No matter what the cause of congenital pseudarthrosis, nearly all observers are convinced that it is local and not general. A sufficient number of calcium and phosphorous blood readings. have been made in this series and others to show, in the light of present knowledge, that it is purely a local condition.

Any deformity that may be present must be carefully corrected either before operation or at the time of operation, so that forces will not be acting to pull the fragments out of alignment.

Before operative procedures are undertaken, the child must be in the best possible state of general health and he should be walking erectly with a caliper, so that the lines of weight-bearing are as nearly normal as possible. Massage of the part should be carried out to stimulate the circulation: heliotherapy in the summer, the mercury-quartz light in the winter, and contrast baths of hot and cold. In the aggregate, I am sure that all of these help. Cod-liver oil should be given almost constantly, and of course the diet should be such that plenty of essential vitamins, and calcium and phosphorus are provided. The administration of preparations from endocrine glands is entirely empiric and although they were used occasionally in this series their effect was not definite.

The bones should be examined roentgenologically at intervals to note the increase in metabolism as evidenced by increase in the size of the lower fragment and the enhanced density, particularly in the area of the fracture.

In spite of the poor results reported by practically all surgeons, I believe that if the child is in excellent general health and an improvement in the condition of the fragments is noted after supervision for a time, a well planned and well executed operation is worthy of trial. Just what the exact details of that operation will be must depend, of course, on the surgeon. When possible, bony contact of the fragments should be secured, even at the cost of slight shortening. In certain cases, in order to secure this, the fibula will have to be fractured. An autogenous massive graft, held closely to the freshened fragments I believe to be the best; of almost equal value, however, is the packing of as much spongy bone as can be obtained about the fracture line and the edges of the graft where it comes in contact with the fragments. Spongy bone, which can be obtained from the vicinity of the epiphyseal line by running a curet up through the opening from which the graft was lifted, is rich in osteogenic properties. The good results with the osteoperiosteal graft reported by French surgeons is encouraging and worthy of more attention.

The younger the patient, the poorer are the chances for success. I would not advise operating on any child less than six years of age. About the time of or after puberty is better. Therefore, if one attempt has failed, rather than cause more scarring and risk of infection by another operation, the child should be carried along with a well-fitting walking caliper until the age of puberty. Amputation should not be countenanced until all other means have failed, and certainly not until after puberty.

In the series of cases herein reported operation was performed in five cases with successful results in two (forty per cent.).