displacement of fragments, say 1 or 114 inch, personally, I think, while it will not break, catgut will stretch.

DR. R. A. KERR, of Peoria, Ill. This is a very interesting subject. Every man who has been practicing medicine for any considerable length of time, has met one or more cases of fracture of the patella, and I know of nothing which causes a man more uneasiness than a fracture of the patella. The fracture of this bone is unique, for in those of almost any other bone in the body the tendency of the muscles is to draw the fragments together. There are forces which must be applied in the other direction to hold the fragments apart or to overcome muscular action that draws them together. Here we have to overcome muscular action, this tendency of separating the fragments making the treatment necessarily unique and different from that of fracture of almost any other bone.

The cases I have had have not been recent; they were mostly confined to times when antiseptic surgery and aseptic procedures were less perfect than they are now, and I was under the necessity of treating them, not always in hospitals, and when operations were not feasible. They were treated by non-operative methods, and while some of the results were satisfactory, I am sorry to say some of them were not highly so. At the present time, with our improved methods, of course we can do more. We can enter the cavity of the knee with comparative impunity now as compared with then. Every case must necessarily be a law unto itself. We can not lay down any hard and fast rules for any one operative procedure in any given number of cases. A great deal depends on the local condition. By a careful examination we can determine something in regard to the extent of the injury to the soft parts, the manner in which the fracture has been produced, and the amount of swelling present at the time. The amount of contusion will guide us to some extent, informing us as to the injury done to the soft parts. Whether or not we can by a reasonable amount of force bring the fragments into apposition and hold them there without any great difficulty is an important element. Another element that comes in here, as in every case of surgical procedure, is not confined entirely to

the local condition, but to the disposition of the patient. Given a patient who will do just what you tell him, who is not obstinate, not opinionated, easily controlled, you will accomplish much more and are much safer in proceeding by a conservative method than you are in a case where the opposite conditions exist. You all know the extent of difference there is between patients. Some are easily managed or controlled. They will do just what you tell them. If you tell them to lie quiet and exert no muscular traction on the leg they will do it; others are flopping about in bed, raising the head and shoulders, producing some motion that will necessarily contract the quadriceps muscle, which has a tendency to displace the fragments. These things all come in in determining whether or not to operate.

I

I was very much gratified to hear the doctor say he had disposed of the silver wire suture. have almost always found that in course of time any foreign material, such as silver wire, left in the tissues sooner or later produces trouble and has to be removed.

DR. G. G. COTTAM, of Rock Rapids, Iowa: I was interested in the essayist's reference to Jacobson. Three years ago I saw him wire a patella in London, and what I want to speak of principally is the simplicity of his technic. I suppose all of us have at some time or another spent five or six dollars for a fancy drill. Jacobson spends about ten cents in English money for a drill. He seems to do anything with a small ten cent shoemaker's awl with wooden handle, and which he used to drill the fragments. As suture material he employed the heaviest silver wire he could get, that is, the heaviest on the market. He gave his reasons for using silver wire, the principal one being that no other suture material except a metallic suture would hold the fragments without some lateral motion.

DR. J. M. RISTINE, of Cedar Rapids, Iowa: I think the essayist has covered the ground thoroughly concerning the advisability of operative intervention and has left little to be said.

I have had one case which I would like to report and perhaps ask a question or two. 1891, a fireman on one of the northwestern roads, stopping at a station to get water, jumped off the engine and alighted with his

knee bent, struck his patella, causing a transverse fracture. He was brought 100 miles to me, and I discussed the proposition with him as to whether he would like to have me operate. I described the manner of treatment, and he was very much opposed to operation. I succeeded in getting the fragments together; I do not think I got bony union, but I did get the fragments together, so they were not more than 1/8 inch apart, and secured good function of the joint. He went to work at the end of four months. He worked six months to a day, and was out in the country, and in going home to his work he slipped on the sidewalk on some leaves (it was wet), and sustained a rupture of the ligamentum patella of the same knee. I heard from him in a short time, and expected of course that he had a re-fracture. I thought there was a separation of the old fracture. I found separation of the ligament inside. I treat ed the case by coaptation; he made a good recovery; the function of the joint was restored, and he went to work again at the end of about four months.

