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Complications in Fractures Involving the Hip Joint

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COMPLICATIONS IN FRACTURES INVOLVING THE HIP JOINT.

Complications connected with a fracture involving the hip-joint are varied and interesting. For convenience they may be divided into those more intimately connected with the traumatism under discussion and those that are more or less remote, both as to time and place. The fractures in question are frequently hazardous, and many of them present difficulties in diagnosis. Under the first class, we include contusions, sprains, dislocations, and fractures involving several of the constituents of the joint, or, in other words, fractures begin ning in the ilium, pubes, or ischium and extending into the acetabulum, as fractures of the vault may involve the basal foss. Shot wounds involve tendons, ligaments, and other soft parts to the extent of laying open the capsule. Shot frac tures likewise implicate the acetabulum, the head, neck, and, in some cases, the trochanters, in such a way as to involve the joint. Injuries, also, of the upper portion of the thigh, whether of the shaft, or whether the case be one of open wound of the soft parts, become important in consequence of the spread of infection to a degree which may involve the hip-joint.

In military practice, shot fractures involving the hip-joint, with their varied complications, present problems most difficult of solution. A tabular statement of 386 shot fractures of the hip-joint exhibits the following : Acetabulum without fracture of the femur ; acetabulum and head of femur; acetabulum, head, and neck of femur; acetabulum, head, neck, and tro chanter major; acetabulum, head, neck, and shaft of femur; acetabulum and neck of femur; head of femur; head and neck of femur; head, neck, and both trochanters; head, neck, and trochanter major ; head, neck, and shaft ; neck of femur; neck and both trochanters; neck and trochanter major; neck and trochanter minor; neck and shaft; trochanter major in volving the hip-joint, upper part or upper extremity of the femur.

Under the bead of remote or general complications, in 249 fatal cases of shot fractures of the hip-joint treated by con servatism, fragments of bone were removed in twenty-one cases, pywmia was indicated in thirty-eight cases, gangrene in thirteen, tetanus in one erysipelas in one peritonitis in five cases, and secondary hxmorrhage in fourteen cases. In one case the femoral artery was tied, and in two instances the external iliac artery was ligated. In four instances the missile penetrated the abdomen; in nine cases the pelvic cavity was pierced, but apparently without injury to the viscera. In fifteen cases a shot fracture of either the ilium, ischium, or os pubis was reported ; in two instances the bladder was involved, and in twenty-two cases the injury to the hip-joint was com plicated by various other injuries of less In shot fractures of the hip-joint, injuries of the femoral vessels, com pound fractures, fractures of the shaft, and wounds of the knee-joint, become serious complications.

In spite of the most laudable efforts on the part of the surgeon, often much anxiety is experienced as to the outcome of the fractures.

Will the vascular supply to the proximal fragment be suf ficient for the purposes of repair? Will union or non-union be the final result? An atheromatous condition of the blood vessels is very common in the aged. May not the same condi tion in the diffused variety exist in the arterial branches which accompany the round ligament, and thus diminish the blood supply? Limited lacerations and a few punctures of the cap sule are common, but the more extensive lacerations of this structure must be considered under the head of local complica tions. Carcinoma and sarcoma, both primary and secondary, have served as the foundation of spontaneous fracture, and in my own practice a fracture occurred at the base of the femoral neck during an examination of sarcoma, involving the upper part of the shaft.

