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pal trunk of the nutrient artery ; and, furthermore, that when a multiple fracture is present, the one which is nearest to the nutrient foramen will be the first to unite; or, in other words, the lower fracture, under these conditions, seems to appropriate to itself whatever reparative material is brought to the injured bone through this channel, leaving the upper purchase stendra fracture mainly dependent upon the small vessels which have first ramified in stendra tablets the periosteum before cnterint; the bone. i7«A.— Temperature 101-4°. 26th. — Temperature normal since last report. Pressings changed to day for the first time (eleven days). No pus; wonnd healed ; tube removed and new dressing applied. March 15th. — Dressing removed ; uniou of fractures not firm ; phi-stor splint applied. Subsequent llUtonj. — The lower fracture united with slight deformity, owing to the iiiipcssihility of keeping the lower end of the middle piece in position, in about the usual time ; but the union of the upper fracture was delayed for many weeks. stendra price Patient discharged July 2r>lh (five months after the wiring), able to support the weight of the body on the limb. Notember ■30th. — Union not absolutely ]>erfect, but patient I able to walk well by the aid of a cane. 478 WRIGHT: TREATMENT OF FRACTURES OF THE LEO AND PATELLA. [N. Y. Med. Joctb., Cask III. — Thomas Rafferty, Irish, laborer, aged forty-tliree, healthy. July 21, ISSJf. — To-day, while working io a quarry, a heavy stone fell from a derrick, striking an iron bar which he held in bis hand, and driving it, with great force, against his right leg. On examination, I found a small incised wound at the junction of tlje lower and middle third, on the inside of the leg, wljich communicated with a fracture of the tibia, and also with a large bieroatoma extending from the wound to below the internal malleolus. The patient bad lost much blood and was still bleed- ing freely. Under irrigation, an incision was made, beginning two inches above the wound and curving downward to include it and the hfematoma, four or live inches in length. The fracture of the tibia was found to be oblique from above downward, forward, and inward, with some comminution of the bone ; one fragment, one inch and a half in length, and sev- eral smaller ones were removed. The internal malleolus was denuded, bruised, and roughened; the sheath of the tibialis- posticus muscle was opened and the muscle itself badly torn ; the connective tissue was lacerated and extensively infiltrated with blood; the fibula was fractured higher up, but not com- pounded. The wound was cleansed, the haemorrhage controlled, the fragments drilled and wired with heavy copper wire coated . with silver, avanafil de 100 mg and the limb dressed like the others. August 2d. — Highest temperature since the operation generic avanafil 100'8°. 11th. — First dressing to-day (twenty days). Wound healthy and healing, with the purchase stendra online exception of a small dry slough at the center of old baematoma. 30th. — Redressed. Slough separated and wound nearly healed. September 6th. — Wound healed and plaster splint applied. 2Jfth. — Plaster splint removed; found twisted portion of w^ire protruding through a small ulceration of the skin ; wire cut and removed ; union not firm ; percussed the bone above and below the seat of fracture with small rubber mallet. This was followed by stendra cost a mild attack of simple cutaneous erysipelas, lasting two cheap stendra avanafil de 200 mg weeks, at the end of which time the union was found to be firm and bony. Patient discharged, order stendra March 29tb (eight months from the date of the injury), with good union of the fracture, but with some stiffness of the ankle joint, due chiefly to his great timidity in using the limb. Case IV. — Henry Hall, American, wall-paper maker, aged forty-six ; healthy. February 22., 1885. — Fell in the street to-day while intoxi- cated and sustained a compound fracture of both stendra online bones of left leg, about three inches above the buy stendra online ankle joint. The fracture of the tibia was very oblique from above downward and inward, the fractured surfaces being four inches long and the ends of the where to buy avanafil/extendra fragments very sharp. Two small wounds of the skin, caused by puncture of the upper fragment, were found on the inner side of the ankle just above the malleolus. Under irriga- tion, an incision, five inches in length, was made to expose the fracture. There was much overriding of the fragments, and generic stendra groat diftlcnity in effecting reduction, even with the patient pro- foundly under the influence of ether, and it was impossible to maintain apposition except by powerful extension atid counter- extension. A bleeding vessel of some size, probably the inter- nal iiialleolnr, was ligated. The fragments were then drilled and wired in two places with heavy silver wire. Dressing and afler-lrcatinent like the others. Marrh 10th (twenty-two days). — First dressing; wound nearly healed ; highest tempenituro since the <)|)eratiiiii IdO-l". Applied pla.stcr splint with fenestra opposite wound. April Int. — Wound healed ; union pretty firm. Discharged July 10, 188.5 (twenty weeks), with good union ; good position of foot; good motion in ankle joint and with no perceptible shortening buy stendra of the limb. Case V. — Leopold Marks, German, tinsmith, aged forty- three; healthy. July 10, 1885. — A cheap avanafil heavy slab of marble fell on his left leg to-day, producing a compound and comminuted fracture at the junction of the lower and middle third. 11th. — Under avanafil online irrigation, an incision four inches long over avanafil cost the crest of the avanafil 50 mg tibia showed the fracture to consist of five frag-

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