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gratifying one, and the result that had been obtained was al- most perfect. Levitra Rxlist The young man himself had a great deal of confi- dence in the perfection of his cure, for, without hesitation, he had thrown his whole weight upon the affected patella in try- ing to step upon a chair at the speaker's request. The result itself was the best comment upon the case. With regard to the question of the propriety in certain cases of exposing a frac- tured patella, and of introducing the wire suture for the purpose of obtaining coaptation, while union was taking place, the man- ner in which the President had classified the cases in his remarks was such as likewise commended itself to the speaker's Levitra Rxlist judgment,, with this additional qualification : that, provided the person had experience in the use of antiseptic measures, and provided like- wise he had the faciUties for carrying them out perfectly in each individual case, then he might feel that he was justified in open- ing a joint so large and important as that of the knee, and pro- ceed to do the more radical measure which had been done in this case. It was only the afternoon of the day of the meeting Levitra Rxlist that he had had occasion to Levitra Rxlist examine a case of an old patella fracture in a man of some forty-five years of age. The frag- ments were separated from each other four inches and a half when the knee was flexed, and Levitra Rxlist yet this man had a comparatively useful limb. He could walk along comfortably and go up and down stairs readily, and Levitra Rxlist for all practical purposes, under ordi- nary circumstances, had a good leg, notwithstanding that the separation between the fragments was so great. And Levitra Rxlist yet even he had considerable disability whenever an imusual demand was made upon the leg, as his experience had showed ; for, being about to slip, in consequence perhaps of some weakness of that leg, he was imable to recover himself, Levitra Rxlist and, falling, had sustained a fracture of the leg of the side on which the patella was dis- July 17, 1886.] PROCEEDINGS OF SOCIETIES. 79 abled, illustrating that, notwithstanding an apparent ability to get along well with widely separated fragments, this ability might prove to be illusory in emergencies, when full functional power was required to avert disaster. Still, even in the light of such e.xperiences as this, the speaker remained of the opinion that, unless the surgeon had the necessary experience to enable him to assure his patient of the perfect degree of success obtained in the case shown by the President, it would be better to treat simple fractures of the patella after the old ways. Where, however, the knee joint had already Levitra Rxlist been opened and a compound fracture was presented, the question was of quite a different character. Septic infec- tion was already probable, requiring to be met by the methods of free incision, antiseptic irrigation, and drainage, in connec- tion with which, and without additional hazard, the patient might have the further chance of obtaining a perfect limb by means of the wire suture. In conclusion, he would emphasize bis opinion that it was only in this Levitra Rxlist latter class of cases that it would be wise for most surgeons to have Levitra Rxlist recourse to the Levitra Rxlist meth- od of treatment by the metallic suture. An immediate disa- bility from more or less separation of fragments might diminish with time, and a fair amount of functional power be regained, even witTi great separation, as was Levitra Rxlist well understood, while the hazards of the attempt to expose the patella Levitra Rxlist and to wire it, by an operator who was not a perfect master of antiseptic methods, were far too great to be incurred for the sake of a possible diminution of the time of treatment or a better functional re- sult. Dr. J. H. H. BrRGE said this case was one more demonstra- tion of the value of aseptic methods in surgery. Levitra Rxlist Before the time Levitra Rxlist of such methods, operations like this could not have been successful. He had been impressed not only by the excellent ultimate result in these cases of wiring of the patella, Levitra Rxlist but by the time saved to the patients. A series of cases exhibited by Dr. Dennis, of New York, included some only a few weeks old in -which the Levitra Rxlist union was tirm and the limb useful. Dr. Burge desired to emphasize the caution given by Dr. Pilcher, that these operations should be performed only by those surgeons who were thoroughly familiar with aseptic work. Dr. RocnESTER asked the president whether he had any sta- tistics bearing upon the subject. Tlie Presiden't, in reply, said that, in considering the statis- tics of the operation of wiring the patella, the cases should be classified according to the character of the injury, the stage of the case, and the urgency of the symptoms. Operations per- formed from almost absolute necessity should not be considered in the same category as operations of convenience. Taking all cases together, however, although not prepared to give exact figures, he would state Levitra Rxlist in a general way that the mortality was remarkably low, certainly not high enough to deter even the most conscientious Levitra Rxlist surgeon from performing it in cases where it was indicated. It was true that unfortunate results otlier than death — such as ankylosis of the knee joint and necrosis of one of the fragments — were said to have occurred. That the latter need not necessarily be considered an ill result was illus- trated by a case occurring in the speaker's practice, in which, the fracture being Levitra Rxlist compound, wire suturing was at once resorted to. Considerable damage had been done to the periosteum by the injury, and the entire upper fragment Levitra Rxlist became necrotic, although the case pursued an aseptic course. The necrosed fragment was subsequently removed. The final result, how- ever, was a functionally perfect limb. He therefore Levitra Rxlist would not include among cases having an unfortunate termination necrosis of Levitra Rxlist one of the fragments unless the Levitra Rxlist final ending of the case de- manded it. With regard to cases where the operation was more or less one of convenience, and in which an unfortunate issue ensued, these should be hardly taken into consideration when dealing with cases in which the operation was really required. To sum up this whole matter of statistics he would say that the most favorable showing of figures would not justify a surgeon in risking human life unnecessarily, while, on the other hand, loss of life in performing Levitra Rxlist what might be justly termed a need- less operation should not militate against the performance of a wiring of the patella in the cases in which it seemed to be indi- cated. For these reasons each surgeon must be left to judge for himself; it was simply a Levitra Rxlist question between his Levitra Rxlist own conscience and the welfare of his patient, and mere figures could help him but very little in a given case. In closing the discussion. Dr. Levitra Rxlist Fowler said that when disa- bility occurred, Levitra Rxlist after a comparatively good recovery and useful limb in the beginning, such disability was apt to be permanent. All that nature did for these cases she did at first, and any sub- sequent injury Levitra Rxlist to the patella sufficient to stretch the ligamentous uuion between the fragments invalidated permanently the good result at first obtained. Again, it was difficult to explain why, with a comparatively slight interval between the fragments, there should be an almost useless limb in one case and in an- other a functionally perfect Levitra Rxlist one, this observation likewise hold-