A STUDY 
OF 
TRANSVERSE FRACTURE pF the PATELLA, 
BY 
H. Augustus Wtusdn. M. D.. 
Lecturer on Fracture Dressings and Microscopical Anatomy in the Philadelphia School of A natomy. 
Ophthalmic and Aural Surgeon to St. Mary's Hospital, Philadelphia. 
Transverse fracture of the patella 
would seem to be of comparatively 
modern recognition for Hippocrates, 
Celsus and Galen are absolutely silent 
upon the subject, Sorannus being the 
first to give a description of it. Whether 
the occurrence of fracture of the pa- 
tella at the present day is owing to 
advance in civilization or deterioration 
of the human economy, or both, will 
not be discussed in this paper. Even 
at the present time, however, fractures 
of the patella from whatever causes 
are not very common, for they com- 
prised only 45 of the 2,328 cases of frac- 
tures treated in the Hotel Dieu, Paris; 
at most one in fifty, or an average of 4 
yearly. 
give the fibres of the tendon of the 
quadriceps a remarkably firm hold. 
The posterior surface is divided by a 
ridge into two facets united angularly, 
each of which articulates by a trochlear 
surface with one of the condyles of the 
femur. The outer one for articulation 
with the outer condyle being broader 
and deeper serves to indicate the leg 
to which the bone belongs. 
The patella is held firmly in place 
by the quadriceps tendon from above 
and the ligamentum patellae from below, 
and in the act of flexion and extension 
the patella glides over the condyles of 
the femur, giving an example of a lever 
of the first order. The extensor muscles 
are the power, the leg the weight, and 
the patella resting on the condyles of 
the femur the fulcrum placed between 
the power and the weight. 
Anatomy. The patella is a sesamoid 
bone situated in the anterior part of 
the femoro-tibial articulation. It is 
enveloped in the substance of the ten- 
don common to the extensor muscles 
of the thigh. It is cellular within and 
covered by very thin but firm plates, 
so that in proportion to its bulk there 
is scarcely a stronger bone in the body. 
(Anat. Phys. and Diseases of Bones 
and Joints, S. D. Gross, M.D., p. 137.) 
The anterior surface is convex and is 
perforated by small apertures for the 
passage of the nutrient vessels and 
marked by rough vertical striae, which 
The predisposing causes of this lesion 
may be age, sex, scurvy, gout, cancer, 
syphilis, rachitis, occupation, attempts 
at muscular feats. The study of age 
and sex and their influence in the 
causation of any disease or deformity 
is always of interest, and I think it 
particularly so in fractures of the 
patella. 
In the following table I have collated 
from the annual reports all the cases of 
transverse fractures of the patella from TRANSVERSE FRACTURE OF THE PATELLA. 
whatever cause, that were treated in 
St. Bartholomew’s Hospital, London, 
during a period of eleven years, from 
1866 to 1877, inclusive, omitting 1869, 
for which year I was unable to find a 
report: 
Between the ages of 15 and 25 there were 20, or one-fourth of the total number. 
“ “ “ “25 and 35 “ “ 70, “ one-fourth “ “ 
“ “ “ “35 and 45 “ “ 98, “one-third “ “ “ 
“ “ “ “45 and 55 “ “ 63, “ one-fourth “ “ “ 
“ “ “ “55 and 65 “ “ 22, “ one-fourth “ “* “ 
“ “ “ “65 and 75 “ “ 9, “ one-thirtieth “ 
“ “ “ “75 and 85 “ “ 2, “ one-i4oth “ “ “ 
Thus it will be seen that 98 cases, or 
about one-third of entire number, oc- 
curred in persons between the ages of 
35 and 45. 
The study of sex is likewise of con- 
siderable importance and none the less 
interesting. From the same source I 
found that 
Between 15 and 25 there were 16 males and 4 females, the proportion being as 4 to 1. 
“ 25 and 35 “ “ 54 “ “ t6 “ “ “ “ 3a to 1. 