a

He worked again for about two or three months; then in playing a game of billiards he slipped on the floor, and in the effort to maintain his equilibrium he ruptured the ligamentum patellæ in the same place. There was considerable separation. I then effected union. In the first place, union was not as good as it would be if I had previously operated. I went into the joint and united the tendon to the bone with suture. (He consented to this operation.) I sutured the aponeurotic layer to the side of the wound. The wound extended into the joint, and closed the ends up tightly. I was able to coaptate the parts quite accurately. He made a good recovery. He went around for six months,

and then resumed work and continued to work (I think about the same length of time, two or three months), and was out of town one afternoon. He went up stairs and in coming down he slipped and sustained a rupture of the ligamentum patellæ again, or, rather, I should say, separation of the ligamentum patellæ from the patella at some point. I tried to induce him to permit me to operate again, but he would not do so. He insisted on having the coaptation treatment instituted.

This was eight months ago, and recently he began to work again.

The question arises in this case, what is the trouble there? Did the original fracture impair the vitality of the lower fragment of the patella and interfere with nutrition to such a degree as to weaken those parts? The case to me is unique. By the time I get home he may have another one. (Laughter.)

DR. H. M. DEAN, of Muscatine, Iowa: I would like to ask the reader of the paper to mention in his closing remarks his ideas in regard to drilling the bone and in uniting the soft parts.

DR. C. KLIPPEL, of Hutchinson, Kan.: In my early practice I saw a case of fracture of the patella with a physician. He placed it upon a posterior splint and used what he called a figure-of-8 bandage of moleskin. I had the opportunity of seeing the case a number of times. The patient made a good recovery.

About two years ago I was called to see the same man, who had sustained a fracture of the same patella. I was very much impressed with the treatment that was instituted in the first place by my colleague. There seemed to be considerably more separation than on the former occasion, and I used straps with an elastic pulley downward, and then, in order to overcome any contraction of the muscles of the thigh, I took adhesive, strips, passed them around the thigh, fitting very closely from near the hip down to within about 4 inches of the knee joint. I believe those gave me a great deal of assistance. I have had an opportunity of watching this case for nearly three years. The man has at present good

union, and a useful joint.

I would like to have Dr. Plummer say some

thing in regard to the prognosis of the different forms of fracture in closing the discussion. In these cases the prognosis is a very important thing, and if I had had more exknow a little more of what to promise when I perience in this particular fracture I might have future cases. In this particular caseI did not promise anything. I would like to know what percentage of successes we may expect in these cases, and what the prognosis generally would be with non-operative and operative procedures.

DR. PLUMMER (closing): Dr. Middleton

thought I did not emphasize the importance of asepsis sufficiently. In my own mind I have pronounced ideas in regard to it as the result of my early experience. Just after I had graduated I saw a case in the hospital where all antiseptic precautions were carried out as well as they were at that day, though insufficient as compared with our present methods. A man with fracture of the patella was operated he got sepsis of the knee joint, followed by general sepsis and death. There was a life sacrificed that might have been saved with a fairly, good limb. He might have enjoyed life many years because he was comparatively a young man. I have been on that account very slow about opening up these joints, because sepsis of the knee joint is the most serious thing one could get. It is much more serious than sepsis in many other places.

on;

In regard to Dr. Bacon's remarks as to suture material, of course there may be cases where non-absorbable material is used, but as Dr. Kerr has said, non-absorbable material, such as silver wire, and SO on, will cause in a certain proportion of cases trouble later on, even if the wound heals aseptically.

