arm, the projection is removed, but it immediately reappears upon giving up the extension, and the natural contour is lost." (pp. 277, 78.)

I am quite sure that I have twice seen this accident in boys of about twelve years old, which, on the whole, corresponded with the appearance of fig. 1, pl. iii., in COOPER'S Paper. In neither of my cases was there the projection at the coracoid process which he mentions, and which I imagine was caused only subsequently by the ossific matter thrown out during the cure, as seen in the figure. In both my cases, the fracture seem to be very oblique from without and above downwards and inwards; the head of the bone remained in the socket; but the great tubercle formed a blunt elevation nearly as high as the top of the acromion, and in one of the cases could not be brought down to its proper place, but united, forming a projection through the outer and upper part of the deltoid muscle.

I have already mentioned, that the accident commonly heretofore spoken of as fraeture of the neck of the scapula, and to which the characters described have been assigned, has been ascertained not to be a fracture of that bone, but of the upper-armbone. It was first determined by ASTLEY COOPER, who calls it a fracture in the surgical neck, (of the upper-arm-bone,) viz., between the tubercles and the insertion of the pectoralis major, coraco-brachialis, latissimus dorsi, teres major, and the deltoides muscles." (p. 281.) He has not, however, given any description of it, but, as would appear from the engravings, (pl. vi.) the broken inner part had slipped down and be. come attached to the inside of the shaft of the bone, so that the head facing directly inwards instead of upwards, has its upper part rather below the top of the great tubercle. The patient was a man of seventy-one years of age, and having lived two years after the accident, the union was complete.

I have also a case of this kind, in which the patient, about sixty years of age at the time of the accident, died twenty years after. His symptoms were precisely those de scribed as fractured neck of the blade-bone. The fracture has extended obliquely downwards and backwards between the front of the great tubercle and the outer edge of the bicipital groove for about three inches downwards and inwards, taking off the head and greater tubercle, which have together slipped down, back, and a little outwards, so that the broken front edge of the neck seems thrust into the shaft on the inside of the little tubercle, although really only lying tilted a little into it. The head of the bone, in consequence, faces directly inwards, instead of as naturally, inwards and upwards, and its top is about the eighth of an inch below the top of the tubercle. The oblique or broken piece of the shaft is seen resting upon the back of the shaft itself, the wall of which is thinned. It seems to me that there is not much difference between COOPER's case, just mentioned, and this, and that which he describes as very frequent in children.-J. F. S.]

646. The setting of this fracture is effected by an assistant, with both his hands fixing the patient's shoulder, whilst another holds the fore-arm, with one hand above the wrist-joint, and presses with the other on the fore-arm. The arm is now to be swathed in a moist roller, a few turns made round the sound shoulder, and the bandage given to an assistant to hold. A narrow splint is then to be applied, from the bend of the elbow to the acromion; a second from the outer condyle to the same height; a third from the olechranon to the edge of the arm-pit; and a fourth from the inner condyle to the arm-pit, and these are to be fastened with some descending turns of the bandage. A pad is to be placed between the arm and the chest, as in fractured collar-bone, with the thick end upwards, upon which the arm is to be fixed with the spiral bandage, which should be carried round the chest; some turns of the bandage are to be taken beneath the elbow over the sound shoulder, for the purpose of supporting the arm, and the fore-arm must be put in a sling. This apparatus must be often renewed, because it very easily becomes displaced; it presses much on the chest, and in women with full bosom cannot be employed. For these reasons, and because we can scarcely act upon the upper end of the fracture, RICHERAND (a) thinks it best to place the injured arm against the body, and so to bend the fore-arm that the hand may lie upon (a) Above cited, p. 143.

the shoulder of the sound side; the arm is then to be kept in this position by circular turns, which are to act especially on the elbow. By this position the lower end of the fracture is approached to the upper, and the side of the chest serves as a splint. The symptoms of bruising and inflammation, must be properly attended to.

[There is not the least necessity for the constrained position which RICHERAND recommends: the method directed by CHELIUS is most convenient, most agreeable to the patient, and serves every purpose.-J. F. S.]

