1. Two hundred and eleven cases of arthroplasty of the hip have been studied in an attempt to establish the causes of success and failure by comparing the excellent, good and bad results.

2. The findings suggest that the result of an arthroplasty depends largely upon four factors: the surgical approach to the hip joint, the acetabular roof, the interposition substance, and the early post-operative complications.

3. Some important points in the technique of operation and in the post-operative management are described.

1. A method of treatment of the congenitally dislocated hip is described.

2. The rationale of the treatment is considered.

3. The subsequent development of the hip generally, and of its individual components, is described.

4. Comparison between the results of other methods of treatment and of this method is not attempted for reasons stated.

5. The advantages of a shortened period of splintage are discussed.

6. The state of fifty completely dislocated hips treated consecutively is described at the end of a follow-up period of from three to seven and a half years.

1. By questionnaire, an attempt has been made to ascertain the characteristics of a hundred cases of slipping of the upper femoral epiphysis.

2. The principal object has been to see whether an etiological classification would be possible pending an assessment of the results of treatment.

3. Proper statistical analysis has proved impossible because of the incompleteness of the data.

4. As usual, boys predominated and were usually affected as much as three years older than the girls.

5. It was exceptional to find epiphysial slipping in a girl once she had begun to menstruate.

6. Nearly a quarter of the cases were bilateral, or became so after six to twenty-four months or more.

7. Little information came from an enquiry about dietary fads, the estimation of urinary ketosteroid excretion in twenty-three of the patients, or some minor pathological investigations.

8. No convincing evidence was found of skeletal retardation or of general thickening of epiphysial discs, such as might perhaps be expected in a hormonal disturbance characterised by defective epiphysial maturation.

9. From each child with the necessary data, indices of height, weight and build were ascertained, which would indicate his expectation of finding a place among a hundred physically normal children of his own sex and age, and, if so, where that place would be. From these studies four groups of children seemed to emerge: I) what may be called abnormally heavy children who would not find a place among a hundred, or somestimes a thousand, physically "normal" children of their own age and sex; 2) unusually heavy children who would find a place in the heaviest minority of the normal hundred; 3) a very small group of abnormally small people, among whom might be expected the subjects of pituitary infantilism; and 4) a large group of children of average physique for their sex and age.

10. From this information and from clinical evidence in the case returns, it appeared that a quarter of the assessable boys and nearly two-thirds of the assessable girls showed evidence of endocrine defect, quite apart from those who were merely unusually fat.

11. By distinguishing these two groups of children from a third group of constitutionally "normal," an attempt has been made to see whether there is any correlation between evident endocrine defect and such characteristics as bilateral affection, delayed epiphysial maturation, a history of relevant injury and its nature, and sudden or gradual epiphysial slipping.

12. No relationship was established between any of these characteristics and endocrine type: bilateral affection was no commoner in the endocrine group; delayed maturation was not demonstrated in either; a history of relevant injury was equally common, and its nature identical, in both; slipping might be sudden or gradual in either indiscriminately.

13. There was a history of seemingly relevant injury in half the patients, and it was much commoner with sudden slipping than with gradual slipping. Sudden slipping was often preceded by symptoms of gradual slipping, or sudden slipping of one epiphysis was sometimes followed by gradual slipping of the other.

14. In gradual slipping the cardinal symptoms were pain and limp, usually starting synchronously and gradually; the pain was usually intermittent and referred much more often to the hip than the knee; the limp was usually continuous.

15. Of signs, demonstrable wasting seemed to be absent as often as present, but shortening was usual. Lateral rotation deformity was usually present, adduction often, and flexion sometimes. In more than a third of the cases limitation of movement was slight enough to be easily missed.

16. The radiographic observations confirmed the seeming widening at the affected epiphysial disc, the greater displacement revealed by the lateral view, and the difficulty of identifying avascular necrosis before collapse.

17. Treatment was delayed in thirty-four cases—a third of the whole; the reasons have been analysed; diagnostic failure was the cause in nineteen.

18. A few cases outside the series have been mentioned briefly because of special points of interest: slipping in gross pituitary disease—in pituitary giantism, and(at the age of thirty-three) in pituitary hypogonadism; slipping with defect of the opposite lower limb—infantile paralysis of the leg, and Legg-Calvé-Perthes disease of the hip; familial affection—slipping in two brothers.

19. The results of treatment in the present cases, supplemented by others, have been studied by Dr John Hall and related to some of the clinical features. His paper appears separately.

1. One hundred and seventy-three hips in 138 patients have been examined and studied in reference to the type of treatment received.