Inversion of the limb in cases of fracture of the hip-joint is so rare that it may justly be classed under the head of com plications. In 359 cases, Hamilton records two cases of inver sion. In my own practice, I have kept no statistics of the whole number of fractures of the hip-joint, but they have prob ably reached several hundred, and among these I have only seen two cases of inversion—one, that of a feeble, old man treated at St. Luke's Hospital. A short time afterwards I en countered the remains of this patient in the dissecting-room and removed the hip-joint. The fracture was impacted in such a manner as to hold the leg in a state of inversion. The case was published in the Chicago Medical Examiner, including a cut of the bone. The second case of inversion above referred to was the following: A male, twenty-seven years old, weighing 172 pounds, came under my care, May 18, 19oo, three months after the accident, which consisted of a fall of twenty-two feet. The fall was broken somewhat by grasping a beam, but he struck on his right foot, which was driven through the floor. When I saw the patient there was shortening of one inch. The leg was straight but in verted. A rectal examination revealed a prominence of the floor of the acetabulum on the injured side, and this prominence did not exist in a corresponding locality on the uninjured side. The radiograph, so far as we were able to interpret it, revealed a fracture of the neck, and of the rim of the acetabulum, with a subluxation of the head of the femur. Under the influence of an anzsthetic, after a fixation of the pelvis and during strong exten sion, the leg, being somewhat abducted, was placed in plaster of Paris reaching from the foot to the waist, and the patient kept in bed. A few days before his discharge from the hospital, August 21, 19oo, the plaster of Paris was removed, and its use discon tinued for three or four days. It was found that the foot remained in its normal position, although the patient was not allowed to get up. After reapplication of the plaster of Paris, the patient went home, having been directed to wear the dressing for two and a half months longer and to use crutches. The plaster was finally removed in the last week of October, since which time the leg has been without a dressing.

Under date of January 21 of this year, patient wrote me that, "owing to sickness in his family, he had been kept on his feet more than usual, but that he was feeling good and getting around pretty well ; that the leg pained some about the hip, but that the more he exercised it the better it seemed to feel ; that in bending it he was making satisfactory progress ; that he could sit with comfort, and could almost bend the knee to a right angle." He called to see me on Wednesday last, January 30. He usually walks with the aid of two canes, but he walked eight or ten feet without a cane ; and he informed me that he was able, at home, to walk about eighty feet without a cane, but he always uses two canes out of doors. His longest walk has been about half a mile. There is now no inversion, the leg being slightly more everted than the uninjured one. Eleven months have elapsed since he was injured.

We may now dwell for a moment on the more remote complications. A neglect to frequently change the position of the upper parts of the body, and a neglect to carry out other treatment indicated, is very frequently productive of bed-sores, —a serious complication in the class of fractures in question ; and, of course, the difficulties in the prevention of these in creases in those cases where there is dribbling of urine, as there is nothing causes a bed-sore so quickly as pressure associated with urine soakage.

Phosphoric acid has been found in the urine in such quan tities as to suggest its origin in the decalcification of the bones, and where this is a marked feature, imperfect union or failure of union might not unwisely be prognosticated. Other remote conditions play an important part, not only in the production of the fracture, but also in its repair. Among these we may mention paralysis, locomotor ataxia, diabetes, pregnancy, and osteomalacia. Obset vation among lunatics, especially those who are also paralytic, manifests the play of diseases of the nervous system in the production and repair of fractures. The loss of the vital powers in the aged and their inability to well bear confinement to bed is a serious complication, and results in many fatalities.

Fatty embolism, septicemia, delirium tremens, and pneu monia are practically fatal complications, except pneumonia, from which a considerable number recover. Nerve injury, as a complication, is not to be ignored I have encountered one such namely, foot-drop, which may be compared to " wrist-drop" from injury or pressure of the musculo-spiral in case of fractured humerus.

A tall, thin man, sixty-five years old, sustained a fracture of the neck of the left femur. Being in good health, the leg was treated by extension and counterextension and by confinement to bed. He was never able to flex the left foot upon the leg, although there were no complications in or about the ankle- or knee-joints.

The condition above referred to arose doubtless from the paralysis of the external popliteal, arising from pressure of the retaining bandage and adhesive straps which were used for ex tension. He had been confined to bed for two months. An ap paratus was devised for the foot, in order to hold it up, and this very much facilitated his walking. Nor did this complication seem to be serious until seven or eight years subsequently, when he fractured the neck of the other femur. Being out of health in other respects, although able to be up and about the house and to walk on crutches with assistance, the disability arising from the two fractures, together with the paralysis and melan cholia, were too much for him to contend with. He subsequently died of pneumonia months after the fracture last named.