“ 35 and 45 “ “ C 2 “ “36 “ “ “ “ if to 1. 
“ 45 and 55 “ “ 36 “ “27 “ “ “ “ to 1. 
“ 55 and 65 “ “ 13 “ “ 9 “ to 1. 
" 65 and 75 “ “ 7 " “ 2 “ 3? to 1. 
“ 75 and 85 “ “ 2 “ “ “ “ 
Total, 188 “ “96 “ “ “ “ 2to 1. 
Transverse fracture when due alone . 
to muscular action takes place always 
when the leg is flexed upon the thigh 
and sudden muscular contraction takes 
place. 
To illustrate The first, suppose that I 
should wish to break a pen holder, I 
certainly would not direct my force in 
the line of the fibres of the wood, but 
would place my thumb near the middle 
(a fulcrum) and apply the force required 
to break the stick at the two ends, 
using the force against the fulcrum, 
thus illustrating power and resist- 
ance. 
So it is with the patella, which would 
require an immense force to break if 
the leg was extended and the power 
was exerted in a line with fulcrum and 
resistance, but when the patella is held 
against the condyles of the femur and 
the leg is flexed a tremendous force, 
the character of which is a cross break- 
ing strain is being exerted upon the 
patella. 
The second element required is sud- 
den muscular contraction. A delicate 
silk cord may be made to sustain a 
certain weight if the power is exerted 
gradually, but if the same cord and the 
weight are submitted to elevation sud- 
denly applied the cord will break. 
A few cases due entirely to muscular 
action may be studied with benefit. 
Cases 1, 2.—Bichat (Packard’s Mai- 
gaigne, p. 602), and Sir A. Cooper 
(Cooper’s Surg. Essays, Part 11, p. 85), 
each saw a case where the fracture took 
place in aiming a kick, the motion of 
the foot being suddenly impeded, frac- 
ture took place. 
Case 3.—Hevin saw the case of a 
dancer who received a fracture in mak- 
ing a great effort in leaping. (Pack- 
ard’s Malgaigne, p. 602.) 
Case 4.—In the operating theatre of 
the Hotel Dieu both patellae of a 
patient were broken by the violent 
spasms of the muscles which followed 
an operation for stone. (Cooper’s Surg. 
Diet., p. 752. 
Case 5.-Bichat (Packard’s Malgaigne, 
p. 602) mentions the case of a man who 
was cut for stone and who in a subse- TRANSVERSE FRACTURE OF THE PATELLA. 
3 
quent convulsion broke both patelke at 
the same time. 
Case 6.-Desault (Gross System Surg., 
sth Edit., Vol. I, p. 1,001) met a case 
in which a man broke both patellae sim- 
ultaneously by a violent effort of the 
muscles to disengage the limbs from the 
constrained position in which they were 
placed during the operation of lithoto- 
my. Before the use of anaesthetics, the 
patients who were to undergo this op- 
eration wrere placed upon their backs 
and the wrists and ankles of corres- 
ponding sides were securely fastened 
together. 
he was discharged, but that the sepa- 
ration had gradually taken place. 
Case 12.—About the same time Mary 
Me was admitted into the same 
Hospital and under the care of Dr. 
Levis. The fracture was also caused 
by a slip upon the ice and an attempt 
to prevent falling. 
Case 13.—Sands {Med. Rec., Feb. 2, 
1878, p. 87) reports a case where the 
fracture was caused by the effort to 
prevent falling on being roughly as- 
saulted. 
Case 14.—A gentleman (Sir A. Coop- 
er, Surg. Essays, vol. I, p. 350) in 
jumping a ditch fractured his patella 
in his effort to prevent falling upon 
reaching the opposite side. 
Case 7.—Boyer {London Med. Repos., 
1823, Vol. XIX, p. 174) speaks of a 
coachman who, being in danger of fall- 
ing from his box, made an effort to save 
himself and heard the crack produced 
by the fracture. 
