1. The history of the genesis of the Putti-Platt operation for habitual dislocation of the shoulder is outlined so far as it is known.

2. The operation is described and briefly commented upon.

3. Since there is both gleno-labrial detachment and defect in the humeral head successful treatment depends upon: i) a block to the exit of the humeral head in front and ii) limitation of external rotation movement.

A review of the pathology, mechanism, and operative treatment of recurrent dislocation of the shoulder, based on an analysis of 180 cases, with 159 operations, is presented. From this analysis the following conclusions have been made and appear to be substantiated:

1. The pathology comprises two important elements: (a) anterior detachment of the glenoid labrum from the bone margin of the glenoid, associated with some degree of stripping of the anterior part of the capsule from the front of the neck of the scapula, found in 87 per cent. of cases examined adequately at operation; (b) defect or flattening of the posterolateral aspect of the articular surface of the head of the humerus which engages with the glenoid cavity when the arm is in external rotation and abduction; this defect is demonstrated most readily in antero-posterior radiographs taken with the humerus in 60 to 70 degrees of internal rotation and was shown to be present in 82 per cent. of cases which had been subjected to adequate radiographic examination.

2. The frequency of the humeral head defect has been under-estimated in the past, because of the difficulty of demonstrating it, particularly when the defect is small.

3. Either type of lesion alone may predispose to recurrence of the dislocation.

4. Both types of lesion are often present in the same shoulder. When this is the case the tendency to redislocation is great.

5. The initial dislocation, which results in the development of one or both these persistent structural abnormalities, may be due to very different types of injury, the commonest of which is a fall on the outstretched hand. The factor common to all these injuries is a resultant force acting on the humeral head in the direction of the anterior glenoid margin.

6. In the treatment of recurrent dislocation of the shoulder joint the Nicola operation is unreliable, and it may be associated with a recurrence rate as high as 36 per cent. It is believed that continued instability after this operation is usually due to the presence of a defect of the humeral head.

7. Operative treatment should aim at repairing, or nullifying, the effects of both types of lesion. For anterior detachment of the labrum this involves either suturing the labrum back to the glenoid margin, or constructing some form of anterior buttress, fibrous or bony: for humeral head defects it necessitates some procedure designed to limit external rotation, thus preventing the defect from coming into engagement with the glenoid cavity. Such limitation of external rotation does not constitute a significant disability.

1. The operative findings in seventeen cases of recurrent dislocation of the shoulder are presented and discussed. Detachment of the glenoid labrum (thirteen cases) and the formation of a posterior humeral groove (eleven cases) were the most consistent findings.

2. In one case recurrent dislocation of the shoulder was due to avulsion of the subscapularis muscle.

3. The surgical treatment of these cases is described, usually consisting of a modification of Bankart's operation.

4. The results of follow-up are given as an intermediate report. No post-operative dislocation has so far been reported.

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.

The purpose of this paper is to call attention to the anterior bone block method of Hybbinette-Eden for recurrent dislocation of the shoulder joint.

1. The operative technique is not difficult, and the after-treatment is short and relatively agreeable for the patient.

2. Sixty of our own cases are described, with four recurrences. The recurrences all occurred as the result of real trauma. In a total of 128 Scandinavian cases there were eight recurrences—that is 6·3 per cent.

3. In our opinion, based on the observations of radiography, arthrography, and operation, it is the compression fracture of the head of the humerus which deserves the name "essential lesion." Destruction of the anterior rim of the glenoid may be very slight, or entirely lacking. No false joint cavity or rupture big enough to receive the head of the humerus was ever observed by arthrography or by inspection during operative exploration.

Recurrent dislocation is an intracapsular subluxation, which occurs when the anterior rim of the glenoid slides into the hollow in the humeral head.

This is the first time that the principle of the mould—the principle of guiding the repair of nature for the purpose of recreating a destroyed or damaged structure, has been applied to surgery. The evolution of the method to its present encouraging stage is the result of the co-operative, professional family spirit of the Massachusetts General Hospital. We all share in it. We share it with the general surgeon because of his contributions to surgical technique. We share it with the "medical man" because of his pre-operative and post-operative care of the patient; because of his guidance as to when, and when not, to operate; and because of the many friendly arguments which are productive of so much good. We share it with the anaesthetist because of his clinical judgment of the patient, his selection of anaesthetic agent, and his continuous, conscientious administration of the anaesthetic throughout the operation.

I am going to change from "we" to "I." I owe so much to my assistants, from the first to the last: Bill Rogers, Eddie Cave, George Van Gorder, Paul Norton, Milton Thompson, Otto Aufranc, and Carroll Larson. I want to thank them all for helping to carry the load, for remembering the things that I forgot, and for making helpful suggestions which often led to improvement in surgical technique or to the construction of a useful instrument. I want to pay tribute to the staff of the Orthopaedic Service of the Massachusetts General Hospital and to thank its members for kindly scepticism, constructive criticism, and neverfailing loyal support.

