attendant pulls the injured shoulder backward. If reposition is imperfect, more force may have to be applied by the assistant pressing his knee against the back of the patient while reposition is tried. Thus reposition is easy; but keeping the fragments well immobilized is a much more difficult matter. Many kinds of appliances have been devised for this purpose, most of them being intended to raise the shoulder and to bring it back and outward, so as to counteract the

displacing causes. These demands are well fulfilled by Velpeau's dressing, which is applied best by means of a long roller bandage. After a small pad is put into the axilla of the injured side, the arm is conducted over the anterior thoracic wall and the hand is placed upon the uninjured shoulder. It is evident that this elevation of the hand pushes the injured shoulder as far upward as possible, while the adductor of the arm pulls the acromial end outward. The bandage is carried obliquely from the sound axilla over the injured

shoulder down to the elbow, whence it runs up to the axilla again, and so forth.

Sayre's dressing (Fig. 22) is also much in favor. It demands three long, wide, adhesive plaster strips, the first one of them being attached to the inner surface of the upper arm of the injured side and passing around the anterior surface of the arm backward over the back to the chest wall. (Fig. 22 a.) This procedure, which rotates the upper arm outward, prevents the clavicle from riding upward and pushes the elbow portion of

Fig. 22. Sayre's dressing: a, First strip; b, second strip, front and back views.

the humerus (and thus the shoulder also) backward, upward, and outward by pressing the elbow forward, downward, and inward. The second strip fortifies the position of the first by fastening the arm and hand of the injured side to the chest wall. (Fig. 22 b.) The strip starts from the uninjured shoulder, and, passing over the antibrachium and elbow to the dorsum, returns to the starting-point on the shoulder again. Now the fragments must be accurately adjusted and the deformity will necessarily disappear. The third strip, therefore, serves as a kind of a mitella only. It

surrounds the carpus of the injured side, and runs to the back after having passed over the fractured area. It, however, elevates the hand somewhat and presses slightly upon the fragments.

The Sayre dressing, while most ingenious, does not afford so firm a support as the Velpeau bandage or the author's. Furthermore, it has the great disadvantage that the adhesive

plaster often creates such a dermatitis that in summer time it can not be tolerated. The results obtained by the author's dressing were just as good, without exposing the patients to any discomfort. Absolute firmness is warranted by employing a moss splint that immobilizes the shoulder as well as the elbow. (Fig. 23.)

Fig. 23-Moss splint, trimmed for author's dressing. (See Fig. 24 b.)

The first step consists in drawing the shoulders backward, while pressing the thorax (Fig. 24 a) or the knee against the patient's scapula. Then a moss splint, suitably trimmed for proper adaptation (Fig. 23), is applied to the shoulder. (Fig. 24 b.) The elbow portion is molded and folded in the same manner. If slightly dipped into lukewarm water, it will adapt itself well to the contour of the shoulder.

The axilla is filled out with a pad of borated gauze. The hand also rests on a thick layer of borated gauze at the anterior thoracic wall, the fingers reaching up to the sound clavicle.

Fig. 24.-a, Reposition of fracture of the clavicle by drawing the shoulders backward and pressing the surgeon's thorax against the patient's scapula. b, Molding the shoulder portion of the moss splint. c, Author's dressing for fracture of the clavicle (completed).

Now the sunken arm is elevated by passing a roller bandage under the elbow, over the clavicular area of the healthy side. Then the lower third of the humerus is tightly drawn to the thorax and transversely fixed by a turn of the bandage. Finally, the elbow is supported by another turn passing over the injured area. (Fig. 24 c.) In children this dressing should be protected by broad strips of rubber adhesive plaster.

The author's dressing can be used in all the different types of clavicular fracture, but has proved to be especially useful when simultaneous injuries of the integument exist. (Compare p. 66 on moss dressings.)

SCAPULA.

Fractures of the scapula are rare, comprising only about one per cent. of all fractures. They concern either its spine, body (Fig. 25), neck (Fig. 26), the acromion (also Fig. 25), or the coracoid process.

Fractures of the spine and the body of the scapula are either simple fissures or fractures without any displacement, and consequently heal under almost any treatment. The principal signs are ecchymosis, crepitus, and pain. A correct diagnosis is often only possible with the aid of the Röntgen rays.

The treatment consists in immobilizing the arm with a splint, which surrounds the shoulder and passes over the scapula to the spine.

Fracture of the neck of the scapula (Fig. 26) in itself is extremely rare. It occurs more frequently in connection with a fracture of the floor of the glenoid cavity. The severed glenoid cavity sinking downward and inward, the shoulder loses its convex shape and the arm appears longer, so that this injury