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ture. Silver wire was then passed through the holes in the fragments, this being greatly facilitated by first introducing a small cannula. Traction being made upon the upper fragment, it was found impossible to bring it to within an inch and a half of the lower fragment. In this emergency I resorted to the ex- pedient first suggested by Macewen, of Glasgow. An incision Levitra 20mg Filmtabletten Bayer about eight inches long was made upon the anterior surface of the thigh and parallel with the center of the quadriceps extensor muscle. The latter was rapidly laid bare for about the same extent of its anterior surface, and four incisions were made in such a manner as to form a W-shaped, transverse, incomplete section. The outer and inner arms of the W, however, were not allowed to encroach to within a finger's breadth of the cor- responding edges of the muscle. By this means a narrow strip upon either edge Levitra 20mg Filmtabletten Bayer of the muscle was allowed to remain intact, while the most unyielding portion, the central, upon a line with the tendon where it is inserted into the upper edge of the pa- tella, was weakened by angularly plhced incisions passing through the entire thickness of the muscle and joining each 78 PROCEEDINGS OF SOCIETIES. [S. Y. Med. Jodb., other in a manner to form the above-described W. This being accomplished, traction was again made and the fragments were approximated without any further difficulty. It was noted that, when traction was made, the lines of incision in the muscle forming the W simply lengthened and closed in upon each other, no gaps occurring ; but the elastic muscular structure at once filled in the spaces which would otherwise have resulted. In other words, the muscle narrowed Levitra 20mg Filmtabletten Bayer transversely as it was in- creased in length. This narrowing served likewise to arrest the haemorrhage, which at first was quite free from the divided muscle. The wires were crossed close to the bone after coapta- tion and passed through holes in a plate of hard rubber, and upon this latter they were twisted, thus firmly securing the fragments in position. Half-inch rubber drains were placed at the outer and inner extremities of the transverse incision so that their ends projected slightly within the joint capsule ; the latter was united by a continuous catgut suture, and the cu- taneous margins of the Levitra 20mg Filmtabletten Bayer wound wer& brought together by a sepa- rate suture of the same material. The longitudinal incision in the thigh was closed in the same manner, but no drainage-tube was here employed. Dressings of wood-flour cushions were ap- plied and the limb was bandaged to a wire-cloth splint. Fre- quent irrigation by means of a 1-1,000 solution of mercuric bichloride was employed during the operation, and before finally applying the wood-flour cushions a stream of this solution was passed through the joint from one drainage-tube to and through the other, until all traces of blood were Levitra 20mg Filmtabletten Bayer washed out of the joint and the solution came out perfectly clear. This patient's temperature never rose above the normal, and his pulse did not exceed 88 Levitra 20mg Filmtabletten Bayer after leaving the operating-room. The primary dressings were not removed until the ninth Levitra 20mg Filmtabletten Bayer day, and then only for the purpose of removing the drainage-tubes. Union by first intention occurred in both incisions ; not the slightest indication of suppuration was found. After removing the tubes a few strands of catgut were substituted therefor, and a dressing of wood-flour cushions was again apphed. These were left undisturbed for a fortnight, when, union being com- plete and perfect, the parts were simply bandaged with a roller and the limb was kept in a splint. At the end of the fourth week, bony union having taken place between the fragments, the wire was released by cutting one of its extremities close Levitra 20mg Filmtabletten Bayer to the integument under the plate of hard rubber and removed by making traction Levitra 20mg Filmtabletten Bayer upon the other extremity. The patient was now Levitra 20mg Filmtabletten Bayer allowed to move about on crutches, but was kept in the hospital under observation until July 10th, when he was dis- charged cured. Considerable power of motion Levitra 20mg Filmtabletten Bayer then existed, and at the present time he walks without perceptible halt, can run up and down stairs, and fiexes and extends his leg with a facility sufficient for all practical purposes ; in fact, almost equal to that of the other limb. Remarks : One of the features of this case worthy of note is the employment of large drainage-tubes. Perhaps, if our an- tiseptic precautious were of such a Levitra 20mg Filmtabletten Bayer character as to be entirely relied upon, the employment of means to accomplish drainage of the joint could be dispensed with. We have not reached, in my opinion, this stage in the surgery of the larger joints, and it is for that reason I advocate the use of drainage-tubes of at least from three eighths to half an inch in their inside diameter. It will be noticed that the first dressings were not removed until the ninth day following the operation. The only indica- tion for their removal at that time was the nece.ssity Levitra 20mg Filmtabletten Bayer for the re- moval of the drainage-tubes. Had I been able to obtain suffi- ciently large absorbable bone drains, a second Levitra 20mg Filmtabletten Bayer dressing need not have been used in this case. As it was, the healing practically took place under the first dressing. As regards the propriety or justifiability of operating in this case, I think all who saw this boy prior to the operation could not but agree with me that the limb was very seriously disabled. The risks of the operation itself, in my judgment, were not suffi- ciently grave to deter me, under the circumstances, from advis- ing and performing it. I may state here the conclusions I have come to respecting the classes of cases in which the patella should be wired. First, I think that all compound fractures of this bone should be sutured. Here the joint is already opened, and the ordinary difficulties encountered in keeping the frag- ments in coaptation are very much increased by the presence of the wound. Second, in cases in which it becomes necessary to open the joint freely in order to expose and tie the bleeding vessel where a hfemarthrosis complicates the fracture, it is like- wise proper to suture or wire the fragments. In both of these classes of cases the drilling of the bone and passing the suture adds nothing to the already existing danger. Third, in cases in which the result following the ordinary methods of treatment is such as to invalidate or seriously impair the efficiency of the limb ; or in which the chances of a good result are destroyed, as in this case, by an accidental overstretching of the ligament subsequently ; and particularly if the patient's station in life is such as to require sound and useful limbs in order to earn his living — in such cases I think the operation, performed under the strictest aseptic surroundings and by a surgeon skilled Levitra 20mg Filmtabletten Bayer in the practical application of the principles of aseptic surgery, is not only justifiable, but is imperatively demanded. I am not prepared to say that all cases of fractured patella should be sub- mitted to this operation. It can not be denied that some dan- ger, lessened though it may be by our improved means of operating, attends Levitra 20mg Filmtabletten Bayer the opening into the knee joint. This, taken in connection with the fact that good results are certainly at- tained by methods other than operative, leads me to exercise caution before declaring that all fractures of the patella, irre- spective of their nature, can be wired or sutured with propriety. Dr. PiLCHER said the case presented was an exceedingly-