The syndromes associated with a narrow lumbar spinal canal are described and discussed. In thirteen cases two main groups were evident, the larger group having mainly backache and root pain, the smaller group having intermittent claudication. A method of recognising the narrow spinal canal on plain radiographs is described, and a comparison made with normal controls. The findings at operation are reported and the importance is emphasised of making a wide laminectomy for decompression. Our thanks are due to the neurosurgeons of the South-West Neurosurgical Unit, Mr G. L. Alexander, Mr D. G. Phillips and Mr A. Hulme, who kindly allowed us full use of their clinical notes. We would also like to thank Mr G. Banham for the reproductions, Mr E. Turnbull for the drawing and the secretarial staff for their patient co-operation.

1. Delta phalanx is a rare congenital abnormality not to be confused with other forms of angular deformity of the phalanges.

2. The deformity needs radical treatment by repeated surgery because there is no tendency to spontaneous correction and growth of the phalanx is prevented by the epiphysial deformity.

1. Forty-eight paralytic dislocations of the hip have been studied and twenty-seven operations for correction of valgus deformity of the femoral neck have been done.

2. The differing features of dislocations occurring in poliomyelitis, cerebral palsy and meningomyelocoele are considered in relation to management after operation.

3. Early recognition of subluxation is essential to a successful varus osteotomy. An angle of 105 degrees rather than the 120 degrees previously recommended is advisable for children under the age of five.

4. Redislocation is most likely to occur in meningomyelocoele in which muscular imbalance is greatest, and in later cases where the acetabulum has become shallow by growth without the femoral head within it. It has not occurred as a late complication after weight bearing has been established, from a recurrence of valgus deformity.

1. A case is described in which the extensor indicis tendon was replaced by a short muscle arising from the soft tissues on the dorsum of the wrist.

2. The patient complained of pain in the hand after heavy use. This was considered to be due to constriction of the muscle by the extensor retinaculum. Division of the retinaculum was followed by a considerable improvement in his symptoms.

1. The results of viscosity measurements on a number of normal, traumatic and osteoarthritic synovial fluids from human knee joints are described and discussed.

2. A decrease of the viscosity of normal synovial fluid with age has been found.

3. The decrease of the viscosity with age and in the pathological groups is analysed and its relation to the viscous anomaly is considered (Fig. 6).

4. The question whether dilution or depolymerisation is the important factor in decrease of viscosity in these groups, and the value of viscosity measurements as a whole, are discussed.

5. Measurements of pH have been made on the same groups of synovial fluids and on the blood of patients in these groups.

6. The mean values for blood and synovial fluid differ significantly, and the pH of the synovial fluid of adolescents is significantly higher than at other ages.

7. There is no significant difference between the traumatic and osteoarthritic groups, but both are significantly less than the normal.

8. In both fluids the peak frequency in all three groups is the same, that for blood being 7·3 to 7·5 and that for synovial fluid being 7·5 to 7·7 (Fig. 7).

1. The clinical and pathological features are given of an example of the rare syndrome of progressive and massive osteolysis associated with haemangiomatous changes in the bones affected.

2. Twenty-six cases have been previously reported, but this is only the second from Britain. Only one other patient is considered to have died as a direct result of the disease.

1. A case of recurrent posterior subluxation of the shoulder is described. After failure of a soft-tissue repair, a posterior bone block operation was performed.

2. The distinction between traumatic dislocations with tearing of the capsule or of the glenoid labrum, and habitual luxations from laxity of the capsule, is emphasised. Although the anterior rim of the glenoid was detached in this case, it is considered to fall into the latter category.

3. A posterior bone block provides a simple and efficient form of repair in this type of case. It is free from the disadvantage of causing limitation of rotation at the shoulder joint; it employs a principle which might well merit more application than at present in the repair of anterior dislocations.

1. The results of treatment of 115 patients with Pott's paraplegia during a six and a half year period are reviewed.

2. The indications for operative intervention—in particular antero-lateral decompression— according to the duration, grade and type of paraplegia, are discussed.

3. No attempt has been made to justify the treatment of individual patients in the series, some of whom would undoubtedly have benefited from earlier operation; but lessons are pointed and conclusions drawn from the results, good and bad.

The skeletal and arterial changes in a somewhat unusual case oligodactyly are described.

1. The spinal branches of the vertebral artery were injected with a suspension of barium sulphate and the blood supply of the vertebral bodies of the lower four or five cervical vertebrae investigated radiologically.

2. Beneath the posterior longitudinal ligament there is a free dorsal arterial plexus from which a large branch arises to enter the back of the vertebral body. This vessel terminates abruptly at the centre of the body where numerous, much smaller, branches radiate towards the upper and lower surfaces.

3. The possible significance of the form of the intravertebral arteries is considered in relation to embolic lesion in vertebral bodies.

1. This is a simple clinical study of the end-results of arthrodesis of the hip joint in patients followed up and re-examined five to twenty-five years after operation.

2. The study was stimulated by our astonishment at recent reports which suggested that arthrodesis of the hip caused serious operative mortality, a high rate of wound infection, and failure of sound fusion in one of every two cases; and that even when sound fusion was gained there was always pain in the back and usually stiffness of the knee. To say that we were astonished puts it mildly.

3. This review includes 120 patients aged from ten to seventy years, treated for osteoarthritis of the hip joint by intra-articular arthrodesis with the internal fixation of a nail, usually with an iliac graft, and with immobilisation in plaster for not less than four months.

4. Of these 120 patients there was sound fusion of the joint, proved radiographically, in 94 per cent; a mortality of nil; and recovery of free movement of the knee joint to the right angle or far beyond in 91·5 per cent. Almost half of the patients regained normal movement, the heel touching the buttock. Only in eight patients was there less than right-angled flexion.