Case 8.—Dr. Kirkbride {Am. Journal 
Med. Sci., Aug., 1835, Vol. XVI., p. 
330) records an instance in a man who 
attempted to jump into a cart and 
broke his patella. 
Case 9.—Fielding {London Med. Re- 
pos., Vol. XIX., 1823, p. 174) met a 
case in a woman caused by attempting 
to lift a heavy basket. 
Case io.-A sailor (Hamilton, Fract- 
ures and Disloc., Ed ? p. 434) caught 
the heel of his boot in a knot hole, 
in the floor, which threw him backward, 
and in the effort to save himself from 
falling the patella was fractured. 
Case 11.—Jno. C k was admitted 
to Dr. R. J. Levis’ ward at the Penn- 
sylvania Hospital January 7th, 1878, 
and said that he had slipped upon the 
ice, and in the effort to save himself 
from falling felt the patella snap. 
There had been a fracture of a similar 
nature of the opposite patella seven 
years before. The fragments on the 
side of the old fracture were separated 
four inches. The patient stated that 
there had been close apposition when 
Case 15.—Sir Wm. Blizard (Lancet, 
Aug. 17, 1833, p. 673) reports the case 
of Wm. A , who, while walking on 
the curbstone slipped off, and in the 
effort to prevent falling, fractured his 
patella. 
Case 16.—A man {Am. Journal Med. 
Sci., July, 1848, p. 220) was tripped by 
the rope of a canal boat, and before 
reaching the ground felt the snap ac- 
companying the fracture. 
Case 17.—M. Sallemont {Cyclopad. 
Anat. and Phys., Todd, vol. hi., p. 70; 
Boyer s Surg., vol. hi., p. 358) reports 
the case of Louis M , who was 
thrown by a comrade with whom he 
was struggling, and in the effort to 
prevent falling broke his patella. 
Case 18.—Mr. Liston (Lancet, Oct. 
14, 1873, p. 81) reports the case of 
Eliz S , who fractured her right 
patella in leaping from an embank- 
ment. 
Case 20.—Dr. Kirkbride {Am. Jnl. 
Med. Sci., Aug., 1835, vdl. xvi., p. 330) 
has reported a case in which both 
patellae were broken in a similar man- 
ner, but at different periods. The girl, 
aged 29, was admitted into the Penna. 
Hospital, Oct. 16, 1833. In falling 4 
TRANSVERSE FRACTURE OF THE PATELLA. 
backwards and in making an effort to 
save herself the right patella gave way. 
She was dismissed on Dec. 2d. 
Lifting heavy weights, 1 
Efforts to prevent falling, threat- 
ened by a misstep in going 
down-stairs, 9 
On April 20th following she was re- 
admitted with a fracture of the left 
patella, produced in the same manner 
as before. 
I believe that muscular exertion is 
the cause of the vast majority of the 
cases that are set down as due to trau- 
matism. When a person falls on his 
knees, the patellae very rarely touch the 
ground, the force of the fall is received 
by the tuberosities of the tibia, and if a 
fracture of the patella should take 
place it would be undoubtedly due to 
muscular action alone. That this must 
be the case is abundantly proved by 
the fact that there is, as a rule, no 
abrasion or contusion of the skin over 
the patella. 
30 
Case 21.—M. De Beauvois {Med. 
Times and Gazette, Oct. 9, 1880, and 
Med. News, Jan., 1881) related at the 
Paris Society de M6decine an example 
of this rare occurrence. A man, thirty 
years of age, and apparently in good 
health, was engaged in the game of 
leap-frog, and having struck the ground 
with his feet, when on the point of 
springing forwards he felt as if he had 
received a blow on the legs and heard 
a crackling sound. He fell on the 
ground, believing that some one had 
struck him. On his being carried to 
the hospital, a transverse fracture of 
each patella, with a separation of not 
more than two centimetres, was found 
to exist. 
