his own chest, holding it firmly there with one hand, while the other, grasping the patient's arm just above the wrist, extends the forearm.

To secure pro- and supination, the operator grasps the patient's hand and locks the third and fourth fingers on either side of the lower end of the radius and of the ulna. Rotary movement of the surgeon's hand produces a rotation of the radius about the elbow.

At the wrist, one frequently finds a flexion deformity due to adhesions. The operator grasps the patient's arm just above the styloid process of the radius and brings the ball of the thumb of the opposite hand against the carpal bones. The pressure of the two hands toward one another forces the carpus and metacarpus into the extended position.

FIG. 59. Arthroplasty of the elbow subsequent to ankylosis due to gunTwo photographs on one plate illustrating the range of flexion For the roentgenogram of this patient see Fig. 58.

shot injury. and extension.

In the lower extremity, when attempting to restore the full range of abduction, the pelvis should be fixed by abducting the opposite leg; when overcoming a flexion contracture, it should be fixed by flexing the opposite thigh forcibly on the body.

For the knee, particular care must be exercised, since the lower end of the femur is easily refractured unless carefully splinted before correction is attempted. To break up adhe

sions to the quadriceps extensor, the calf is grasped above the ankle and with a suitable pad in the popliteal fossa the surgeon's weight is brought to bear in such a way as to force the ankle toward the ground. A strong webbing band holding the thigh to the table is of assistance.

Mobilizing Methods Following Infectious Processes or Injury to the Cartilage. In these cases forcible attempt to

FIG. 60.-Roentgenogram of wrist fully ankylosed as sequence of severe gunshot injury to the lower end of the radius and to the carpal bones. result of treatment see Fig. 61.

For

move the joint is contraindicated, because there is danger of re-establishing infection or of stimulating increased bone production at the site of the joint injury. Gentle methods must therefore be pursued. I have found the simple effect of gravity to be the most efficacious. In the case of the shoulder which has been immobilized in the abducted position, removal of the splint allows gravity to do its work, and within a few days or

even hours some change in the angle has occurred. If the patient is now able to abduct the arm to the original position, the splint may be left off still longer. If not, it should be again applied. So too, in the case of the elbow fixed in the position of flexion. Removal of the splint allows the forearm to be extended with the least degree of traumatization. For the knee which has been fixed in the extended position, I allow

FIG. 61.-Roentgenogram of the wrist shown in Fig. 60 three months after arthroplasty. 90° flexion and extension; 10° abduction and adduction. Almost the full range of pro- and supination.

gravity to do its beneficent work by applying a little splint while the patient is lying in bed, so constructed as to support the thigh but to leave the calf unsupported. The weight of the calf gradually causes a flexion of the knee. As in the case of the shoulder and elbow, the power of the patient to resume the original position should be tested frequently, and failure on his part constitutes for the time being a contraindication to the continuance of the mobilizing process.

Another effective method in the mobilization of joints is the application of a steady, gentle corrective force. This principle, frequently applied by the orthopedist, in overcoming early deformities of tubercular coxitis and gonitis, has been rendered feasible for military surgery by a number of devices. Of these the simplest are, I believe, those of Schede. Fig. 56 illustrates the splints used. Each one is so constructed as to be a flexor as well as extensor of the joint. They are easily

FIG. 62. Arthroplasty of the metacarpophalangeal joint of the middle finger for ankylosis due to gunshot injury. a, The finger extended. b, The finger flexed.

applied by the patient himself, who regulates the degree of force by tightening or loosening the cord which approximates the arms of the lever.

When by these methods some slight degree of motion has been secured, the patients begin appropriate work in one of the shops connected with the hospital. Thus, the man with an injury to the shoulder is allowed to hammer, at first for a short time only, and if the first effort results in an inflammatory reaction the arm is again immobilized for a time. If none