647. Fracture of the body of the Arm-bone is distinguished as occurring above the insertion of the m. deltoides, in the middle of the arm, or at its lower end. In the first case, the upper end of the fracture always inclines inwards, and the lower outwards; in the second, the upper end inclines outwards, and the lower inwards, and if the fracture be oblique, also upwards; in the third instance, if the fracture occur where the bone is surrounded by the m. triceps and brachialis, without these muscles being attached to it, displacement may happen in every direction; but in fracture near the joint, it can be only forwards or backwards. The diagnosis of the fracture is generally easy. Fracture at the lower end of the armbone is alone liable to be mistaken for dislocation of the elbow. The olechranon is drawn upwards and backwards by the action of the m. triceps, is raised from half an inch to an inch and a half, and above it is a hollow; the upper end of the fracture projects forwards, forms a large uneven projection, the diameter of the arm near the elbow is much increased from before to behind; the fore-arm is slightly bent, its perfect bending or straightening is impossible, and every attempt thereto very painful. The Surgeon has however a guide in that, by extension the deformity, as in dislocation, readily subsides, but recurs when the extension is left off; by moving the ends of the fracture, crepitation is felt, (which, however, is often wanting,) and especially, that by pressure with the fingers replacement is possible; and the distance of the olechranon from the condyles of the arm-bone, which is natural in dislocation, is here as great again (a). This fracture is much more frequent in children than in adults.

648. In general, fracture of the upper-arm is not an important injury. But an unnatural joint remains after its fracture in the middle, more frequently than in all other fractures, and when at the lower end of the bone there is commonly stiffness at the elbow-joint.

649. The setting is to be performed in the same way as in fracture of the neck (par. 646.) Slight extension is sufficient to put the fracture into place. The fore-arm being then bent at an obtuse angle, both it and the upper-arm are to be swathed in a moistened roller, which is to make three successive turns on the seat of fracture; four narrow splints are then to be applied on the upper-arm, which are to be fixed with the descending turns of the same bandage. The fore-arm is then to be supported in a sling, over which some circular turns are to be made around the arm and chest, for the purpose of fixing the former as firmly as possible. If one or other end of the fracture be disposed to turn outwards or inwards, a pad, of which the thicker end is to be directed upwards or downwards, may be put between the arm and the trunk.

The fracture at the lower end of the upper-arm is to be treated in the same way, the arm put in a bent position, both it and the upper-arm swathed with a circular bandage, and two pasteboard splints, notched at their

(a) DUPUYTREN, Leçons Orales, vol. iii. p. 394.

middle on both sides, applied on the whole length of both upper- and forearm, and upon the sides of flexion and extension, and fastened with another bandage. The fore-arm should also be put in a sling. The apparatus must be re-applied as often as it gets displaced, and the patient treated according to the inflammatory symptoms. In forty days the consolidation is usually effected.

In all fractures of the upper extremities in which swathing with a circular bandage is used, it is always best to enrol each finger in a small bandage, and to commence the application of the larger one at the wrist; by which we prevent the turns above the hand being so readily loosened and stripped off.

In the permanent apparatus of SEUTIN, the five fingers should first be swathed, and afterwards the hand and fore-arm surrounded with a circular bandage, to be applied during the extension and counter extension also over the fore-arm. The bandages may be overspread with plaster of Paris, and the fore-arm kept half bent, between pronation and supination. A pair of pasteboard splints, an external and an internal one, should be cut out to fit, which, as they are applied throughout the whole length of the limb, should correspond to the angle at the elbow-joint, so as to exactly fit the bend of the fore-arm. They should be only so broad, that when applied there may be a finger's breadth between them before and behind, so that they may be capable of being brought nearer together. The splints, moistened and spread with plaster, may be applied, fastened with a new bandage, with which, if you please, a bandage may be formed beneath the opposite arm-pit, and a spica on the injured shoulder. The bandages are to be smeared with the plaster. If it be necessary to perform the motions of flexion and extension at the elbow-joint, the splint must be either divided into two parts at the elbow-joint, or it must be torn at the proper part, after it has been moistened with water, and the elbow-joint surrounded with a fresh bandage, covered with a thin layer of plaster, by which the part may attain its suitable firmness. In fracture of the lower part of the upper arm, I have always found the above-described apparatus sufficient. DUPUYTREN laid the arm on a pillow, applied on the front and back of the seat of fracture circularly two graduated compresses, three or four inches long and two inches broad, fastened with two long pads and SCULTETUS's bandage, and then applied below two chaff bags, and splints on the front and back, and fastened them with bandages.