Dr. Cottam speaks about the cheap instrument used by Jacobson. Dr. Murphy, who does a great deal of bone surgery, uses a carpenter's drill, which costs 75 cents, and which is better than any of the high-priced surgical drills with which I am familiar. So cheap instruments are often better than those that cost more.

Dr. Dean asked whether I usually drill the bone. I think drilling complicates the operation and requires handling of the joint more, and if we can get equally good results without it, and I think we can, it is better not to resort to drilling.

The prognosis for a good result is better if you operate, provided you get asepsis. If you get sepsis after the operation, the prognosis is much more serious than it would be after a non-operative case. The chances of getting a good result after operation are good in the majority of cases, but I hardly think we can get absolutely perfect results often. With the non-operative method of treatment the prognosis must be guarded. A large proportion of them will get good results, but not perfect.

They will not have complete control over extension, nor will they have complete power of flexion to the full range, but may have good useful limbs. Occasionally one will get a bad result; the power of extension in some is entirely lost, and the patient can only walk by hanging his leg forward with the knee and putting his weight cautiously on it. We can not promise these patients perfect results. The limit of one's skill will not guarantee anything but a good useful limb, and in some cases not even that.

On account of the glamour that is attached to an "operation," aided by the dictum of some enthusiastic operator, it sometimes requires courage to follow one's cool judgment, and to refrain from the use of the knife. This temptation often comes at such a time, or in such a manner that the surgeon is not fully prepared to maintain his position. There is no better preparation than a free discussion of the questions involved by such a gathering as this. Though the subject was discussed at our last gathering, the question of operative or nonoperative treatment was not perhaps sufficiently emphasized. As a basis for my remarks I shall report a recent case.

J. W., aged 36, while dancing August 6th, 1903, three couples came together in a corner, and in trying to prevent his partner from falling Mr. W. fractured his patella and dislocated his knee. Just how it occurred no one knew, but it is probable that while his knee was flexed and the quadriceps femoris was tense, his partner's knee may have struck his. Dr. Arthur Reynolds, who was present, reduced the dislocation, applied a posterior splint, and sent him home. An account of the accident got into the papers, and Mr. W. received letters from others who had suffered the same misfortune, urging him to have the fragments wired. One of these letters came from New Jersey, advising him to go to a certain eastern

surgeon.

*Read at eleventh annual meeting C., M. & St. P. Ry. Surgical Association, Chicago, December 18 and 19, 1903.

When the patient reached home I found considerable swelling of the tissues of the knee, with separation of the fragments of the patella, which was transversely fractured just below the middle. I removed the temporary dressings, and after cleaning the integument first, applied a U-shaped piece of adhesive plaster, fitting around the upper fragment. I then put on a plaster cast, extending from the hip to the ankle, leaving a window at the front of the knee. This was for the purpose of permitting frequent inspection of the joint, and to give exit for the ends of the U-shaped plaster. By

pressure should be by some tough yet soft substance, permitting a variation in degree. 1 therefore took two pieces of grooved whitewood / in. thick, 1 in. wide, and 31⁄2 in. long. The under side I hollowed out to fit the limb. Near each end I made a hole, through which I passed stove bolts. (Fig. 1.) This wooden clamp I then applied, substituting shorter bolts,

FIG. 1.

extension applied to these straps the upper fragment was drawn down to the lower fragment. This extension caused considerable pain, and the swelling of the tissues gradually forced the fragments apart. To firmly bind down the upper fragment with a bandage might, I feared, interfere too much with the circulation, and thus favor necrosis. Malgaigne's hooks have the disadvantage that they puncture the skin. It occurred to me that the integument over the patella is not very sensitive; neither is it supplied by any large blood vessel. The fragments of the patella may be approximated by pressure upon the four quadrants, but pressure may not be satisfactorily applied at the middle of the superior or inferior borders, on account of the tendons of the quadriceps. The

FIG. 2.

