1. Twenty-nine patients with traction lesions of the brachial plexus have been studied.

2. The methods of study have been by clinical examination, by operative exploration and biopsy and by examination of axon reflexes.

3. Results in each of these sections have been related to the progress of the lesions.

4. The results suggest: a) that the reason for the generally poor prognosis in traction lesions of the brachial plexus is the frequency of intradural preganglionic damage and of tearing apart of the plexus; b) that the former occurrence can with some accuracy be diagnosed by examination of axon reflexes and that the latter can be detected at operation.

5. Indications for operative exploration are given and a plan is outlined for the management of these cases.

We believe that this technique has several advantages. After poliomyelitis recovery in the clavicular head of pectoralis major may exceed that in the sternal head; there may be considerable but incomplete recovery in both heads and it is then desirable to use all the active muscle available. Girls and women dislike conspicuous scars; the incisions used in this technique are unobtrusive when the arm is by the side.

1 . Twenty-one cases of poliomyelitis and twenty cases of brachial plexus injury in which muscle transplantations had been performed to restore elbow flexion have been reviewed. The average follow-up period was four and a half years.

2. The results were graded objectively and subjectively. They were better when passive extension of the elbow was limited; such limitation always occurs after Steindler's operation, but infrequently after pectoral transplantation.

3. The results of pectoral transplantation are good when there is no significant shoulder paralysis; if there is shoulder weakness arthrodesis of the joint may be required to control medial rotation and adduction of the shoulder on flexion of the elbow. In brachial plexus lesions the results of pectoral transplantation may be marred by simultaneous contraction of the triceps. This can be overcome by transplanting triceps into the flexor apparatus. Triceps transplantation is rarely indicated because loss of active extension of the elbow is a grave disability.

4. Subjective results tended to be worse than objective results in brachial plexus lesions because impairment of sensibility in the hand often limited the usefulness of the limb. In striking contrast the subjective results were in general far better than the objective in patients who had had poliomyelitis. In them the smallest gain can be of functional value.

The operation has the advantage of simplicity, and it avoids the slight danger of secondary cicatricial contracture of the nerve when it is transplanted anteriorly and implanted in muscle. There is a slight hazard from external injuries because the nerve is unprotected by the epicondyle.

A study of limb shortening after poliomyelitis in 225 children in whom paralysis was confined to one leg shows:

1. The paralysed leg became shorter than its fellow in 219 patients (97 per cent).

2. The discrepancy in leg length only once exceeded three and a half inches.

3. Both the tibia and the femur were shorter than their fellows in 171 out of 184 studied (93 per cent). In only one patient was the femur alone shortened.

4. Three patterns of progress of shortening are described. No evidence was found that reduction of shortening ever occurs.

5. It is impossible accurately to predict shortening. In general, the more severe the paralysis the greater the shortening, but there are notable exceptions.

6. No relationship could be found between the amount of shortening and the incidence of paralysis of any individual muscle-group.

7. There was no significant difference in leg shortening in adult life between those who had developed the disease in the first two years of life and those who had developed it later.

8. A cold blue limb is not more likely to undergo severe shortening.

9. When the paralysis was confined below the knee the greatest shortening seen was one and three-quarter inches. When muscles both above and below the knee were involved severe paralysis may produce shortening up to three and a half inches.

10. Lengthening of a paralysed leg can occur during the first two years after the onset of the disease, but this is always a temporary phase.

11. The cause of leg shortening is unknown. In only two patients in this series was there evidence of premature epiphysial fusion.

1. A method of correcting poliomyelitic lateral rotation deformity of the thigh by transplant of one or more of the hamstring muscles to the femur is described.

2. The results in seven cases are recorded.

3. Though it is emphasised that this is no more than a preliminary communication and the number of patients so treated is small, the satisfactory results suggest that the procedure is mechanically and physiologically sound.

1. Nineteen patients with congenital shortening of the femur without associated coxa vara have been examined and discussed.

2. The diagnosis is made on finding a short, bulky thigh, held in lateral rotation. The radiographs commonly show no abnormality apart from shortening, but delay in ossification of the head of the femur, with lateral bowing and cortical sclerosis of the shaft, are occasionally present. The overall shortening of the limb seldom exceeds three inches.

3. The place of various surgical procedures to control limb length is briefly discussed.

1 . A new surgical approach to the treatment of pes cavus is suggested. The operation consists in a subcutaneous division of the contracted plantar fascia and correction of the varus deformity of the heel by removing a wedge from its lateral aspect. It is submitted that, by approaching the deformity from behind and overcoming the varus of the heel, the foot is rendered plantigrade and that thereafter weight bearing exerts a corrective influence which results in progressive improvement of the deformity. The operation is essentially a prophylactic one and, for the best results, it should be performed before there is gross structural deformity and while active growth is still taking place.

2. Even in patients over the age of fourteen, improvement is obtained by doing nothing more than this simple operation. In the presence of fixed deformity of the forefoot, as encountered in older patients, inversion is corrected by removing a lateral wedge from the calcaneum and the cavus by taking a dorsal wedge from the tarso-metatarsal region. This has the double advantage of producing good correction of deformity, while at the same time preserving movement at the mid-tarsal-subtalar joint. Fixed clawing of the toes will require appropriate corrective treatment, but if the toes are malleable the simple effect of weight bearing on the plantigrade foot produces gradual correction.