2. Shepherd's method of assessing the results of arthroplasty operations has been adapted to this series.

3. Satisfactory results were found in 77·9 per cent of all patients.

4. The value of straight longitudinal traction is questioned. Medial rotation appears to be an essential step in the reduction of the deformity.

5. Manipulation was found to be a relatively safe and effective method of reducing the deformity in patients seen soon after an acute episode, and should be reserved for them.

6. Complications were common after nailing operations, and included subtrochanteric fracture in three cases.

7. Avascular necrosis was the commonest cause of a poor result. The two types of avascular necrosis are discussed.

8. Avascular necrosis was found in 37 per cent of cases in which a manipulation was followed by a nailing operation.

9. Avascular necrosis was not found in any case in which a manipulation was combined with the use of Moore's pins, but such cases were kept under observation for a shorter time.

10. Avascular necrosis was found in 38·1 per cent of cases of cervical osteotomy.

1. Fifty-six cases of tibialis posterior transplant for drop foot are reported.

2. The results are known to be satisfactory in forty-nine of the fifty-six cases.

3. Serious complications have been few.

4. Re-education has been easy in the great majority of cases.

1. Three cases are described in which ischaemic necrosis of certain leg muscles followed exercise.

2. Previous reports of this condition are analysed, and the histology is discussed.

3. The term march gangrene is suggested for this condition.

4. The treatment advised is early and extensive fasciotomy.

1. Three cases of metaphysial fractures in infants are described. Obstetrical trauma was probably responsible in two cases, and in the third case direct injury was admitted by the parents.

2. These fractures are associated with bone destruction and periosteal new bone formation in the metaphyses. They are important because they can be confused with syphilis, tuberculosis, scurvy, osteomyelitis and neoplasm.

3. The fractures respond to conservative treatment and usually heal rapidly in a matter of weeks.

1. A case of arthritis of hip complicating osteitis pubis after retropubic prostatectomy is described.

2. It seems likely that bacterial infection was responsible in this case, although it was not proved.

3. Antibiotics did not appear to influence the course of the disease.

4. The progress of the disease was followed clinically and radiologically to its conclusion by natural healing with absorption of the femoral head, leaving a painless joint with good function.

1. A left-sided, paravertebral, hour-glass tumour causing destruction of the neural arches of the third and fourth thoracic vertebrae with evidence of spinal cord compression, is described. The tumour presented the typical histological appearance of a chondroblastoma.

2. The intraspinal part of the tumour was excised and the mediastinal part curetted. Post-operative radiotherapy was given. The patient was symptomless two years after operation.

3. No example of Codman's tumour with similar features and in such a situation has been described before in the literature. Pathological, clinical and radiological aspects of chondroblastomata are briefly discussed and some remarks concerning their treatment are added.

1. Three cases of traumatic arterial spasm are reported.

2. In each case there was increased tension in a neighbouring myofascial compartment.

3. The cause of this tension was oedema, possibly supplemented in one case by haematoma.

4. Release of tension by splitting the sheath was followed by relaxation of the artery.

5. It is suggested that tension in a fascial compartment may provide the stimulus that maintains arterial spasm and that the consequent ischaemia aggravates the oedema, so that a vicious circle is established.

6. It is further suggested that if spasm persists in spite of the usual measures, including exploration of the artery, the distal myofascial compartment should be decompressed. Division of the deep fascia of the cubital or the popliteal fossa is not enough.

7. Such persistent arterial spasm is uncommon, and further observations are needed to define the significance of increased tension in a distal myofascial compartment.

A case of complete rupture of the axillary artery in a man aged eighty-seven is described. The injury occurred in connection with an antero-inferior dislocation of the shoulder. It is not known whether the rupture was caused by the dislocation itself or by the reduction. A successful suture of the artery was performed. A review of the literature is given, and earlier attempts to suture the artery in cases of this type are noted. The indications for this operation are discussed.

1. Since the publication by Bradford and Spurling in 1945 of The Intervertebral Disc, there has been argument about the figure of 1,600 pounds that they calculated as the load on each lower lumbar intervertebral disc when a person lifts a heavy load with the trunk flexed, especially since experiments have shown that intervertebral discs subjected to increasing pressures yield at values well below this figure. In the author's experiments the discs were destroyed by pressures ranging from 350 to 1,400 pounds, with a mean of 710 pounds.

2. It occurred to the writer that the spine is not necessarily the only structure in the body that can transmit pressure forces from the shoulder to the pelvis. A raised intra-abdominal pressure impacts a thrust under the diaphragm, which will be transmitted to the thoracic spine and the shoulders by means of the ribs. This thrust can take care of part of the lifted weight and thus decrease the load on the spine.