If this fracture be not set it forms a misshapen callus, and the upper end continuing to project, the bending and straightening of the upper arm is considerably interfered with.

[Fracture through the middle of the upper-arm may be very well treated with a gum roller. Fracture of the lower third of the bone is best managed with AMESBURY's angular splint placed in front of the bend of the elbow.-J. F. S.]

650. A bad complication of the fracture at the lower end of the upperarm-bone is the separation of the condyles. They are either both separated by a vertical cleft which extends to the transverse fracture, or one or other condyle is separated by an oblique fracture. In the first case the deformity of the joint is distinct, the fore arm is generally in a state of pronation, and the mobility of both condyles and crepitation are perceptible; in the second, mobility and crepitation of one condyle only is felt. In fracture of the outer condyle the crepitation is felt, especially in rotation of the hand and spoke-bone; if the fractured piece be large it is drawn backwards, and the spoke-bone with it. In fracture of the inner condyle, the cubit is drawn back and its point of support lost; if the fore-arm be straightened the hand is drawn inwards, but this disappears on bending the fore-arm. In these cases there is always considerable swelling, which renders the diagnosis very difficult. If the fracture be set and the condyle put in its proper place, the apparatus must be applied as already described, and displacement prevented by four splints, which must be arranged to prevent bending of the elbow-joint. The inflammation is always very considerable, and after cure the motions of the joint are much interfered with

or completely destroyed. According to ASTLEY COOPER these fractures unite merely by ligamentous inter-substance except when the fracture is external to the capsular ligament.

[The splitting of the lower end of the upper-arm-bone into the joint is certainly the worst kind of fracture of this bone; but the higher it splits up, of the less consequence is it, as there is then ample room for its bony union external to the capsule.

Fracture of the condyles, especially of the inner, is a very common accident in children, and, if not seen immediately after its occurrence, is difficult, to distinguish on account of the very great effusion which speedily occurs. If it cannot, therefore, be easily discovered, it is best to apply an evaporating lotion for a few days, and then examine it. No bandage should be put on till the swelling has subsided, for at first it cannot be worn on account of the pain from the pressure, and afterwards if applied whilst the swelling is subsiding, it is continually loosening and needing repeated reapplications. The best mode of treating it is, to bend the fore-arm whilst supine, which relaxes all the muscles attached to the condyle; and then having applied a piece of wetted pasteboard, notched on each side at the bend of the joint, both before and behind the upper- and fore-arm, to wind a roller around it. A very important part of the treatment consists in employing gentle passive flexion and extension of the fore-arm about a fortnight after the accident, and gradually increasing it from day to day, otherwise the ligamentous matter thrown out often restricts the movements of the joint.

Fracture of the outer condyle is less frequent but is to be treated in the same manner. —J. F. S.]

651. In Compound Fractures of the upper-arm the limb is to be placed in a slightly bent position upon a pillow, the arm bandaged to suit the wound with SCULTETUS's bandage, and the splints fastened with a double bandage. The rest of the treatment is to be according to the ordinary rules. SAUTER has proposed his suspensory apparatus for compound fractures of the upper-arm.

[In treating compound fracture of the upper-arm care should be taken that the splints, if applied immediately, should not be bound tightly. I think it is best, merely to bandage the arm to a single well-padded splint, upon which it may lie till the wound be healed, or at any rate till all inflammation has subsided. If the wound be considerable and the patient restless, it is advisable to put on, as a second, ABERNETHY's bracket-splint, by which the ends of the bone are kept quite quiet, and the wound can be daily tended without disturbing the apparatus. When the wound is perfectly healed, the case is to be treated merely as a simple fracture.-J. F. S.]

XIII.-OF FRACTURE OF THE BONES OF THE FORE-ARM.

652. Of these are distinguished fractures of the spoke bone alone or of the cubit alone, fracture of both bones together, and fracture of the olechranon.