Thrombophlebitis as a remote complication would not be so unexpected where the blood-vessels had been injured or as a result of sepsis; but without apparent injury, phlebitis asso ciated with a fracture of the hip-joint is exceedingly rare.

A male, seventy-three years old, fairly healthful, with the exception of atheromatous arteries, sustained a fracture of the neck of the right thigh-bone, October 17, 1900. Extension was effected by the employment of Hodgen's modified splint ; there being nothing particularly unfavorable, the patient was kept in bed for two months. Deep respirations were employed several times during the day and the administration of strychnia and such other tonics as the patient seemed to require. October 28, eczema, to which the patient had been subject from time to time during the latter part of his life, appeared under the adhesive straps, in consequence of which it was necessary to remove them. The moist patches were liberally dusted with a desiccating pow der. The leg was enveloped with bandages of sheet wadding to a point just above the knee. Plaster of Paris was then applied. Incorporated with this were two strips of ordinary bandage, one on each side. By means of these, together with the plaster of Paris, I was able to continue the extension. November 7 the plaster of Paris was removed and mole-skin plaster substituted, the eczema having disappeared. The extension was finally re moved on December ii, the leg being in fair condition as to its nutrition, and the condition of the knee- and ankle-joints func tionally satisfactory. Varicose veins did not exist.

The shortening was in three measurements, at varying in tervals, three-eighths, seven-eighths, five-eighths of an inch. From December 13th to the i6th, the patient, with assistance, sat for a few moments on the side of the bed, the feet being on the floor, this with a view of getting him accustomed to the upright position. On December 17 he was placed in a chair by the side of the bed for a few minutes. From December 17th to the 24th he sat up a part of the day ; was instructed in the use of crutches, and was able to walk across the room on crutches, further assisted by the nurse or myself. After the removal of the extension appa ratus, massage was employed for both legs. On the last named date, December 24, symptoms of phlebitis appeared on the left or uninjured leg. The limb became moderately swollen ; the skin shiny; superficial veins enlarged; inability for a day or two to completely extend the limb, and soreness on pressure in the course the more imminent by the fact that these men are surrounded by total darkness, save for the flickering lights on their caps, which may easily be extinguished, and thus aid in, or even cause, the accident. Above ground, too, the coal-breaker, with its complex and relentless machinery, as well as the nu merous railroads running to and from the mines, furnish sources for injuries which are not surpassed, if equalled, else where.

In his "Text-Book on Surgery" (Vol. i, p. 962), Agnew says that ninety-four cases of pelvic fracture were admitted to the Pennsylvania Hospital during a period of fifty-four years. Pilcher, in the "International Text-Book of Surgery" (Vol. i, p. 564), speaks of eighteen cases brought to the Meth odist Episcopal Hospital, in New York, in nine years. This makes it appear that about two cases a year is the average number admitted to a large city hospital. The accompanying chart records fifty-four cases admitted to the State Hospital, Hazleton, Pennsylvania, in a little less than ten years; an average of over five cases per annum.

Pelvic fractures are almost invariably due to external violence delivered directly or indirectly upon some portion of the affected structure. A fall of a heavy weight upon the pelvis, the car-coupling accident, the passage of a heavy vehicle over the pelvis, a gunshot injury, or a fall, are the commonest causes.

The pelvic bones, like those of the skull and vertebral column, form a cavity containing delicate structures, and.it is permanent disability or death due to injury of these viscera which the surgeon fears more than he does deformity or anky losis from the fracture itself. Any of the pelvic bones may be broken, and multiple fractures are not unusual. According to some authorities, the pubis is the part most often affected ; according to others, the ilium; at any rate, fractures of the ischium and acetabulum are uncommon, and of the sacrum and coccyx rare. The pelvic bones are strong and broad; it requires great force to break them, and for these reasons pel vic fractures are often comminuted. Compound fractures of these bones are but infrequently met with, although five cases are herewith reported.

