382 Extra-articular Suture in Fractured Patella.

has, no doubt, seen. I t occasionally happens that a patient does not present herself for treatment until deep fluctuation is already perceptible. Under such circumstances we may afford the patient considerable relief by applying the bandage, but taking care not to use much compression, as otherwise we should only entail more suffering. In this way we shall naturally lessen the congestion in the breast, and limit the extent of the abscess. When it becomes necessary to open an abscess, I would do so by Lyster's method, and still use the elastic pressure over the dressing, as being much more easily applied than the ordinary strapping.

I have arrived at the following conclusions from my experience in the management of the puerperal breast : - -

I. Mastitis is rarely seen, except in patients who have suffered from fissured or crushed nipples, and is the result of infectious matter gaining entrance.

II. That, as a rule, the secretion of milk continues only while the natural stimulus, as nursing or other means, continues to be employed.

I I L That the secretion of milk, either in the normal or inflam- matory state, begins to abate when such stimulus is withdrawn, and will entirely cease after a week or two.

That in all cases of threatened or inflamed breast, well regulated pressure by means of an elastic bandage should be applied, and no attempt should be made to nurse or withdraw the secretion until the entire subsidence of the inflammatory movement.

The advantages of the elastic bandage over an ordinary roller are :--1. I t is easier of application. 2. The pressure is more uniform. 3. I t is not so likely to slip. 4. I t is more comfortable to the patient, as requiring much less material. 5. I t is not neces- sary to apply it over the shoulders.

ART. XVII . - -Fractured Patella, Treatment by Extra-Artlcular Suture. a By T. MYLES, F.R.C.S: ; Demonstrator of Anatomy, Trinity College, Dublin; Surgeon, Jervis-street Hospital.

I FEEL tempted to apologise to the Royal Academy of Medicine for bringing forward such a threadbare subject as Fractured Patella. So much has been already written about it by better men than I am that I fear I must trespass upon the kindness

i Read before the Section of Surgery of the Royal Academy of Medicine in Ireland, on Friday, Feb. 22, 1889.

By MR. T. MYLE8. 383

and good nature of the members of the Academy if I ask them to listen to the few observations I mean to make upon the subject.

I propose to discuss only four points in connection with this injury, but I think you will agree with me in considering them of primary importance.

1. What is the prospect to the average day-labourer when he fractures his patella, and the so-called ligamentous union results ?

2. Why is bony union so rare in this accident ? 3. How can bony union be obtained ? 4. Under what circumstances is the surgeon justified in adopting

severe measures to obtain this result ? In spite of all that has been said to the contrary, l venture to

assert, as the result of my observations of cases long after they have left the hospital, that to the man who has to earn his bread by laborious toil a fractured patella means permanent disable- ment. In almost every case that I have seen such has been the result.

I do not mean to assert that there are not cases in which men have been able to follow laborious occupations after the injury, but I do state that such cases constitute but a small minority, and cannot justifiably be made the basis of a prognosis in any given case.

As there is a possibility of this statement being misunderstood, I will define the position I take up a little more clearly.

When one is shown a case in hospital of a so-called successfully treated fractured patella, the patient is told, by way of illustration, to walk up and down the room, to swing his leg about, to stamp upon the ground, to flex his leg upon the thigh, and to perform other evolutions of an equally innocent and harmless character, but almost absolutely valueless as a test of successful treatment.

There are three tests which ought to be applied to such a patient before a success in treatment can be claimed by the surgeon :--

1. He should be asked to spring off the floor by an effort of the injured limb alone.

2. He should be asked when lying on his back or sitting on the bed to raise the heel from the ground, when the leg has been previously fully extended upon the thigh.

3. The band between the fragments should be felt to become tense and hard when the patient, in walking, bears upon the injured limb.

384 Extra-articular Suture in Fractured -Patella.

I have gone to the trouble of testing these three points in a number of cases, and the results of my observations are as follows : - -

] only once met a patient who could spring a foot off the ground, and he had met with the accident in early life--in fact, at eleven years of age--and, although considerable separation between the fragments existed, he could do nearly as much with the injured as with the healthy limb.

In his case, probably, the reparative power of early youth was responsible for the successful issue.

In every other case I have examined the patient was unable to make any attempt at jumping from the ground, and in most cases, with what I think commendable prudence, refused even to make a vigorous or determined effort to do so.

The second test, raising the heel from the ground when the leg is fully extended, is very rarely accomplished. I confess I was very much astonished to find how few patients could do it.

They will raise the heel readily enough when the foot is flexed, but not at all when fully extended; in other words, the value of the quadriceps as an extending force is practically nil when the patella is broken and the fragments are appreciably separated.

The third test is only an amplification of the second. The patient may be able to walk fairly well, but if you put your hand upon the uniting bond between the fragments you will notice that it is in many cases quite lax when it ought to be tense in extension of the leg. ]n fact, the power of the quadriceps is transmitted, not through the bond of union, but through the lateral expansions which pass down from the sides of the patella to the top and sides of the tibia, and the advancement of the injured limb in front of its fellow is accomplished, probably by the psoas and adductor muscles.