In cases where the fracture is due to 
direct violence and no muscular force 
is exerted, the fracture is apt to be in 
any other than a transverse direction, 
the skin in many cases being severely 
pulpefied. I have, upon several occa- 
sions, in the anatomical rooms of the 
Philadelphia School of Anatomy, tried 
to produce a transverse fracture of the 
patella upon the cadaver. I have com- 
minuted it, but I have never without 
using a chisel or similar instrument, 
been able, to produce a transverse 
fracture of the patella, because the 
essential of that fracture the muscular 
exertion was absent. 
9 Cases.—There are nine cases where 
the fracture was caused by a mis-step 
in going down-stairs, and falling back- 
wards, the patients made powerful 
efforts to prevent falling : 
Lancet, Feb. 15, 1840, p. 770. 
St. George Hosp. Reports for 1870. 
Am. Jnl. Med. Sci., July, 1848, p. 220. 
Lancet, Sept. 5, 1835, P- 74-8. 
Am. Jnl. Med. Sci., vol. xxx. (Hay- 
wood). 
New Eng. Quart. Journal, July, 1842. 
Packard’s Malgaigne, p. 600. 
Hamilton Fracts. and Disk,4th Edit. 
P- 434- 
Transverse fractures of the patella 
are very rarely united by osseous tissue, 
and the reasons for this are sufficiently 
simple, and may be briefly stated as 
follows : 
ANALYSIS OF THIRTY CASES. 
In aiming a kick, 2 
In leaping, 3 
In leaping (double), 1 
During lithotomy (double), . . 1 
In convulsions subsequent to lith- 
otomy (double), 2 
Effort to prevent falling, ... n 
a. The intervention oftynovial fluid 
between the fragments. 
b. The blood supply of one or both 
fragments being cut off. 
c. Muscular action prevents perfect 
coaptation. 
a. The synovial fluid, when exces- TRANSVERSE FRACTURE OF THE PATELLA. 
5 
sive, may be drawn off by an aspirator, 
or its absorption may be promoted by 
stimulating lotions applied externally, 
but if complete coaptation is accom- 
plished and maintained this will not 
interfere to a very marked extent. 
b. The blood supply of the upper 
fragment is largely cut off, owing to 
the rupture of the nutrient arteries 
which come from the anastomoses of 
the internal and external articular 
branches of the popliteal artery. The 
principal blood supply of the upper 
fragment is derived from the perios- 
teum and from the lower fragment, if 
it is kept firmly in apposition. As 
strange as it may seem, this fact is 
often ignored by surgeons who are 
called to treat such cases, for by their 
very treatment they frequently tend 
still further to diminish the blood sup- 
ply, by tight bandages, adhesive strips, 
in fact by nearly all the appliances 
which make pressure upon the skin 
over the bone. Thus they defeat the 
very object which they are endeavor- 
ing to bring about. 
cases have been sufficient to hold the 
fragments firmly together. This seems 
to me to indicate that the method of 
treatment to be adopted is that which 
holds the fragments in perfect apposi- 
tion, and, therefore, excludes all syno- 
vial fluid from between the fragments, 
and does not interfere with the blood 
supply of the affected part. 
Some surgeons raise the very serious 
objection to bony union, that it will 
form a ridge of callus on the articu- 
lating surface, which will be sure to 
cause serious impediment to the use of 
the limb. I have been unable to find 
authentic records of a single patholog- 
ical specimen of transverse fracture 
where bony union was claimed by the 
originators of the various appliances 
for the treatment of this lesion. Their 
claims are based upon the examination 
of living specimens, and it therefore 
seems to me as though the theory of 
the ridge of callus was raising an ob- 
jection not founded upon fact, but 
merely a possibility. 
c. The principal cause in the preven- 
tion of ossific union in transverse frac- 
ture of the patella is the muscular 
action. If this be properly overcome 
and the bone held firmly in position, I 
cannot understand why the transverse 
fracture should not unite by bone just 
as well as the vertical fracture, for the 
latter certainly must contend against 
the presence of the synovial fluid, and 
the probable ruptured nutrient artery, 
but it has in its favor the absence of 
muscular action. 
