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occurs, the working hours are gradually lengthened and the type of work made more energetic.

Lesions of the wrist and finger joints are given this form of exercise treatment in the bookbindery or in the clay modelling department, or in the school for typewriting. The patient suffering with injury to the knee or to the ankle is placed at the

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Fig. 63.—Roentgenogram of shrapnel bullet in the knee joint. The anteroposterior view showed the bullet directly in line with the tuberosity of the tibia. There was no indication for operative removal, since the function of the joint was in no way disturbed.

turning lathe in the mechanic's shop or at the sewing machine in the tailoring department. Some appropriate work can be found for almost every type of injury.

In addition, careful massage of the extremity combined with warm baths and baking, helps restore the strength of the muscles and may add somewhat to the mobility of the affected joint.

The athletic field and the farm are also of great assistance. Great care must, however, be employed in adapting the exercise to the particular requirements of the patient, since much harm can be done by injudicious treatment.

The Zander machines and other pendulum devices frequently used in mechano-therapeutic institutions, do not, in my opinion, accomplish their purpose, and are for the patient as well as the physician a most irksome mental and physical strain.

Ankylosis.-When ankylosis has occurred, and no improvement whatever is noted by the means already suggested, the question of operative interference confronts the surgeon. In deciding for or against operation, the following factors play an

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Fig. 64.—Infantry bullet lodged between the articular processes of the eighth and ninth dorsal vertebræ. The severe pain produced by the bullet was completely relieved by extracting it.

important rôle: (1) Has the joint been immobilized in such a position as to give the patient a useful limb? (2) What is

? the social condition of the patient? Thus, for a professional flute-player who must take his seat daily in the orchestra, the criteria are altogether different than in the case of the blacksmith who must have an absolutely firm limb to stand on. (3) Which joint is involved? Thus in the case of the knee, it would be distinctly advantageous for the flute-player to have an arthroplasty performed, whereas for the blacksmith the operation would be contraindicated.

In deciding upon the type of operation, the surgeon should be guided by a consideration of these three factors. If the position of the joint is unsatisfactory and if, at the same time, there is no indication for mobilizing it, a juxta-articular osteotomy should be performed to correct the position of the limb. Thus, for flexion of the knee, the supra-condylar osteotomy can be used to secure extension; or, if the ankle be ankylosed

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Fig. 65.—Roentgenogram of elbow in which the shrapnel splinter had been lodged between humerus and ulna. Extraction under local anesthesia by posterior incision along the lateral margin of the olecranon process.

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Fig. 66.-Photograph illustrating the range of motion subsequent to extrac

tion of the shell splinter shown in Fig. 65.

in equinus, a wedge can be removed from the astragalus and the foot forced into the right-angled position.

If motion at the joint is necessary for the patient's happiness and efficiency, I strongly favor performing an arthroplasty, even in those cases where the joint destruction has been most extensive. The results are particularly good for the jaw, elbow, wrist, and hip (see Figs. 58, 59, 60, 61, and 62). In three or four cases in which I attempted the oper

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Fig. 67.—Roentgenogram of shrapnel bullet lodged in the calcanoastragaloid joint. The bullet caused no pain or limitation of motion but produced a chonic purulent discharge which was cured by its extraction.

ation at the knee and the ankle, the results gave a moderate degree of motion and the patients were able to walk with comfort, although a splint was in each case necessary to prevent undue strain upon the operated joint.

In the operative technic, I employ longitudinal incisions wherever feasible, free the bone ends with mallet and chisel, remodel them so as to reconstruct a joint which is mechanically as much like the normal anatomical structure as possible, and cover the articular surfaces either with a strip of fascia lata and fat transplanted from the patient's thigh, or, in certain instances, by a pedunculated flap taken from the neighborhood of the affected joint. Since my technic does not differ in any important principle from that advocated by

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Fig. 68.—The technic of a lateral roentgenogram of the left hip. (Method

of Lilienfeld.)

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Fig. 69.—Tracing of roentgenogram showing shell splinter lodged in the femur after traversing the quadriceps bursa. For technic of removal see

page 103.

Murphy, Payr, and others who have had extensive experience, I shall not go into detailed account of the operation.

In those instances where limitation of motion is due to a

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