Ashhurst speaks of a complicated fracture as being one which is associated with some marked lesion of the same part of the body. In dislocations of the symphysis or fractures of the pubis, rupture of the urethra is very common ; next in frequency comes rupture of the bladder, which may be extra- or intraperitoneal. Urinary extravasation accompanies the latter, and is often associated with the former, but reten tion is the usual sequel of urethral laceration. Cases of rup ture of the rectum are rare ; I am only able to report one. Rupture of the great vessels in the pelvis is probably more common than is suspected, the symptoms of internal hmmor rhage being ascribed to "shock." Contusion or rupture of the kidney is frequently associated with fracture of the ilium. I have met with two cases of luxation of the hip complicating pelvic fractures. Injuries to other parts of the body received at the time of the pelvic fracture, while not being complications in the sense in which Ashhurst uses the term, are such for pur pose of convenience, and I have so classified them. The latter class of complications in some of the cases which I report are as grave as the pelvic injury itself.

I have seen but one case of fractured pelvis in the female (No. 52 in the tabulation). The young woman was watching an exhibition of fire-works, when a cannon burst, and a large fragment of metal entered the anterior abdominal wall just internal to the right anterior superior spine of the ilium, form ing an enormous, irregular, contused wound of entrance; it passed out of the girl's body just above and anterior to the posterior superior spinous process, causing a wound of exit which was smaller and less contused than the first wound. The bottom of these wounds was formed in places by the transver salis muscle, in others by the subserous areolar tissue, and the anterior superor spine as well as almost the entire iliac crest behind it was carried away. The bone was trimmed so as to form an artificial crest and anterior spine, torn tissue and splinters of bone were removed, the wounds rendered as aseptic as possible and sutured. The bridge of tissue between the two wounds—about three inches wide—retained its vital ity, and, aside from considerable sloughing in the wound of entrance, the girl made an uneventful recovery. I saw the patient four months after she was discharged, and there was not the slightest loss of function. The chief surgeon of this institution, Dr. Lathrop, said, and I believe that he is right, that it was the resiliency of the ends of the woman's steel corset ribs which deflected the missile from its course and prevented it from entering the peritoneal cavity. The same cannon fragment, continuing in its course, struck a small boy, who died from intraperitoneal hemorrhage.

Another interesting case (No. 51 in tabulation) was ad mitted to the hospital some little time before the former. The patient was a laborer in a coal-breaker, and his accident was caused by being caught in the "rollers." The rollers are two heavy cylinders of iron held some distance apart, and have spikes about two and one-half inches long projecting from their surfaces. When these cylinders rotate, the spikes or teeth of the upper roll pass between those of the lower one like a cog gearing, except that the teeth do not strike each other. The man attempted to lift a heavy rock out of the chute which fed these rollers with coal ; his foot slipped, and he was drawn in as far as the lower portion of his abdomen before the machinery could be stopped. Examination showed that the teeth had pierced the right lower extremity in twenty places, producing multiple compound fractures of the leg and punctured wounds of the thigh which passed down on both sides of the femur. The spikes caused several punctured wounds of the left calf and bad lacerations of the scrotum and perineum. One of these projections struck the right horizontal ramus, causing a compound comminuted fracture ; another pierced the lower portion of the inguinal canal, pushed the spermatic cord before it, and drew the right testicle into the external ring. This wound did not involve the peritoneal cavity, but it was enlarged under anaesthesia, in order to ligate several bleeding points and disengage the spermatic cord so as to draw the testicle into the scrotum. The wounds were cleansed from coal-dirt as well as possible and dressed antiseptically. The right leg was placed in a fracture-box and sand-bags laid along both sides of the man's body. The patient suffered greatly from shock, soon rallied, and gradually made a complete recovery. When he left this institution his wounds were entirely healed, and he could walk without the slightest difficulty.