The same may be said of the sur- 
geons who claim that ligamentous 
is far superior to any other union after 
this fracture. The fact that the ex- 
tensor quadriceps muscle has the bony 
patella to glide over the condyles of the 
femur, seems to me to indicate that 
bone is the correct substance for the 
purpose and in case of fracture to se- 
cure bony union if possible, and I be- 
lieve it possible. I can not say that I 
ever saw bony union, because I did 
not see the cases after death, but I cer- 
tainly have seen cases under the care 
of Dr. R. J. Levis, of this city, that 
were treated by his modification ofMal- 
gaigne’s hooks, that so simulated os- 
seous union that no one seemed able to 
define any separation, and the two 
patellae measured very nearly the same. 
I believe it is now an undisputed fact 
that in transverse fractures uniting by 
ligamentous bands, the ends of both 
fragments are very often covered by a 
bony deposit.—Edinburg Med. and 
Snrg. JuL, 1837, No. 130, Chelius’s Sur- 
gery, p. 630, vol. 1. 
This ossific deposit would in most 
It is certainly remarkable that pa- 
tients seem to be able to walk quite TRANSVERSE FRACTURE OF THE PATELLA. 
\vell when there is a separation of a 
considerable distance between the 
fragments. Benj. Bell makes one inch 
the limit of separation, allowing of 
firmness of the knee. Velpeau as- 
serts that he has seen the functions of 
the joint completely re-established with 
an interval of two or three inches 
between the fragments. Malgaigne 
says that such assertions are in his 
opinion only accounted for by some in- 
accuracy in examination. He said he 
never saw the function of the limb com- 
pletely restored even when the separa- 
tion was limited to one-third of an 
inch. 
Hamilton speaks of two cases (Ham- 
ilton, Fracts. and Dislocations 4th 
Edit., p. 436). 
Morgagni saw two cases, and others 
have been recorded by Richter, Ortalli, 
Dupuytren, Roux, Velpeau and others. 
I have seen out one case. 
Sir Chas. Bell saw a case where the 
skin gave way at the same time that 
the ligament ruptured, thus laying open 
the joint. Subsequently it became 
necessary to amputate the limb. 
The most serious sequella of liga- 
mentous union is the great liability to 
a fracture of a similar nature of the 
opposite patella. This is occasioned 
by the increased strain placed upon the 
sound side by the presence of defective 
union of the side first fractured. 
Among the many disadvantages of 
ligamentous union is its tendency to 
stretch, an elongation is most certain 
to follow the fibrous union, and espec- 
ially is this the case if the patient is al- 
lowed to use his limb too soon. 
There is a case quoted by Hamilton in 
his excellent work on Fractures and Dis- 
locations, in whom after three months’ 
treatment by splint the separation was 
one-half to three-quarters of an inch. 
The knee was much ankylosed. Soon 
after this the upper fragment began to 
draw up and at the end of a year the 
separation was three inches. 
In case No. 11 the second fracture 
occurred seven years after the first 
one. 
In case No. 20 the left patella was 
fractured six months after the right one. 
The great necessity of striving, by all 
honest means, after bony union in cases 
of this kind of fracture is evident, for 
even though osseous union be not at- 
tained, the shorter the bond of union 
the better. “ For it is found that the 
“joint will always be weak and unpro- 
“ tected precisely in proportion to its 
“ length and thinness.”—Gross, System 
Surgery, sth Edit., p. 946. 
Kirkbride {American Journal Medi- 
cal Sciences, Vol. XVI), has reported a 
case in which the ligament had stretch- 
ed two and a half inches. 
Dr. Watson (Watson Jour. Med. and 
Surg., Vol. 111, p. 366), refers to a case 
in which the ligamentous band of union 
measured three and a half inches. 
