The pathology of pulp space infection is discussed. It is recommended that a direct incision which is localised precisely to the abscess site, even if the incision is in the tactile pad, is better than a lateral incision, which fails to maintain drainage, causes longer incapacity, and may injure the digital nerve and give rise to causalgia. Fifty cases of pulp space infection in which a direct incision was used are reviewed.

1 . Voluntary activity of any given muscle in the hand is not an absolute indication of the state of the nerve which usually supplies it.

2. Significant variations in the standard pattern of innervation have been found in 20 per cent of 226 cases studied.

3. The pattern of innervation described in standard text-books occurred in only 33 per cent. of cases.

4. A striking variation is the supply of every thenar muscle by the ulnar nerve. In other cases the first dorsal interosseous muscle may be supplied by the median nerve.

5. In order to arrive at an accurate diagnosis when anomalous innervation is suspected, nerve blocks at appropriate levels are required.

6. Great care must be taken during operations to avoid damage to connections between the ulnar and the median nerves, especially in patients with anomalous innervation of the hand muscles.

1. Sixteen cases of thenar paralysis are reviewed in which a bone graft was inserted between the first and second metacarpals to maintain fixed abduction and opposition of the thumb.

2. The technique of the operation is described and the causes of failure are discussed.

3. The operation is intended for those cases in which tendon transplantation to restore active opposition of the thumb is unsuitable. Rotation of the first metacarpal into full opposition is the most important feature of the operation.

1. Fifty-nine patients with various inter-carpal dislocations have been reviewed.

2. In this series trans-scapho-perilunar fracture-dislocation was the commonest injury. Early cases can be reduced by closed manipulation but in late cases operative reduction is usually advisable. When the injury is more than three months old, arthrodesis of the wrist joint is indicated.

3. When trans-scapho-perilunar fracture-dislocation was complicated by avascular necrosis of the proximal scaphoid fragment, the results in a small series treated by early excision were approximately equal to those treated by continued immobilisation. The results of grafting the scaphoid were poor.

4. Dislocations of the lunate seen within ten days of injury could usually be reduced with good results; no such case developed Kienböck's disease within the period of review. In late cases excision gave satisfactory results.

5. Forward dislocation of the lunate with half the scaphoid gave good results when manual reduction succeeded, but the results of excision of fragments were less satisfactory.

6. There was one case of forward dislocation of the lunate together with the distal half of the scaphoid.

7. Subluxation of the scaphoid is disclose in antero-posterior radiographs by a typical gap between it and the lunate bone. The subluxation may become recurrent and present a characteristic syndrome.

8. Other rare dislocations of the carpal bones are described.

1. The technique of excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint is described.

2. The results of eighteen operations in fifteen patients are analysed.

3. The operation is of value particularly when the arthritis is monarticular. Results have been less satisfactory when the affection of the joint is part of a generalised arthritis.

A bilateral congenital abnormality of the trapezium and first metacarpal is described. The condition may be related to abnormal ossification of the trapezium in accordance with Pfitzner's plan. It is quite distinct from osteoarthritis of the trapezio-metacarpal joints.

1. The range of variation in full extension at the interphalangeal and metacarpo-phalangeal joints of the thumbs of 133 male and 100 female Europeans, and of 31 male Indians and 30 male Africans, has been investigated.

2. There is considerable variation between individuals in the maximum extension of both joints of the right and left thumbs in all groups studied.

3. The distribution for each joint in both thumbs in all groups is fairly symmetrical.

4. There is a high correlation between the right and left thumbs for both joints in all groups

5. The mean angle of extension at the right and left metacarpo-phalangeal joints in all groups is similar. Female Europeans, however, show a significantly greater mean angle than male Europeans.

6. The mean interphalangeal angle of extension in male Europeans is significantly greater than that in female Europeans and the mean in the Indian and African groups is significantly greater than in the male European group.

7. There is slight negative correlation between the metacarpo-phalangeal angle and interphalangeal angle in each thumb in the European groups.

8. Many subjects in all groups can increase extension at the metacarpo-phalangeal joint after flexing the carpo-metacarpal joint. Marked hyperextension (over 40°) is more frequent in the left than in the right thumb, in females than in males, and in male Indians than in male Europeans and Africans.

9. Maximum extension at the interphalangeal joints is not related to the presence of a sesamoid bone in the anterior part of the capsule of the joint.

10. The surfaces of the metacarpo-phalangeal joints vary considerably in shape. Those which are flat form about 10 per cent. of the sample and do not show hyperextension.

11. The factors influencing the amount of extension at the interphalangeal joint is the degree of laxity of the anterior capsule. The problem at the metacarpo-phalangeal joint is more complex; both the capsule and the shape of the joint surfaces play important roles.

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 late results in nineteen cases of total excision of the carpal scaphoid bone for ununited fracture have been reviewed.

2. The results are least satisfactory when there is clinical evidence of arthritis on the dorsal aspect of the wrist, or subluxation of the os magnum and semilunar. In other cases good results usually can be expected.

3. The operation must be done carefully without injury to the neighbouring bones and ligaments. Total excision is preferable to excision of the proximal pole alone.

1 . Anterior dislocation of the head of the radius with or without fracture of the ulna is a forced pronation injury.

2. Full supination is essential for reduction, and immobilisation in full supination is the surest safeguard against recurrence of the deformity.