effects from excess of callus are liable to ensue. An attempt
should first be made, under anaesthesia, to replace the head in its
socket, by making extension on the arm in the hyper-abducted
(vertical) position, and manipulating the upper fragment from the
axilla.

On no account should the lower fragment be employed as a lever in
attempting reduction. When reduction by manipulation fails, recourse
should be had to an open operation. The upper fragment should be
exposed by an incision over its lateral aspect, and made to return to
the socket by using Arbuthnot Lane's levers or M'Burney's hook, or a
long steel pin may be inserted into the fragment to give the necessary
leverage.

Reduction having been accomplished, the fracture is adjusted in the
usual way, advantage being taken of the open wound, if necessary, to
fix the fragments together by plates. The best position in which to
fix the limb is that of abduction at a right angle. Massage and
movement should be commenced early to prevent stiffness of the joint.

When it is found impossible to reduce the dislocation, it is usually
advisable to remove the upper fragment.

The method of allowing the fracture to unite without reducing the
dislocation, and then attempting reduction, usually results in
re-breaking the bone, or else in failure to replace the head in the
socket, and has nothing to recommend it.

#Old-standing Dislocation of the Shoulder.#--It is impossible to lay
down definite rules as to the date after which it is inadvisable to
attempt reduction by manipulation of an old-standing dislocation of
the shoulder. Experience of a hundred cases in Bruns' clinic led
Finckh to conclude that, provided there are no complications,
reduction can generally be effected within four weeks of the accident;
that within nine weeks the prospect of success is fairly good; but
that beyond that time reduction is exceptional.

The patient is anaesthetised, and all adhesions broken down by free yet
gentle movement of the limb. The appropriate manipulations for the
particular dislocation are then carried out, care being taken that no
undue force is employed, as the humerus is liable to be broken. If
these are not successful, they should be repeated at intervals of two
or three days, as it is frequently found that reduction is
successfully effected on a second or third attempt.

Should manipulative measures fail, it may be advisable to have
recourse to operation if the age of th