as the fragments came together. This was done August 10. The change was marked, pain disappeared, and there was approximation. Had this clamp been applied at first I think the approximation would have been perfect. With Malgaigne's hooks sometimes the fragments are everted. With this clamp the upper tongue of wood prevents eversion. (Because from the structure of the joint there is no support for the upper edge of the inferior fragment, in another case I should make the under tongue longer on the lower piece of the clamp.) The next day the patient telephoned that his

leg was so comfortable he thought there must be something wrong, but there was not. To keep the clamp from slipping I passed a plain bandage behind the knee over the bolts, and back behind the knee. This still left the patella free for inspection. A rubber plaster is not so good, because it interferes with the turning of the bolts. In about three weeks the patient was getting around the room. September 5 I removed the dressings for examination. There was as free motion as I dared to test, and fair union. I reapplied the same dressings. September 18 I removed the old dressings and applied a sole leather splint, extending from the crotch to the ankle. This was firmer and much lighter than the cast. Just above the patella I put a K-shaped strap to prevent the upward pull of the patella. (Fig. 2.) A cane was substituted for crutches, and soon after the patient resumed his business. The splint was gradually shortened. The cane abandoned, and finally the splint was left off entirely. Sixteen weeks after the injury I saw the patient, without cane or splint, drawing a sled on which sat his little boy. He walks with a slight limp, which is decreasing, and the degree of motion in the knee is increasing. From the second week I used massage to prevent adhesions. There is good union, with slight separation-less than 1/4 inch. An x-ray shows that apparently the lower fragment is everted, but palpation does not confirm this impression. Dr. Ridlon gave it as his opinion that the union is bony.

I have not been able to find any reference in medical literature to the use of wooden clamps, though I am told that they were once used in Cook County Hospital. In what shape I do not know, nor to what extent. Wyeth says in his Surgery "the most unjustifiable method of treatment ever introduced in this facture is that of opening into the joint and wiring the fragments together." He reported a case in which in spite of strict antisepsis amputation through the thigh was subsequently

necessary.

At a recent meeting of the Chicago Medical Society M. L. Harris reported some of his recent cases of wiring the patella. He introduced his remarks with a reference to a recent paper by a German surgeon of prominence,

in which operative measures were condemned' because of less uniformly good results, longer time of disability, and greater danger to the patient. Harris said such results were so at variance with the opinion of American operators that he felt moved to show his cases. neither Harris nor Ferguson said anything of the dangers of the operation, nor did they give any comparative statistics. In fact, they quite ignored the nonoperative treatment. I was surprised to find in the Annual of Medical Sciences for 1889 a report of a case in which, in spite of strict, antiseptic precautions, Fergu son was obliged to amputate after wiring. In the same place Stimson speaks of 3 cases in New York that year, in which amputation followed wiring, and two died. These cases were not reported.

Von Bergmann (Deut. Zeit. f. Chir.) said: "Whatever faults may be charged against the unsuccessful surgeons and their antisepticmethods, the fact of frequent failure can not be disregarded, and all the more because the majority, the very great majority, of transversefractures recover with relatively good restoration of function, without suture and without operation, even when the reunion of the fragments is not close and bony." Kirmisson (Gaz. Med. de Strasbourg) meets the assertion that the failures were due to defective antisepsis by, pointing out that some of them occured in the practice of surgeons known to be the most skillful.

Bull (Medical Record) on the other hand, reported a large number of most satisfactory results without operation. Thomas, of Liverpool, who treats these cases with his long splint, with which he treats tuberculosis of the knee, over extending the leg, and permitting the patient to go about his work from the first, says that of the important fractures, that of the patella is the "easiest to restore and repair, and least cripples the patient during treatment."-(Provincial Med. Journal.)

Among the unfavorable results following suture I find mentioned necrosis of the patella, ankylosis, amputation, death. I have found no mention of like results in nonoperative cases, and in conversation with Prof. Ridlon he tells me that he knows of no such case. The worst result is lack of function from too great separa