piece applied. February 6th, 1894. Now taking eleven drops t. i. d. constitutional effects noted. Increase one drop each dose. March 6th. Twenty-nine drops taken t. i. d. No symptoms. Spasm seems most marked in left trapezius. 15th. Thirty-eight drops t. i. d. No symptoms, spasm less. 27th. Marked improvement since March 24th-was then taking forty-seven drops. Can now hold head straight without aid of chin piece, and move it some without bringing on the spasm. April 5th. Fifty- nine drops t. i. d. Much better control of Can hold it in a good position unaided for several min head. utes. spasm. 10th. Sixty-four drops t. i. d. Feels a little nausea. May 1st. Seventy-nine drops t. i. d. No symptoms. 29th. Ninety-four drops t. i.d. Still a good deal of July 10th. One hundred drops t. i. d. No symptoms. August 16th. Fifty drops. Caused weakness in legs, etc. symptoms of nausea, First dose of a new supply of conium. November 20th. Has been laid up two weeks with facial erysipelas, in bed a good deal of the time and conium was stopped; now take fifty drops again, and Fowler's solution two drops t. i.d. December 4th. Take sixty drops t. i. d. and increase five drops daily in each dose. Increase Fowler's sol. to five drops t. i.d. Head is very rigid. 13th. Spasm less strong. Increase conium to ninety-five drops t. i. d. 18th. Spasms notably better for two weeks. 22d. Make conium one hundred and thirty drops t. i. d. Spasm less severe. January 3d, 1895. Increase five drops a day to one hundred and fifty drops. 12th. Walked easily about room several times and head was held easily-not perfectly; will make conium one hundred and sixty drops and Fowler's sol. seven drops. 19th. Make it one hundred and seventy drops. Head not so easily held as last week. 31st. Increase to one hundred and eighty drops. February 14th. All her friends who have not seen her for some time say she is much better. Is taking one hundred and eighty drops without constitutional symptoms. General health fair. Increase dose to one hundred and ninety drops t. i. d. 26th. Make dose two hundred drops. This was kept up for several days without bad effects, and without more effect on the spasm than was seen after the forty-seven-drop dose. Patient is discouraged and conium is stopped. April 4th. Muscular spasm is neither greater nor less since conium was stopped. The spasm seems chiefly in left trapezius, not on right side at all. There is a tender spot one inch behind and one inch below mastoid process on left. September 14th. Patient has been taking Fowler's solution and Bland's Pills and massage since April. She has worn brace Chin is a little She can her all through her treatment. There is no pain now. to right of median line, and head inclines to left. self, without help, correct the position of her head, which was an impossibility a year ago. She can go out of doors and about without attracting attention. The use of conium in this case, as in the first, seemed a failure. Both these cases, however, were steadily growing worse when they came to me. This advance has been stopped, and both are decidedly better than they were when first seen. We cannot ascribe this change to the conium, nor to the atropine, since the effect produced by the latter seemed temporary, in the doses in which it was possible to give it. The improvement must have been due therefore to the direct or indirect action of the braces. They did not increase the muscular spasm as has been claimed, on the contrary they relieved the patients, I feel sure, from a good deal of unconscious nervous strain, and thus they were enabled to get about, exercise, and enjoy out of door life more than otherwise would have been possible. The general tone of the nervous system was thus improved, and the mental impression that they were going to improve also exerted a powerful influence for good. REMARKS UPON OPERATIVE TREATMENT OF FRACTURED PATELLA. BY CHARLES PHELPS, M.D., The occurrence of fracture of the patella in private practice is relatively infrequent, but the occasional instances encountered. are likely to be the source of much anxiety during treatment, and often of disappointment in result. Even apparent coaptation of the fragments is difficult, and usually impossible. The cases are exceptional in which osseous union can be effected by the use of apparatus. The patient cannot always be made to comprehend the gravity of a fract, in so small a bone, and may hold his medical attendant to an unjust responsibility. Many reasons have been assigned for the usual lack of osseous union, of which those most insisted upon have been inability of coaptation by reason of the contraction of the extensor quadratus muscle, and deficient vascularity of the fragments. Since the open operative method has been employed the immediate cause of failure has been found to exist in the interposition of the anterior capsular fibres. As this condition is seen to be habitual the ordinary result of fibrous union is no longer matter of surprise, since want of absolute osseous contact is everywhere fatal to osseous union. The contraction of the extensor muscle may be overcome by apparatus; the supposed lack of blood supplied to the fragments is demonstrably unfounded; but mechanical treatment is necessarily ineffective because it fails to reach the proximate cause of difficulty. It has been noted in operative cases in which the parts are open to inspection, that in rare instances the intervention of capsular fibres has not occurred; and this explains the exceptional osseous union which may be had with any treatment, or no treatment at all. But the rule is fairly general that absolute contact of the osseous surfaces is prevented by a veil of fibrous tissue which drops down between them, and that recovery is had with non-union, or fibrous union with a ligament of variable length, and with a limb which is of various degrees |