A patient may be able to walk fairly well--in fact, deceptively well--but if he fails in the three tests I have given it is obvious that he will be unable to earn his breacl by laborious toil, and my assertion that he is permanently disabled will be fully justified.

I have gone to considerable length to attack the so-called liga- mentous union, and my reason for doing so is simply this : -

One of the commonest statements in the text-books of surgery, and one of the most frequently reiterated assertions at clinics, is that ligamentous union is all that can be hoped for in fractured patella, and that such a result is to be considered satisfactory. I

By MR. T. MvLEs. 385

have read and heard this statement again and again, and, with the simple credulity of youth~ believed it implicitly.

From this state of assured bliss I was once rudely awakened by a poor woman coming to me for a note for the Union. Her husband had broken his patella some time previously, and was now unable to earn his bread. He had been treated in the orthodox manner, with a back-splint, pads, and bandages, and had left the hospital apparently well, with the fragments closely approximated, but six months afterwards a hideous gap had developed between the pieces of bone, his leg was wasted, and he was barely able to walk with the aid of sticks.

This may have been an exceptionally bad case, perhaps, but it at any rate had the effect of focussing my attention upon such cases, and as the result of my subsequent experience I do not hesitate to say that the so-called ligamentous union is only too frequently, so far as the dynamics of the leg are concerned, a mockery, a delusion, and a snare.

I now come to the most interesting of the four questions I have set down for discussion--namely, Why is bony union so rare ?

From amongst a host of explanations I select four as worthy of consideration :--

1. ~Ton-apposition of the fragments from inability to overcome the contraction of the quadriceps muscle.

2. ~Non-apposition of the fragments, due to prolapse between them, under the influence of atmospheric pressure of the tissues in front of the patella, as described by Macewen.

3. Separation of the fragments by the synovial or bloody effusion and defective formation of new bone, due to the fact that the fragments are constantly bathed in the synovial fluid of the joint.

4. Defective productive power in the bone itself, due either to the defective supply of blood or the absence of periosteum on the post surface of the patella.

These four will, I think, include the more important theories usually advanced to explain the non-union.

The two last are knocked out of court at once by one fac t - - namely,-that in eomminuted fractures, where, .of course, these con- ditions as regards blood-supply, periosteum, and synovia are found, bony ration occurs fairly frequently.

The first--that muscular spasm is responsible for the non- union--will hardly hold water.

Every practical surgeon knows well that but a very slight effort

386 Extra-articular Suture in Fractured Patella.

is necessary in an ordinary case to approximate the fragments when the muscle is relaxed.

Any one of the many ingenious devices used in practice will overcome the contraction of the muscle and keep the fragments apparently together. I am sure that many hospital surgeons will support me in this statement.

Macewen's theory, that the torn structures in front of the bone will, under the influence of atmospheric pressure, be forced into the cleft between the fragments, is no doubt a very plausible one ; I should be inclined to say more plausible than probable. Of course nothing but actual dissection of recent cases can determine the question, but from ~ priori reasoning the theory seems to me to be untenable.

A glance at a frozen section through the knee-joint will show that the tissue in front of the bone is very thin, and it is almost impossible to conceive that the torn fibres of such tissues could exert the extraordinary influence he attributes to them.

I have endeavoured to test this point by experiments upon the cadaver, but in vain ; in every case I find that the muscles of the thigh will tear before the patella will break. We can only there- fore, in the absence of actual dissections of recent c~ses, accept Mr. Macewen's theory as a hypothesis.

I think I have now fairly shown that none of these theories, with the exception of the last, perhaps, can be considered a sum- cient explanation of the absence of bony union.

To what, then, is it due ? I would suggest, subject, of course, to correction, that in many

cases the treatment is largely responsible for the bad result. When discussing the question of muscular spasm, [ stated that

any one almost of the ingenious mechanical appliances devised for the treatment of the injury will overcome the contraction of the muscles and approximate the fragments, and so they will; but they will also do something more, as I will now make clear. ]f pressure be made upon the upper end of the patella, so as to force it downwards, it will be noticed not only that it travels downwards, but also that the lower end tilts forward. Anyone can demonstrate this in his own leg if he takes care to relax the quadriceps.

Further, the lower fragment sinks towards the tibia by its own weight, and pressure of any apparatus now forces it towards the cavity of the joint. The result, therefore, is that the fragments are now lying in totally different planes. Is it any wonder, there-

By Ma. T. MYLE8. 387

fore, that bony union does not result ? The real matter of astonish- ment, I think, is that any kind of union at all results.

Now, as far as I can see, no splint or external mechanical appliance can be devised that will remedy this, because it depends upon constant anatomical conditions. The useful frozen section shows us that the posterior border of the patella is convex from above downwards, and the patellar surface of the condyles is also convex from above downwards. That being so, any attempt to shove down the upper fragment by pressure from above and in front will cause the rotatory movement I have endeavoured to describe.

How then can we get the broken surfaces together ? The ready answer is, by opening the joint, drilling the bones, and wiring the fragments together after the manner practised by Sir J . Lister.