In instances like the above the diagnosis can be made visually; ordinarily, however, we have to depend on our senses of sight, touch, and hearing for the signs of deformity, undue mobility, and crepitus. Deformity is never well marked. Scudder, in his work entitled the "Treatment of Fractures" (p. 92), says, "practically all parts of the pelvic bones may be palpated." This, together with the context, would lead one to suppose that these bones may be felt with a degree of ac curacy sufficient to render the existence or absence of a fracture a certainty. In some cases it is easy to elicit abnormal mobility and crepitus; but in others, local tenderness is all that can be found. This statement is based on the result of several autopsies. In the female, the vagina as well as the rectum may be resorted to for purposes of examining the interior of the pelvis, and I have no doubt it enables the surgeon to make a more extensive investigation ; but I believe, in spite of this fact, that pelvic fractures can occur in the female and not be detected. The only case of fractured pelvis that I have seen in a woman is the one already described ; and, since it was unnecessary to resort to vaginal examination in this in stance, I cannot discuss the value of this means of diagnosis from a stand-point of experience. In cases where pressure over a portion of the pelvis elicits intense, circumscribed ten derness, I think it judicious to make a provisional diagnosis of contusion, but at the same time to resort to all the precau tions necessary for the treatment of fracture. I have seen cases of fractured pubis dealt with in this manner show signs of undue mobility and crepitus several days after admission. The ways in which the signs of fracture may be sought after, and injury to the urinary tract determined, are too well known to require description.

The prognosis in all cases should be guarded ; in some instances the grave complications preclude recovery from the beginning. The cases reported show a mortality of fifty per cent.; twenty-five cases recovered and two were improved. Many of these patients died from the injuries associated with the pelvic fracture.

Simple uncomplicated cases of fractured pubis require rest in the recumbent position, with pressure so exerted as to keep the fragments in apposition. Dennis, in his "System of Surgery" (Vol. i, p. 571), advises the use of Liston's long splints. I have no doubt that good results can be obtained by this means, but at the same time am more in favor of long sand-bags. The latter can be adjusted to the form of the patient's body, require no displaceable padding, and are kept in position by their own weight. Broad pieces of muslin passed around the patient's body and sand-bags will aid in keeping the injured part at rest. If the pubic fracture be com plicated with laceration of the urethra, a catheter should be tied in this canal for several days. J. William White, in any condition which requires the introduction of a sound or cathe ter, first injects the urethra full of sterile olive oil. In cases of injury to the urethra, the oil, when injected, will distend the mucous lining, press torn tissue into place, and lubricate every portion of the canal. Should the catheter be inserted in the ordinary manner, the greater portion of the lubricant is wiped off the instrument by the external meatus. A soft rubber catheter should be tried first, and, should it fail to reach the bladder, success may be attained by the use of a silver instru ment. Care should then be taken to keep its point pressed rather firmly against the urethral floor while it passes under the sym physis, as the urethral roof is often the only part torn. This operation should be done under the most minute aseptic pre cautions, and the instrument should be kept in for several days by tapes and adhesive straps. This will keep torn pieces of mucous membrane pressed into place, obviate retention of urine, and minimize the likelihood of subsequent stricture. It is needless to emphasize the folly of using force in catheter ization. Should it be impossible to introduce the catheter, an external urethrotomy should be performed.

If the bladder is ruptured into the peritoneal cavity, a laparotomy should be done immediately and the rent sutured. If the rupture is extraperitoneal, the bladder should be con stantly drained, urinary antiseptics, such as salol and boric acid, administered, and early free incisions made to relieve extravasation. Some cases, especially those in which other portions of the body are injured, will be attended with so much shock as to absolutely contraindicate all operative pro cedures.