As I have previously said the reasons 
why this fracture does not unite by 
osseous tissue are : 
a. Presence of synovial fluid between 
the fragments. 
b. Faulty nutrition, due to rupture of 
the nutrient vessels or compression. 
c. Difficulty of maintaining complete 
coaptation. 
It therefore follows that the treat- 
ment to be adopted is that which over- 
comes these difficulties best, and at the 
same time does not endanger the pa- 
tient’s life. 
In case No. u, of the 30 previously 
mentioned the ligamentous band mea- 
sured four inches after seven years. It 
was supposed to be a case of bony 
union and the case was noted as such 
upon the books. 
The liability of the new formed liga- 
ment to rupture, is a serious objection 
ro this form of union. TRANSVERSE FRACTURE OF THE PATELLA. 
7 
It is stated (Med. andSurg. Reporter, 
Nov., 1874), that at the Hospital Lari- 
bosiere, the surgeons becoming con- 
vinced that bony union cannot be at- 
tained, “ dispense with all apparatus 
“ to coaptate the fragments, which is 
“ perfectly useless, as whatever is done 
“the surgeon can hardly expect any 
“ thing more than a fibrous union which 
“ after all does not interfere with loco- 
“ motion.” 
feet state of approximation which is 
absolutely essential for the production 
of osseous union—therefore it seems to 
me that they should be discontinued as 
unscientific. 
The above objections cannot be rais- 
ed against those appliances which act 
directly upon the bone, and these 
appliances are hooks originated by 
Malgaigne and modified by Levis and 
Morton, and the wiring together of 
the fragments. 
“ Dr. R. J. Levis, of Philadelphia, 
“ (Med, Times, Dec. 5, 1874), says he 
“ has seen three instances in which frac- 
“ ture of the patella was left without 
“ further treatment than a state of rest, 
“no attempt being made to secure 
“mechanically the coaptation of the 
“fragments. In one case the fracture 
“ was associated with other injuries al- 
“ most necessarily of a fatal character, 
“but the patient survived for nearly 
“ three months. In another instance 
“ the fracture was complicated with 
“ severe injuries of the limb which 
“ were attended with such great swel- 
“ ling that the fracture was not recog- 
“ nized until after the lapse of more 
“ than two months. 
Malgaigne was the first to use the 
patella hooks, and his uniform good 
results caused other surgeons to resort 
to this form of apparatus. 
About 1877 (Med. and Surg. Reporter, 
Aug. 31st, 1878), Dr. R. J. Levis of 
Philadelphia, while using Malgaigne’s 
double hooks in a case of fracture of 
the patella was impressed by the fact 
that the double hooks implied that the 
patella was a symmetrical bone, but as 
it was known not to be so, it occurred 
to him that single hooks would be 
much preferable, and he had made an 
instrument with two hooks instead of 
four. The general principle of the 
hooks has remained the same, but the 
attachments have been somewhat 
changed, until now the hooks are held 
together with a rachet on a pinion, 
greatly facilitating the application, and 
removal. 
“ In the third case the fracture was 
“treated as a simple sprain with rest 
“ alone by a Homoeopathic surgeon and 
“ the patient came ultimately under my 
“ care on account of permanent disa- 
“ bility of the limb, due to a separation 
“ of the fragments of not less than five 
“ inches. In each of these cases the 
“ separation of the fragments remained 
“far greater than I have ever seen it 
“ as the result of ordinary treatment, in 
“ which approximation is effected as 
“ thoroughly as possible.” 
M. Nelaton (Clin. Surg., Translated 
by Atlee, p. 171), used the hooks a 
“ number of times, but never found any 
“ of those inconveniences to result from 
“ its use which have been so singularly 
“ exaggerated.” 
Campbell De Morgan (Am. Jnl. Med. 
Sci., July, 1863, Brit. Med. Journ., May 
24th, 1862), mentions the fact that a 
large number of cases have been treat- 
ed by means of Malgaigne hooks in the 
Middlesex Hospital and the results 
were most satisfactory. 
