474 ON THE TREATMENT OF FRACTURES OF 



thing was repeated every two days or so, till the limb could be placed quite 

 horizontal. 



This preliminary operation has taken a long time to describe ; but in execu- 

 tion it is of the simplest character, no paring of the broken surfaces being done 

 at this stage, and there being almost no bleeding and no shock. The wound 

 having healed (I need hardly say without suppuration), the patient was allowed 

 to leave her bed, and left the hospital soon after to practise using the limb. 



Before long she was readmitted, and the second operation was performed. 

 The lower cicatrix was opened and the wire removed, and two interrupted wire 

 sutures placed in the tracks of the previous continued one ; the fragments, of 

 course, being this time pared to clear them of fibrous tissue of new formation, 

 and produce smooth surfaces for coaptation. This was all satisfactorily effected, 

 though not without the use of the powerful hook and the vertical position of 

 the limb. The result was restoration of the use of the joint in a manner so 

 satisfactory that I determined to try the same procedure in the other limb. 

 The only difference which I made in this case was that, as the upper fragment 

 was too small to bear drilling, I passed the ends of the wire, in dealing with that 

 fragment, through the tendon of the quadriceps just above the upper border 

 of the bone, the lower fragment, which was, of course, very substantial, being 

 drilled as in the other limb. By this means, aided by the vertical position of 

 the limb and the hook, I was able to bring down the upper fragment very satis- 

 factorily, so much so that I did not feel it needful to have the patient use the 

 limb in walking before proceeding to the second operation, but did this before 

 she left her bed, soon after the wounds had healed. In the second operation 

 I applied two interrupted sutures, passing them, as in the first operation, through 

 the track in tendon and bone which the first wire had occupied. 



The continued wire suture, which was first used by Dr. Hector C. Cameron, 

 of Glasgow, has the great advantage, where much traction has to be made upon 

 the fragments, that the pressure of the wire is distributed over the anterior 

 surface of the bone instead of being concentrated upon the limited portion of 

 tissue included in an interrupted stitch. And this is peculiarly valuable in 

 old cases of fracture ; in which, as a result of long disuse, the bone undergoes 

 interstitial atrophy that sometimes makes it very soft. But this suture has 

 the disadvantage that it may tilt the fragments so that their anterior edges do 

 not come well into contact with each other, as indicated in this diagram (Fig. 5). 



This was my reason for preferring the interrupted suture in the second stage 

 of the proceeding. In the first stage, in which the principal dragging probably 

 takes place, this circumstance is a matter of no consequence, as accurate apposi- 

 tion of the fragments is not then aimed at ; and in any case admitting of being 



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