FRACTURE OF THE PATELLA 467 



treatment upon another, and it happened that the case seemed especially 

 favourably circumstanced for osseous union. There was nothing between the 

 fragments ; the two could be brought into apposition with the utmost facility. 

 I applied an apparatus which appeared to have the effect of maintaining per- 

 fect immobility of the fragments ; and, when I came back from mv holida}', 

 I found them as I had left them, with no interval between them, and I hoped 

 there might be osseous union. Eight weeks after the accident the patient 

 was allowed to get up and walk, and I was told that he was walking exceed- 

 ingly well. Six weeks after this, I asked him to come and report himself, 

 and I was sorry to find that there was already half an inch of separation of the 

 fragments. He was then about to start for India. What the separation may 

 be now, I do not know. It is true that there may be a very useful knee- 

 joint, with a very considerable length of fibrous union. Still, when there is 

 a great length of fibrous union the knee is not equal to the original. 



Some of our experience with these cases, where we had the opportunity 

 of inspecting the actual state of things, will serve to explain the uncertainty 

 of the results of ordinary treatment. We have found, for instance, such dense 

 masses of clot so mixed with fibrous tissue as to make it quite impossible that 

 the fragments should be brought into apposition. I found in one case, also, 

 such a tilting up of one of the fragments that it would have been perfectly 

 impossible to get the osseous surfaces in contact by any other means than 

 direct operative procedure. Considering, therefore, the great inconvenience 

 which results in many cases when the treatment is conducted on ordinary 

 principles, I believe that if we can really say that we are morally certain that 

 we do not subject the patient to risk, w^e are in duty bound to give him the 

 benefit of this method. It has been said that it is not justifiable in recent 

 cases, though it is justifiable in ununited cases where there is a useless limb. 

 I must confess that if I believed I was subjecting a patient to serious risk 

 to life, I should not feel justified in operating on the ununited case, and 

 the ununited case is in every respect worse as a subject of operation than 

 the recent. The ununited case has the fragments probably dwindled by 

 absorption, and these fragments, already dwindled, have to be pared. There 

 is a separation, it may be a very considerable separation, and this has to be 

 overcome, it may be by dividing the quadriceps extensor, an operation of 

 difficulty ; and in ]-)ro]^ortion to the length and difficulty of the operation is 

 the chance that the surgeon may forget some point of importance witli 

 regard to llic antiseptic element. Then, again, when you come to di\ide 

 the quadriceps extensor, you divide a very vascular structure, ami xou may 

 have haemorrhage ; and, further, when the fragments are brought into apposi- 