In some cases of fractured ilium the fragments remain in apposition themselves, in others reduction cannot be main tained. Should the broken fragment become united in its abnormal position, loss of function or apparent deformity rarely result. Unless a fragment of the ilium has a tendency to be displaced outward, which is unusual, broad bands of adhesive 'plaster or muslin should not be drawn around the pelvis.

In Hamilton's "Treatise on Fractures and Dislocations," edited by Stephen Smith (p. 340), the following statement is made regarding the treatment of fractures of the ischium : "The posture best suited to these cases will be indicated usually by the sensations of the patient himself." In some of these cases it is impossible to prevent the fragment from be coming united in an abnormal position, but the patient usually escapes deformity and loss of function.

If the head of the femur be driven into the pelvic cavity, death is the usual result. The diagnosis in the case which I report was made at autopsy. Should the upper portion of the acetabular rim be broken off, the head of the femur should be restored to its cavity and extension applied.

It is difficult to prevent forward displacement of the lower end of the sacrum when this bone is broken. It is desirable, for obvious reasons, to avoid inserting packing or cannulas into the rectum to prevent this displacement. Should I meet with such a I would try the effect of Malgaigne's hooks, or a modification thereof, applied to the back of the sacrum. Frac ture of the coccyx usually only requires rest for its treatment. Should coccygodynia be a result of this injury, excision is demanded.

A NEW KNOT TIGHTENER.

Among the objections urged by the opponents of the vaginal route in operating, one of the weightiest is the diffi culty of controlling haemorrhage by means of ligatures per vaginam. They claim that in most cases it is difficult, and in many impossible. It is beyond controversy that the field of operation in vaginal surgery is both narrow and deep. It is often impossible to hold both ends of the ligature with clinched hands in order to tighten it, as we do in an open field. The usual method adopted by operators to overcome this in convenience of the narrow vaginal field consists in the fol lowing: Both ends of the ligature are grasped some distance from the knot ; the index-fingers, being extended, are pushed in the angle formed by the knot, so that the points of the fingers rest close to the knot ; the balls of both hands are brought together, and now, in order to tighten the knot, the apices of both index-fingers are separated (as shown in Fig. 1).

The more frequent disagreeable consequences of this pro cedure consist in secondary hemorrhage as the result of in sufficient tightening of the ligature, in frequent breaking of the thread, in incised wounds to the forefingers of the operator, due to the tension which has to be employed. These difficulties naturally occur oftener to operators who prefer the vaginal route on account of its many advantages, even in cases where larger fibromas or ovarian cysts are to be removed.

In contradistinction, the views expressed by my former chief, Professor Schauta, of Vienna, an expert in all questions of vaginal surgery, are, that since he has adopted the knot tightener suggested by me (Centralblatt fiir Gyniikologie, 1898, No. 4), he meets with no difficulty in controlling hwmor The favorable notice given this instrument by Pro fessor Schauta, and latterly by Professor Macnaughton Jones, of London, besides my personal experience with it, has in duced me to call the attention of my American colleagues to it.

The main difference between my instrument and other knot-tiers and knot-tighteners so far presented to the pro fession is in the fact that it automatically holds securely both ends of the ligature, and in all other respects imitates exactly the mechanism employed by the hands in tightening a knot (as illustrated in Fig. ).

It consists of two levers (B and attached by means of the hinge, A, in about the middle of their length, resembling a glove stretcher. The flat spring, C, attached to the lower end of one of the handles and pressing against the other, keeps the points of the levers in closed apposition. On the top of each lever is a groove (D and to admit both ends of the ligature. Below the hinge, A, and between the handles the mechanism which automatically holds fast the two threads is placed. It consists of two small blocks (F and which are movable around their axes (E and The portions approximating each other are made eccentric in shape. These are pressed close together by means of a small spring placed below the small blocks (not to be seen in the cut). On account of the diam eters of these eccentric blocks in creasing in the downward direction, it is only possible to turn them around their axes in the same downward direction. An upward motion causes them to lock each other tightly. This mechanism produces the result that a thread placed between these eccentric blocks can be easily pulled downward, due to the ability of the blocks to turn in a downward direction. But should tension be applied to the thread in a reversed direction, their eccentric shape causes them to im mediately approach and lock each other. By this means the thread is automatically held fast. It is impossible to pull the thread upward when placed between these blocks. Should, however, these results not be obtained, it is an indication of faulty workmanship in the construction of the instrument. The two axes (E and are mounted in a small plate, hinged in the middle and joined to both handles by means of the levers G and The following is a description of the rationale of this instrument and the necessary instructions for using it.