The subject of this lecture, "Evolution of Mould Arthroplasty of the Hip Joint," is appropriate for a Moynihan lecture. It is not the work of one man alone. It is the work of one man, supported by a co-operative, helpful, and friendly hospital staff. This is what Lord Moynihan strove so hard to bring about at a time when surgeons viewed one another as rivals. To quote Dr William Mayo: "It is to Lord Moynihan's everlasting credit that, largely as a result of his unceasing efforts, surgeons came to consider themselves as fellow-workers in a cause."

1. In this series of 150 cases of arthritis of the hip joint treated by vitallium mould arthroplasty (182 arthroplasties), 80 per cent. of late results are satisfactory to both patient and surgeon.

2. Striking features are the relative painlessness, smooth hip joint movement, progressive improvement in function, and reformation of the joint lines as seen radiographically in the post-operative period.

3. Function after arthroplasty for traumatic and degenerative arthritis approaches the normal hip joint much more closely than in cases of infective and rheumatoid arthritis.

4. There is a complete absence of low back symptoms or postural difficulties, and there is no difficulty in preventing stiffness of the knee joint.

5. Different technical procedures are indicated according to the degree of absorption of the femoral head or neck, and the stability of the mould in the acetabulum.

6. The operative mortality rate in this series was nil, and during the six-year follow-up period only one case died as the result of a complication of the arthroplasty.

7. In addition to meticulous operative technique and the use of special instruments, the importance of careful and prolonged after-treatment must be stressed.

8. It must also be emphasised that secondary operative revisions are often necessary, particularly in cases of infective and rheumatoid arthritis.

1. A series of cases of Morton's metatarsalgia is reported in which twenty-seven selected patients have had thirty-five operations on the sole of the foot.

2. At operation, degeneration of the plantar digital artery to the cleft between the third and fourth toes has now been found to precede the fibrous thickening of the nerve described by Betts in 1940. Similar changes rarely occur in neighbouring clefts.

3. Local resection of the nerve almost always gives complete relief from pain, and the plantar scar gives rise to no trouble.

4. Histological findings show that the nerve lesion is ischaemic in nature.

5. Acute pain arising as a new event in cases of the deformity of "anterior flat foot" may prove to be due to this condition.

6. Morton's metatarsalgia is a distinct clinical and pathological entity which can best be described as a plantar digital neuritis.

1. Fifty cases of arthrodesis of the hip joint in tuberculous arthritis are analysed; in forty cases the late end-result has been ascertained two or more years after operation.

2. The indications for arthrodesis are discussed. The operation should not be performed when disease is active; it should not be undertaken before the age of twelve to thirteen years; it is not advisable in elderly patients; it may be contra-indicated when there are multiple foci of infection. Subject to these limitations every patient with unsound ankylosis after adequate conservative treatment should be treated by arthrodesis; painful fibrous ankylosis and late onset of deformity are definite indications.

3. Three types of operation have been used: intra-articular arthrodesis; extra-articular ilio-femoral arthrodesis; combined intra- and extra-articular arthrodesis. Extra-articular ilio-femoral arthrodesis is preferred, deformity being first corrected by traction or osteotomy.

4. Post-operation complications were few; the mortality rate was low (2 per cent.).

5. There was bone ankylosis with solid incorporation of the graft in 87·5 per cent., failure of union of the graft (to the trochanter) in 10 per cent., and destruction of the graft in 2·5 per cent.

6. Late end-results show full working capacity in 87·5 per cent. of patients, part working capacity in 2·5 per cent. and inability to work in 7·5 per cent.

The writer wishes to express his thanks to Professor Harry Platt and Professor T. P.. McMurray for criticism and advice in the preparation of this paper, and to Dr F. C. S. Bradbury, Central Consultant Tuberculosis Officer of the Lancashire County Council, for permission to publish these cases.

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.

1. Acute osteitis as seen in a large children's hospital is described briefly.

2. Treatment of a series of cases of acute osteitis with penicillin is discussed under the headings of investigation, penicillin administration, surgical procedure, radiographic appearance and results. The findings are tabulated.

3. Recent investigations suggest that no time limit can be set to the duration of penicillin administration. At present, routine marrow puncture appears to be the only certain method of control. We see no reason to alter the dosage set out in Table III. Administration should be continued until the marrow culture is sterile.

4. The methods adopted in subacute and chronic pyogenic bone infections are described separately.

1. Fifteen new cases of plasma cell tumour are reported with a review of the literature.

2. Case examples are quoted to show the gradual merging of the different clinical and pathological syndromes into one entity.

3. A comprehensive analysis of the various manifestations of the disease is made.

4. An attempt is made to correlate the widely differing features of the disease-process and a classification is given.

5. It is considered that metastasis plays no part in this condition.

6. The variety of forms of plasma cell tumours are shown as gradations of an essentially similar disease-process, and are not regarded as separate conditions.

Osteochondral fractures of the patella should be recognised early, loose bodies removed, and defects in the articular surfaces smoothed off, or the patella removed if it is extensively involved. Plication of the capsule on the medial side is recommended in order to prevent recurrence of the injury and to prevent dislocation of the quadriceps tendon. in cases where the patella is removed.

Patellectomy is at present the best operation for recurrent dislocation, not only because the immediate result is excellent, but because it avoids the later arthritis which must inevitably arise if a patella so damaged is retained.