653. Fracture of the Spoke-bone alone (Fractura Radii, Lat.; Bruch der Speiche, Germ.; Fracture du Radius, Fr.) is more frequent than that of the cubit and mostly consequent to a fall on the hand, when the arm is outstretched, in which case it usually happens in the middle of the bone; more rarely it is produced by direct violence. The diagnosis is not dificult; the seat of fracture is felt, and during pronation and supination, crepitation also. The fractured ends turn towards the cubit. Only when the fracture is near the lower end of the bone is the diagnosis difficult, and its confounding with sprain so much the more possible, as frequently at the first there is scarcely any or no distortion of the hand, nor is its motion interfered with. The following appearances arise from the displacement of the fractured ends: the hand is more perfectly prone than if it were dislocated to the dorsal or radial side; the lower end of the forearm is narrower, less flat, more rounded; there is a bending inwards of

the fore-arm, half an inch or an inch above the wrist on the radial side, which extends to the dorsal surface of the spoke-bone; the head of the cubit makes a considerable projection and the wrist-bones are more inclined to the ulnar side; the carpus seems to project somewhat on the dorsal surface of the spoke-bone, and, therefore, the back of the joint is generally rather swollen. On the palmar surface of the fore-arm, corresponding to the concavity of the spoke-bone, there is a very full, elastic swelling, often accompanied with extraordinary tension of the flexor tendons. In consequence of the depression on the edge of the spoke-bone and the projection of the head of the cubit, the whole radial side projects more at the carpus and thumb, i. e. the hand is inclined to the radial side and its length inclines much outwards from the fore-arm. The hand is movable at the joint and both styloid processes are in natural relation to the carpus. The patient has less pain at the joint, than at the lower end of the spokebone, at the depression on the radial side, and in the swelling on the palmar side, on the head of the cubit, and in the capsular ligaments, beneath it; the pain is increased by pressure. On both surfaces of the lower end of the spoke-bone may be easily felt the irregularities arising from displacement of the fractured ends, and which consist in a transverse, often oblique projection of the upper end of the fracture, three or four lines above the wrist-joint, and in a less distinct projection of the upper part of the lower fractured portion on the dorsal side, eight or ten lines above the joint. Frequently, if the fracture be somewhat higher, both ends may form an obtuse angle towards the palmar surface, in which case the depression on the dorsal surface is greater. Motion and crepitation are not always felt. JÆGER found the upper fractured end firmly resting on the cubit. Pronation and supination, bending and violent straightening of the hand, are very painful and restricted. In pronation, the rotation of the head of the spoke-bone is wanting, the fingers are usually half bent; the deformity is generally diminished by extension, but soon returns. The inflammatory swelling often spreads considerably. If the fracture be not, or if it be only imperfectly set and improperly treated, the deformity and incapability of perfectly bending the hand remain. This fracture is distinguished from dislocation by the natural position of the styloid process which has not lost its connexion with the carpus, which is movable and has its long axis separated only a little from the spoke-bone (JÆGER (a).) The upper end of the fracture is somewhat displaced towards the side of extension or flexion; but the fingers can be moved freely, and when the hand bends the joint ends of the spoke-bone follow the movement of the wristbones, by which this fracture is distinguished from dislocation (b).

The fracture of the lower end of the spoke-bone is extremely well explained by the observations of DUPUYTREN (c), and the opinion put forward by him and by BRODIE, that it is mostly confounded with sprains and dislocations is confirmed by the more recent observations of Surgeons.

[Fracture through the neck of the spoke-bone is not an uncommon accident, and very liable to be confused with dislocation of the bone forwards on the outer condyle of the upper-arm. It is accompanied with much distortion and swelling, and being naturally deeply embedded in the muscles, is difficult to make out satisfactorily. The head of the bone must be grasped with the thumb and finger of one hand, whilst the other draws the lower end of the bone from it by pulling at the hand alone, and then upon rotation if there be fracture the crepitation will be felt.

(a) Above cited, vol. iii. p. 275. l'extrémité inferieure du Radius. Paris, 1836; and (b) GOYBAND, Mémoire sur la Fracture de in Journal Hebdom., 1836, Feb. (c) Above cited, vol. iv. p. 161.