By means of a long aneurism-needle we pass the thread around the blood-vessel or through the ligament, being guided by the eye in passing same. We tie a surgical knot and tighten it as high up as we can by means of the fingers. In order to complete the tightening of the ligature, we now make use of the instrument. The handle is grasped with the right hand, the two ends of the ligature with the left. We introduce the tips of the instrument between the two ligatures, so that each end is contained in either groove (D and Both ends of the ligature are now pressed between the two eccentric blocks as seen in Fig. 2. We begin to press the handles of the instrument together, which produces the following result. The tops of the levers begin to separate, causing the thread to become tense, and at the same time exert an upward pull on the parts of the thread, situated between the grooves and the fixation blocks, forcing them to come together. This fixes the ligature. Continued pressure on the handles increases the tension of the ligature, and, as the tops separate the more, slack of ligature is taken up, thus tightening the knot. The pull on the knot is directed in the most favorable direction, namely, at the tangent, as is done with the forefingers, as shown in Fig. T. As the handles approach each other, the whole fixation mechanism moves in toto downward, and thus stretches the threads. This is a considerable advantage. A wet silk ligature is very elastic. The force applied does not produce its effects on the knot before the limit of the ligature's elasticity is reached. By means of this downward movement of the whole fixation mechanism, the elastic thread is somewhat stretched without causing any surplus separation of the lever tops, a point to be taken into consideration on account of the narrowness of the field of operation. The ability of the mechanism to allow a thread to pass downward, but not upward, adds the following great advantages. Should ex treme narrowness exist to such an extent as to only permit the separating of the lever ends to a small degree, or if we deem that the complete pressure of the handles is not sufficient to attain a complete tightening of the knot, we can very easily readjust the threads in the instrument. By removing the press ure of the hands on the handles, the spring, C, brings the lever ends together. The thus loosened threads we can stretch by simply pulling them through the eccentric blocks down ward. After this is accomplished, we can immediately further tighten the knot by again pressing the handles. This procedure can be repeated as often as is required.

Practice with this instrument teaches one to judge when the maximum amount of tightening is reached. The feel imparts this fact. A very simple way for one to keep himself informed as to the force employed while tightening the liga ture, is to make use of a finger of the left hand in feeling that part of the thread situated between the grooves at the top and the fixation blocks. When we find that we have reached the limit, we release the pressure on the handles and remove the threads by pulling them from between the fixation blocks in a downward and outward direction. The second turn of the knot we tighten simply by means of the fingers ; but we can do so readily with the instrument should the occasion demand it.

If we overlook the moment when extreme tightening is reached, the thread naturally breaks. Usually this occurs where it was held between the eccentric blocks, and if such be the the ends are long enough to take the second turn in completing the knot.

This instrument was devised especially for silk ligatures, and is not practicable when catgut is used, since the fixation blocks destroy the integrity of such soft material. It is neces sary for ligatures to be at least from seventeen to eighteen inches long in order to make use of this instrument, and there fore it can hardly be employed if silkworm-gut ligatures are used.

In conclusion, I would add that this knot-tightener is used by the operator without the help of an assistant; it is simple to handle, and insures the certainty of tightening a ligature to its maximum tensity even in very unapproachable places. It thus gives security against secondary hmmorrhage in vaginal sur gery, and also it proves useful in abdominal work when we are called upon to tighten a ligature deep down in the pelvis.

fracture, neck, patient, femur, head, knot and instrument