5. There was no pain in the back—none whatever—in 64 per cent of the patients. In 36 per cent there was some pain or discomfort. One alone said that the low back pain was worse than before the operation. Many others said that pain in the back had been relieved by the operation.

6. It is emphasised that these results were gained only from sound fixation of the joint in the mid-position with neutral rotation, no more abduction than is needed to correct true shortening, and no more flexion of the joint than that with which the patient lies on the table. The limb was immobilised in plaster for at least four months after operation. The stiff knee was mobilised by the patient's own exercise without passive stretching, force or manipulation.

7. Two other groups of patients are considered. There are fourteen treated by fixation of the joint with nail alone, an operation that was never intended to arthrodese the joint and which has long since been abandoned. The other small group is that of patients with old unreduced traumatic dislocation of the hip, a procedure in which the risks of operation are so great and the number of successful results so small as to dissuade us from attempting operative reduction.

8. After successful arthrodesis of the hip joint patients can return to every household activity and every recreation including ski-ing, mountaineering, rock climbing, or whatever else they want.

1. Twenty-two dislocations of the hip occurring in patients paralysed from an early age have been studied. All showed abnormal coxa valga. The coxa valga, which may gradually reach 180 degrees, precedes dislocation and makes it inevitable. The presence of unbalanced adductor power may hasten dislocation, but the latter can occur in complete flaccid paralysis.

2. The combination of structural instability of the hip joint and muscular weakness may make independent walking impossible, but restoration of stability gives considerable improvement in any remaining muscular power and may alter the patient's whole future.

3. A method of correcting the basic deformity of coxa valga by osteotomy is described and the results of nine operations are reviewed.

1. A series of 1,211 cases of infection of the hand and fingers is reviewed. Of the 1,066 which required operation about two-thirds were treated by excision and suture, and the results in these cases are analysed.

2. The criterion of success was per primam healing in seventeen days or less, and 54 per cent of the cases treated by this method (excluding paronychiae) fulfilled this criterion.

3. The causes of failure are discussed.

4. It is concluded that excision and suture is the method of choice in well localised infections, but that it should be avoided in diffuse infections and in some cases with sinuses. Its use is unnecessary in trivial infections.

One hundred and sixty-four cases of intramedullary nailing of the long bones have been studied with special reference to the difficulties and complications encountered.

There was one death not attributable to the method.

Two cases of pulmonal fat embolism and one case of thrombosis occurred, all in fractures of the femur.

The lessons we have learned from our mistakes can be summarised as follows:

1 . The method requires technical experience and knowledge and is not suited to inexperienced surgeons or surgeons with little fracture material at their disposal.

2. Intramedullary nailing should only be used in fractures to which the method is suited. In general, comminuted fractures or fractures near a joint are unsuitable.

3. Open reduction is preferable to closed methods.

4. The nail should never be driven in with violence. It should be removed and replaced with a new one if difficulty is encountered when inserting it.

5. In fractures of the femur the nail should be driven in from the tip of the trochanter after careful determination of the direction.

6. The nail should be introduced only to the level of the fracture before exploring and reducing the fracture.

7. Distraction of the fragments must be avoided.

8. If the nail bends it should be replaced by a new one, at least in femoral fractures.

9. If union is delayed, the fracture should be explored and chip grafts of cancellous bone placed around it.

10. Improvised nails or nails which are not made of absolutely reliable material should never be used.

11 . Make sure that the nail is equipped with an extraction hole for removal.

1. A condition of fibrous dysplasia of the jaws occurring in four brothers and a sister has been under observation since 1931.

2. Three of the five patients have been operated upon for correction of grotesque deformity, with satisfactory results.

3. The pathological nature of the disorder is discussed.

1. Léri's pleonosteosis is characterised by broadening and deformity of the thumbs and great toes, flexion contracture of the interphalangeal joints, limited movement of other joints, and often a Mongoloid facies. Four such cases are described.

2. A review of the twenty reports in the literature, and the cases now described, shows that the deformities are due to capsular contracture rather than deformity of bone.

3. In one patient there was striking evidence of fibro-cartilaginous thickening of the anterior carpal ligaments. It is suggested that the primary pathological change in pleonosteosis may be in the joint capsules rather than in the epiphyses.

4. The patient with thickening of the anterior carpal ligaments had bilateral median palsy from carpal tunnel compression.

5. The causes of carpal tunnel compression of the median nerve are reviewed. Acute compression may be due not only to dislocation of the semilunar bone but to haemorrhage in the palm. Late compression by bone may occur twenty to fifty years after injury. Late compression without bone abnormality has been attributed to occupational stress, but it is suggested that pathological thickening of the anterior carpal ligament may be the cause.

6. The patient with pleonosteosis and bilateral median palsy had also bilateral Morton's metatarsalgia with large digital neuromata.

7. Plantar digital neuritis has already been shown to be an ischaemic nerve lesion preceded by degenerative changes in the digital artery. The significance of the fibrous tunnel through which the artery passes to reach the digital cleft is considered.

1. The explosive type of painful shoulder due to rupture of a calcified deposit into the sub-deltoid bursa is described.

2. A brief report of six cases is presented.

3. No treatment other than rest and sedation is needed.

1. The behaviour of penicillin injected locally into knee joints is investigated and found to be the only satisfactory way of using the drug in joint wounds and infections.

2. Penicillin persists within the joint for forty-eight hours after injection unless the effusion is being actively absorbed.

3. The additional administration of penicillin by intramuscular injection is recommended when other considerations demand it.

Summary—Fifty-two cases of exposure of the glenoid labrum are recorded. Fifty-one operations with anterior exposure, followed by capsular reefing and shortening of the subscapularis, were successful. One operation with superior exposure, and without capsular reefing or shortening of the subscapularis, was unsuccessful.