1. Bond's Splint in Colles's Fracture; 2, Two Straight Splints in Fracture of both Bones of the Forearm; 3, Anterior Angular Splint in Fractures in or near the Elbow-joint; 4, Internal Angular Splint and Shoulder-cap in Fracture of the Surgical Neck of the Humerus; 5, Internal Angular Splint in Fracture of the Shaft of the Humerus; 6, Fracture-box in Fractures of the Bones of the Leg

direct force, the impaired movements, the slight deformity, and the absence of crepitus. In all fractures of the upper end of the humerus the distinction can be made from dislocation by feeling the head of the bone under the acromion and by noting that it does not move on rotating the arm. The prognosis of these fractures is good.

Treatment.—In treating a case of fracture of the surgical neck, take an internal angular splint (Pl. 7, Fig. 6) and pad it well, putting on extra padding at the points that are to rest against the palm, the inner condyle, and the axillary folds. Lay the arm and pronated forearm upon the splint. Apply a padded shoulder-cap. Fix the splint and cap in place with a spiral reverse bandage terminating as a spica of the shoulder, and hang the hand or forearm in a sling (Pl. 8, Fig. 4). The dressing is to be worn for five weeks, and the rules to be followed in changing it are the same as in fractures of the anatomical neck. Motions are to be made after four weeks to keep the shoulder from stiffening. Another plan of treatment is the same as for fracture of the anatomical neck, supporting the hand only in a sling, so as to get the extending weight of the elbow, increasing this weight in some cases by hanging to the elbow a bag of shot. In rare cases those with strong anterior projection of the upper end of the lower fragment-apply an anterior angular splint (Brinton).

Longitudinal and Oblique Fracture of the Head of the Humerus. By this term may be designated separation of the great tuberosity, or separation of a portion of the aṛticular surface, together with the great tuberosity, from the shaft and lesser tuberosity (Pickering Pick, Guthrie, and Ogston). The cause is direct violence to the front of the shoulder.

Symptoms.-The symptoms in longitudinal and oblique fracture of the head are broadening and flattening of the shoulder with projection of the acromion. The upper frag

ment passes up and out, and the lower fragment passes up and in to rest on the margin of the glenoid cavity below the coracoid. The elbow is drawn from the side, there is some shortening, and the patient cannot abduct his arm. If the elbow be grasped and held to the side and the arm be rotated while the other hand grasps the upper fragment, crepitus is very positive. Examination develops wide separation of the fragments. The deformity cannot be entirely corrected, because the biceps tendon gets between the fragments (Ogston), but a useful limb can usually be obtained.

Treatment. The plan which gives the best result in treating longitudinal and oblique fracture of the head is to place the patient on his back upon a hard bed with a small firm pillow under his head, and to abduct the arm above the head, rotate it outward so that the back of the hand rests on the bed, and hold it in place by sand-bags. This position should be maintained for three weeks, at the end of which period the fracture can be dressed for three weeks more as a fracture of the anatomical neck. If the patient refuses to go to bed, treat the injury as a fracture of the anatomical neck, padding well over the tuberosities. The dressings should be worn for six weeks, passive motion being made after four weeks. In all the above injuries-in fact, in all fractures of the humerus-feel at once for the pulse, to see if the artery has been torn.

Separation of the Upper Epiphysis.-The epiphysis is united during the twentieth year, its separation being a rare accident and being produced by direct force.

Symptoms.-The chief symptom in separation of the upper epiphysis is projection of the upper end of the lower fragment inward, forward, and upward beneath the coracoid, and consequently a projection of the elbow backward and from the side. If only the lower fragment passes forward, the

elbow simply passes back. The upper end of the lower fragment is smooth and convex. Rotation of the shaft develops

soft crepitus.

The prognosis is good for bony union, though the future growth of the limb may be impaired.

Treatment. The treatment for separation of the upper epiphysis is a pad in the axilla, a shoulder-cap, binding the arm to the side, and hanging the hand in a sling.

2. Fracture of the Shaft of the Humerus.-Fracture of the shaft of the humerus is a very common accident. The cause is usually direct violence, such as a blow. The fracture may arise from indirect violence, such as a fall upon the elbow. Muscular action is not rarely also a cause, as in throwing a ball, in catching a tree-limb while falling, or in turning another's wrist as a test of strength (Treves).

Symptoms. The symptoms of a fractured shaft are pain, swelling, ecchymosis, inability to move the arm, mobility, and distinct crepitus. Shortening to the extent of three-fourths of an inch occurs. The displacement varies with the situation of the fracture and the direction of the force. If the fracture is above the insertion of the deltoid, the lower fragment is pulled up by the triceps, biceps, and deltoid, and pulled out by the deltoid, and the upper fragment is pulled inward by the arm-pit muscles. In fracture below the deltoid this muscle is apt to pull the lower end of the upper fragment outward, while the lower fragment passes inward and upward because of the action of the biceps and triceps.

The prognosis is good, but the fact should always be remembered that ununited fractures are commoner in the humerus than in any other bone. Treves believes this to be due to entanglement of muscle between the fragments, lack of fixation of the shoulder-joint, and imperfect elbowsupport. Hamilton believes that it is due to the facts that the elbow soon becomes fixed at a right angle, and that any