The serious objection to the various 
appliances which aim to maintain co- 
aption through the medium of the skin 
is that they tend still further to reduce 
the blood supply of the fragments, and 
do not keep the fragments in that per- 
Mr. Mitchell Henry, (Lancet, Aug., 8 
TRANSVERSE FRACTURE OF THE PATELLA. 
iB6O, p. 146), saw the hooks in use for 
many years in Malgaigne’s wards in 
Paris without any serious incon- 
veniences. 
mind was occupied in watching intently 
the phenomena of repair. lam not 
aware of any application of this princi- 
pal to the human subject made by 
Cooper. 
I have had opportunities of seeing 
quite a large number of cases in the 
Pennsylvania Hospital treated in Dr. 
Levis’ wards by his modified hooks, and 
am convinced that if bony union was 
not attained, it was impossible to deter- 
mine the space between the fragments, 
and I cannot remember one instance of 
serious difficulty arising from the hooks. 
But Mr. Lister Med. and Surg. Re- 
porter, Jan. 12, 1878), cut down upon 
the fragments in a case and drilled the 
two portions of the patella and tied 
them together with silver wire. Six 
weeks after the operation the wound 
was completely healed, the ends of the 
wire projecting through the scar. 
There was in this case no constitutional 
disturbance and the patient obtained 
excellent use of his limb. Dr. John 
Rhea Barton performed a similar opera- 
tion, but lost his patient—Gross,System 
Surgery, sth Edit., vol. I, p. 1,004. 
Cases when admitted to that insti- 
tution are usually allowed to remain 
quietly in bed for a week, the leg and 
thigh being bandaged to control mus- 
cular action. Attention is paid to the 
inflammatory condition of the parts, 
which is reduced as speedily as possi- 
ble with solutions of acetate of lead, 
etc. 
Dr. T. M. Logan performed this ope- 
ration once. {Pac. Med. and Surg. 
Journ., Dec., 1866), {Agnew's Surgery, 
Vol. 1., p. 781). The fracture had ex- 
isted for nine weeks when the wiring 
was done. The wire remained six 
weeks, the patient being kept under 
treatment for four months and a cure 
is recorded. 
The hooks are applied generally 
about one week after the receipt of the 
injury, and are permitted to remain for 
about four weeks, when very gentle 
passive motion is indulged in. The 
patient is not allowed to rest his 
weight on the affected side for at least 
two months after the accident. 
Dr. J. E.Van der Meulin, of the Uni- 
versity of Utrecht Cameron of Glasgow 
(-Hamilton Tracts, and Dislocations, 
Edit. 1880, p. 516), Mr. Rose of Lon- 
don {N. V. Med. Journal, May, 1876, 
page 463, Med. Rec., April 3, 1880, p. 
384), G. McClelland (W. V. Med. 
Journal, May, 1876) have recorded 
cases, but I believe the procedure to be 
such a dangerous one, presenting no 
superiority over the hooks when pro- 
perly applied, that I believe it should 
be resorted to only after every other 
known method ||as failed ; and even 
then only after a deliberate study of 
the cases previously operated upon. 
Sir Astley Cooper, (Sir A. Cooper, 
Surg.EssaysPJol. 11., p. 350),performed 
a series of experiments upon rabbits 
with reference to the solution of the 
question,—Why does not the patella 
unite by bone? In experiment VI, 
having divided the bone by means of 
a chisel, he sewed the two portions 
together, the suture being passed 
through the tendinous covering of the 
bone, but the ligatures separated and 
the bone united by ligament. 
It is quite evident that Sir Astley 
Cooper had grasped the thought of 
wiring the fracture in the human sub- 
ject, but it does not seem to have made 
much impression, either because of its 
failure in the experiment or because his 
In closing I would say that it is my 
conviction that the hooks are the only 
scientific method of treating transverse 
fracture of the patella.