This review shows that inter-body spinal fusion can be achieved in a satisfying percentage of cases, and the assertion that there is an intrinsic factor peculiar to the vertebral bodies which prevents such a fusion cannot be supported. The operation has a limited but definite place in the field of spinal surgery, and should be reserved for those patients with spinal instability associated with intractable and persistent backache. Spondylolisthesis is the indication par excellence. A new operative technique, which has been developed during ten years, has become standardised. The trans-sacral approach provides a better and safer exposure than those described before. In the event of failure of inter-body fusion, it is suggested that further attempts at grafting should be restricted to one of the posterior methods which have a 75 per cent chance of producing successful bony fusion.

Clinical photographs are reproduced in Figures 16 to 18 to show that patients suffering from a painful spondylolisthesis may be restored to normal activity by this operation.

1 . The theoretical requirements for optimal correction of thoracic scoliosis and kyphosis are discussed, and observations are made on the limitations of methods in current use for their ambulant correction.

2. The experimental use of hydrostatic pressure in an endeavour to satisfy these clinical requirements is described.

3. It is suggested that the use of hydrostatic pressure as the source of corrective force has considerable advantages, and that, with refinements, the techniques described may prove a useful addition to rigid mechanical methods of correction.

Four cases are reported in which infantile idiopathic structural scoliosis gradually decreased during the period of active growth.

1 . Dislocation of the upper end of the fibula is probably less unusual than the paucity of the published reports suggests.

2. Dislocation may be anterior or posterior, anterior dislocation occurring about twice as often as posterior. Rarely the fibula moves proximally.

3. In most cases a closed manipulation suffices for reduction, and a full and rapid return of normal function follows.

4. Five cases are described. In one case operative reduction was required.

The place of internal fixation in the treatment of fractures of the shafts of the radius and ulna in adults is discussed, and the results in 130 fractures treated by internal fixation are reviewed.

Non-union was found to be the most frequent and serious complication after internal fixation.

The incidence of non-union can be greatly reduced if operation is delayed for at least one week, and preferably two to three weeks after injury.

Evidence is presented to support the value of delayed operation in the promotion of union of fractures.

1. Two cases of osteoid osteoma of the vertebrae are presented.

2. The unusual clinical histories and findings are reported in detail.

The radiological appearances in twenty-five patients with Reiter's disease have been compared with those in eighty-one with rheumatoid arthritis and thirty-eight with ankylosing spondylitis. The similarities and differences have been analysed. Changes of periosteal new bone in the calcaneum appear to be the only significant differentiating factor, although minor differences in incidence and distribution occur elsewhere. Sacro-iliitis is a common radiological feature of long-standing Reiter's disease.

1 . Sloughing of homogenous skin grafts and clouding of corneal transplants have been shown to be due to antigen-antibody reaction; antigens A and B have been demonstrated in human epidermis and corneal tissue; and anti-red-cell agglutination has been observed in dogs after homogenous bone transplantation. Human bone was therefore examined in thirty-three experiments to determine the presence or absence of A and B antigens.

2. The bone was separated into hard cortical bone, hard washed cancellous bone and soft-tissue washings of bone.

3. Adsorption experiments showed that A and B antigens are absent from cortical bone. A and B antigens are present in cancellous bone.

1. Experiments show relative weakness of the second metatarsal epiphysis at a certain stage of epiphysial maturation.

2. It is shown that at this stage Freiberg's infraction is likely to occur.

3. It has been demonstrated that even gross comminution with disruption of the articular cartilage of the second metatarsal head is compatible with a radiograph of almost normal appearance.

1 . Fresh bone autografts to a muscle bed in the rat gave rise to vigorous new bone formation from about the fourth day. The graft took the form of a hollow ossicle with central bone marrow at eighteen days: it became progressively more regular in outline and was still present at six months.

2. Fresh bone homografts produced two separate phases of new bone formation–early and late. In the early phase non-lamellar woven bone appeared at about the fourth day, continued to grow until eight days, and subsequently died. It arose from osteogenic cells of the homograft. In the late phase, which developed in relation to a few grafts after four weeks, the new bone was lamellar in character, and remained closely applied to the graft surface. Evidence is presented that this bone arose by metaplasia of the host connective tissues at the graft site. There was a local inflammatory response to the bone homograft.

3. Both phases of homograft new bone formation were abolished if the animal was prepared by a skin homograft from the same donor four weeks before, but not if four months elapsed between the two grafting procedures.

4. Freeze-dried bone homografts did not give rise to the early phase of homograft new bone but produced a few examples of the late phase after five months. The inflammatory response was less intense with freeze-dried homografts than with fresh homografts.

5. Skin homografts three weeks after fresh bone homografts from the same donor underwent an early rejection at five to six days.

6. Skin homografts three weeks after freeze-dried bone homografts from the same donor had a mean survival time of twelve days, which was significantly longer than the mean survival time of l0·9 days in normal rats.

1. A pair of clavicles and the corresponding scapulae were found to possess definite articular facets indicating the presence, in life, of a coraco-clavicular joint.

2. The bones are described and illustrated.

3. These cases are compared with others reported in the literature.