Part of a Letter from Mr. Deverel Surgeon at Bristol; Concerning a Case in Chirurgery, Which is Commonly Mistaken for a Fracture of the Patella

I. Part of a Letter from Mr. Deverel Surgeon at Bristol; concerning a Case in Chirurgery, which is commonly mistaken for a Fracture of the Patella. Richard Burt, a Gardiner, living with Mrs. Lloyd of Stoke near Bristol, was thrown from his Horse, and in the fall receiv'd such a hurt in one of his Knees as made him incapable of remounting: He felt somewhat crack in that Knee (as he express'd it) before it touch'd the ground. Upon examining the Part I found (as I then thought) the ends of the broken Bone drawn above four fingers distance from each other: But upon a stricter examination of the parts, I found the Patella (which was drawn upwards by the extensors of the Leg) retain'd its natural Figure, and that the hardnes which was felt below was the end of the torn Ligament that ties it to the Tibia. The ends of the Ligament were brought as near as possible, and kept so about three Weeks without any very remarkable accident intervening. He then began to walk, which was a little too soon, causing thereby some pains, and loosening the Cicatrix, which made it the longer before it was perfectly firm; however he walks without any perceptible lameness. I have met with two others in the same case, the one a Person of distinction, who has not met with the good Fortune of walking so well as she used, tho' not for want of all the care and circumspection imaginable; for it is hardly to be expected that one in ten, to whom this Accident happens, should ever go right, it being next to an an impossibility that the ends of the torn Ligament should be so exactly plac'd, and retain'd as not to lie one over the other. Pareè in the 22d Chapter of his 15th Book affirms, that he never saw one of those who have had this Bone broken, but that halted during the rest of their lives: I am very apt to believe what this excellent Author affirms about the halting, and am sorry I must dissent from his notions of the case, and the cause of the Lameness. Hildanus in his Observationes Chirurgicae. Cent. 5th. Observ. 88. P. m. 485, has given us a History of a transverse Fracture of this Bone, which, after all the Symptoms were remov'd, was cur'd. Sed claudicatio ac summa imbecillitas totius cruris secuta est, ita ut non nisi maxima cum difficultate ambulare possit. He afterwards mentioning the cause of the Lameness makes a Query, if what Pareè (to whom this Observation is dedicated) says in his Exc. lib. de ossibus, lib. 4. cap. 2. can be the cause of the Lameness; his words are, Etsi vero Opinionem hancce rationi consentaneam esse in dubium revocare minimè conabor, unus tamen restat scrupulus, videlicet, an, fractâ patellâ, extuberantia calli talis esse possit, ut cavitatem hancce (qua inter femur & os tibia magna est) adeo adimpleat, ut motum actionemque genu impedire possit? Videmus enim ut plurimum in reliquis ossium fracturis, (nisi contritio ossis & periostei fuerit maxima) naturam tam decenter & eleganter connectere ossa, ut rarò relinquatur vestigium fracturae. Periostium enim, quam diu integrum est, materiam calli retinet, quo minus in extuberantiam excrescere possit, nisi, &c. Deinde in hoc nostro Ægro callum non fuisse causam claudicationis ex sequentibus apparebit: quapropter distinctione hic opus est. After this he goes on to show us how many ways this Bone may be fractur'd, but doth not observe that he ever saw it any other way broken, (unless in a Gun-shot- shot-wound) than transversely; if he had, I am persuaded, that this curious Observator would never have omitted it in his Observations. Ruysh in his *Centuria observationum Anatomico-Chirurgicarum* 4e. observatio 3, writes as follows. *Patellam propter duritiam suam haud frangi posse nonnulli perverse asserunt. Nos vero eandem non solam a casu graviori in genu frangi experti sumus, verum etiam sine casu; cujus rei Historiam recensere animus est. Ante tres praterpropter annos, visitavi cum Magistro Petro Adriani filio, virum satis robustum, qui a ponte descendens in terram ferè ceciderat; uno pede lubrico, resistens tamen quantum potuit, in Terram non fuerat prolapsus; sed ab illa resistentia vehementissima transversim fracta ejus patella, adeo guidem evidenter, ut inter utrumque locari potuerit manus, una enim supra altera infra genu sentiebatur.* This Observation is so like in all its circumstances to that which I related above, especially in that the Fracture was made without a fall, that I am very apt to believe it is the same; and do imagine he might be deceived by mistaking the hard end of the Ligament for the broken Bone. And when these sort of Accidents, which are now called Fractures of the *Patella*, come to be nicely examined; they will perhaps be found to be generally of the same Nature.