3. In experiments in which the intra-abdominal pressure was measured by means of a small balloon in the stomach it was found that the pressure rose proportionally with the amount of weight lifted.

4. It is suggested that the abdominal fluid ball can exert a longitudinal force only if there is no contraction of the longitudinal muscles (at least anteriorly). Electromyographic studies of the abdominal muscles during weight lifting showed that the transverse and possibly the oblique abdominal muscles contract, but not the recti.

5. It thus seems that the load on the intervertebral discs is not necessarily so great as Bradford and Spurling calculated, but can remain within safe limits. It is hard to give accurate figures for the amount of load that is taken off the spine in this way, but an estimate would put it at several hundred pounds. The importance of a reflex contraction of the abdominal wall during effort as a protective mechanism for the spine must therefore be appreciated. Voluntary contraction may also be called upon to increase the intra-abdominal pressure and so reduce the load on the discs. This is done by many weight lifters.

1. At an operation for recurrent posterior dislocation of the shoulder observations were made on the mechanism, head defect, method of reduction, and the position of greatest stability.

2. Experimentally, avulsion of the glenoid labrum in a monkey was shown to be capable of sound repair without operation.

3. In the treatment of primary posterior dislocation it is suggested that the position of abduction, lateral rotation and extension is favourable for the approximation of the stripped labrum and capsule to the glenoid rim, and for an effective buttress after cicatrisation.

4. If the risk of recurrence is to be reduced to a minimum the shoulder should be retained in the position of greatest stability for at least four weeks, to allow firm union of the avulsed soft tissues.

5. This position for an optimum buttress would also apply after surgical repair for recurrent posterior dislocation.

1. Twenty-eight patients subjected to excision of the coccyx for coccygeal pain during the last ten years have been reviewed.

2. No constant means of selection appears to have been used in recommending these patients for operation, and, in retrospect, no factor in the history or examination emerges as reliable for making such selection in the future.

3. Operation may be recommended as likely to provide a cure in about 45 per cent and to give worthwhile relief in another 45 per cent of cases.

4. When conservative treatment has succeeded, operation will not, of course, be required, but failure of conservative treatment is not an essential pre-requisite in recommending operation.

5. If more care were taken to eliminate the markedly psychoneurotic patients the worthwhile results of operation could probably be increased even above 90 per cent.

6. Excision of the coccyx is certainly a useful operation and should not be discarded.

1. "Reed" osteotomy has proved a satisfactory method for the correction of torsional deformity of the tibia and of associated minor varus or valgus deformity.

2. It is an "osteotomy in continuity" and maintains stability of the bone.

3. The position of the limb may be adjusted at the first change of plaster.

4. Three cases of non-union occurred in thirty-eight operations.

5. The operation should not be done on adults. Perhaps it may be wise to reserve it for even younger patients because its success depends on the pliability of cortical bone, which rapidly diminishes with increasing age.

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

1. The influence of various methods of preserving bone on the calcifying mechanism of the tibial epiphysial cartilage of rachitic rats was studied. An in vitro calcification technique was employed.

2. Preservation by deep freezing, aqueous merthiolate, boiling, or acetone inactivated the calcifying mechanism.

3. The inactivation was reversed with calcium ions, most readily in the deep-frozen bones, less readily in the merthiolate treated bones, still less readily in the acetone stored bones, and least in boiled bones.

4. Exposure to calcium ions before preservation in the deep-freeze chest prevented inactivation.

5. The inactivation, reactivation and survival of the calcifying mechanism were confirmed by metachromasia studies.

6. The theory of the mode of action of calcium chloride on reactivation and survival of the calcifying mechanism is presented.

1. By the surgical division of the main capsular artery supplying the upper femoral epiphysis of the rabbit it is possible to cause changes which resemble those occurring in human osteochondritis.

2. The phase of anaemia (ischaemia and hypovascularisation) lasts in the rabbit less than fifteen days. The whole process lasts approximately ninety days, and only for one-sixth of this period does the femoral head suffer from a reduction in its blood supply.

3. After the fifteenth day until the end of the process the condition changes to one of hypervascularisation, which lasts six times longer than that of ischaemia or relative anaemia.

4. By the ninetieth day the whole process has lost its activity and only some permanent deformities remain. The vascular pattern is from then on the normal in the rabbit.

5. The "osteochondritic" changes cannot be elicited in the distal femoral epiphysis. The apparent reason is the presence of anastomoses between the main artery and other epiphysial vessels.

6. There seems to be reasonable experimental evidence, by implication, in favour of the vascular theory of osteochondritis of the upper femoral epiphysis in children.