single bony spur projecting into the joint, excellent results are obtained by the operative removal of this abnormality.

Foreign bodies in or near the joint deserve special consideration, since they are of peculiar interest from the standpoint of operative indications, the technic of their localization, and the method of extraction. When a foreign body gives no symptoms whatever, there is no justification for its removal. Strange though it may seem, there is sometimes surprisingly

FIG. 70.-Photograph of the right leg of patient whose roentgenogram is shown in Fig. 69 two months after extraction of the shell splinter. The two exposures were made on the same photographic plate, so as to illustrate the range of flexion and extension.

little interference with the normal joint mechanism, even when a foreign body of considerable size lies directly in the joint. Fig. 63 shows a shrapnel bullet lodged in the knee-joint; the patient in question had no symptoms whatever referable to the injury, and was discharged to his regiment fit for service in the field.

The indications for removal are: (1) pain; (2) interference with function; (3) the presence of a persistent sinus. These three indications may in some instances all be present, but

any one of them necessitates removal of the foreign body. Fig. 64 shows an infantry bullet lodged between the transverse processes of the 8th and 9th dorsal vertebræ. The only symptom caused by the bullet was pain on motion of the spine. This was relieved entirely by removal of the bullet. In this instance there was little interference with the motion of the spine, but in Fig. 65 is an illustration of almost complete

ankylosis of the joint due to a fragment of shell lodged in the elbow. Under local anesthesia, working from a posterior incision, the joint was opened, the fragment removed, and almost the normal range of mobility restored to the joint (see Fig. 66). Fig. 67 illustrates a case in which there was neither pain not interference with motion although the shrapnel bullet was embedded in the calcaneo-astragaloid joint. The sole indication for removal was a purulent discharge which ceased with the extraction of the foreign body.

The technic of localization of these foreign bodies has been

discussed in such detail in treatises dealing with Roentgenology that I wish to emphasize only one detail which has been of much value to me. All the roentgenographic methods of determining the depth of the fragment help somewhat in localizing it exactly, yet they are, I find, of less practical value

FIG. 72. Roentgenogram of a shrapnel splinter lodged in the hip joint. Lateral view. For the technic of removal see page 104.

than accurate exposures of the joint in question made directly at right angles to one another. By this simple test, combined with careful study of the corresponding bony points, the position of the foreign body with reference to the bone can be more clearly grasped than by the statement that it lies so and and so many centimeters from the skin, measured from one point, and so and so many centimeters measured from another. For some joints it is difficult to secure the lateral exposure.

This applies particularly to the hip, yet I have been able to secure excellent results by the method illustrated in Fig. 68 as advocated by Lilienfeld.

In removing these foreign bodies, each case must be individualized, since it seldom happens that exactly the same

incision can be employed for two successive cases. The essential is to disturb the joint as little as possible by the traumatism of the operation. A few instances will illustrate some of the methods followed.

In Fig. 69 is shown a shell splinter embedded in the femur, at the level of the quadriceps bursa, which had been opened up by the bullet in its course. The operative incision was planned so as to leave the bursa (which is really a part of the

joint) intact; it was therefore made directly over the lateral aspect of the bone, which was then chiselled open, the bullet extracted, and the small bony canal packed. Fig. 70 shows the range of motion resulting.

In another instance, the projectile was lodged in the tibia. (see Fig. 71). The track of the bullet ran through the condyle of the femur downward through the outer angle of the joint into the tibia. As in the first case, the track of the bullet was

FIG. 74.-Tracing of roentgenogram of infantry projectile in the astragalus with the tip projecting through the ankle joint into the internal malleolus. For technic of extraction see page 105.

not followed, but through a small incision the tibia was chiselled open at the level of the projectile. Here the resulting motion was not as satisfactory as in the preceding case because of the extensive injury to the cartilaginous surfaces of the bone.

In the case of the hip, the incision depends entirely upon the position of the foreign body. In Fig. 72 is shown a shell fragment lodged near the lesser trochanter. Here the most advantageous incision was the anterior, running along the outer border of the sartorius, retracting the nerve, and the