To this there are, however, very decided objections. At present there appears to be a superstition current that provided you have a spray going, gauze dressings, drainage-tubes, perchloride solutions, and other necessary paraphernalia, you can cut into a knee-joint and do pretty much what you like with it.

Professor Dennis, of New York, has collected the records of 186 cases in which the joint has been opened and the fragments wired, and'the results are interesting indeed. Of these 186, 11 died, 4 resulted in amputation, 34 suppurated, 31 had either partial or complete ankylosis ; in 24 the result is described as poor, in 35 as fair, and in 75, or less than half, as good.

Now these results are not encouraging, and I think most of us as yet would hesitate to recommend Sir Joseph Lister's method as a primary treatment.

In a discussion some years ago on the same subject, Dr. Robert M'Donnell put the question in a nutshell when he asked which of us, if his patella were fractured, would permit the joint to be opened and the fragments to be wired together ? In a crowded meeting there was only one answer in the affirmative, and that was from my friend Mr. J . Lentaigne, who, with a martyr-like enthu- siasm, declared his willingness to submit to tile sacrifice provided always Sir Joseph Lister was the officiating high priest.

When cogitating over these things it occurred to me that it was possible to bring the fragments together and keep them there without opening the joint; that it would be possible to obtain the advantages of Sir J. Lister's method without the dangers.

Through the kindness of Professor Cunningham I was given

388 Extra-articular Suture in Fractured Patella.

ample opportunity for testing the feasibility of my plan on the cadaver before trying it on the living.

My method, which I have ventured to designate "Extra-Arti- cular Suture," is simply this : -

The limb being cleaned, the skin is drawn well up; a small puncture is then made through the skin on either side with a common bradawl; the upper fragment is cautiously drilled from side to side, the drill being constantly kept accurately parallel to the anterior surface of the fragment; through the drill hole a stout nickel-silver pin is passed~ its two ends project on either side of the fragment, its centre is buried in the substance of the frag- ment. The lower fragment is then similarly drilled and transfixed, the skin having been previously drawn well down.

With the i~ins now in position you have a powerful grip on the fragments, and it is astonishing how little force is necessary to overcome the muscular contraction. When the fragments are drawn together and fixed in proper apposition, a gauze tape can be passed under and around them in a figure of 8, as in a hare-lip operation, or the free ends can be securely wired together.

A thick pad of lint, dipped in perchloride solution~ 1 in 500, is wrapped around the joint, and outside that a layer of gutta percha tissue, to delay evaporation.

A posterior splint and flannel roller completes the dressing, which is not stilted for five or six weeks.

After the preliminary puncture and drilling the treatment is absolutely painless, as my patients have again and again asserted.

Such is briefly the method I employed in the first of my series of cases, and it is the method I hope to follow in subsequent ones.

In two other cases I modified the method slightly. Instead of drilling the bones I passed the pins between the bone behind and the expansion of the vasti muscles in front, hoping that by doing so I would obtain as good a grip on the fragments as in the first method.

The result, however, was disappointing in these cases~ the tissue ill front of the patella evidently not giving a sufficiently good and enduring grip to the pins.

I have abandoned that method now, and will adhere to my original idea in future cases.

The advantages I claim for the method are : - - 1. That it is effective--that is to say, it will keep the fragments

in perfect apposition without the tilting incidental to mechanical appliances.

By Ma. T. MgLE$. 389

2. I t is free from the danger of septic infection, as the joint is not opened.

3. I t is easy and simple, and within the reach of everyone, requiring no costly appliances.

The only methods that I know of that it can fairly be compared with are Professor Volkmann's method and Mr. Treves' modification of Malgaigne's hooks.

Professor Volkmann's method consists in passing a wire ligature through the border of the quadriceps above and the ligamentum patellae below.

The objections to this method are so obvious that I will not waste time by detailing them.

Mr. Treves' method of using Malgaigne's hooks is open to several objections : - -

1. Everybody has not, and may not be able to procure, the hooks. 2. The joint is often perforated above or below. 3. The hooks also tend to tilt forwards the lower end of the

upper fragments as they press the patella from the front and above. 4. They are painful and cumbersome. I think I may, without either arrogance or conceit, assert that

with either of these methods the plan I suggest will bear com- parison of safety, efficiency, and simplicity, and these should be regarded as the basis upon which a decision is to be given.

I will now conclude by stating that I honestly believe if bony union can be obtained by any means short of opening into the joint it will be obtained by the Extra-Articular Suture.

DR. CORLE~'S UNUSUAL CASE OF THYROID TUMOUR.

OUR readers will remember this remarkable case, which Dr. Cor|ey presented to the Section of Surgery, in the Royal Academy of Medicine in Ireland, on March 29th, 1889, and which appeared as an " Original Communication" in the last number of the Journal (see page 294). We have much pleasure in presenting the illustration of Dr. Corley's case-- which~ unfortunately, did not reach us in time for insertion with his paper. I t will add to the value of this unique clinical report of an operation, which Mr. Edward Hamilton~ when speaking upon it~ well described as " a triumph of surgery." We are gratified to learn that the patient continues up to the present date in excellent health.