ARMY SERVICE FORCES FIFTH SERVICE COMMAND UROLOGICAL CONFERENCE AND SYMPOSIUM ON THE PARALYZED PATIENT 11-12 MAY 1945 NEWTON D. BAKER GENERAL HOSPITAL MARTINSBURG W. VA. ROSTER Major General Norman T. Kirk The Surgeon General .. 7 _ Major General Shelly V. Marietta Commanding General, Army Medical Center Brigadier General Raymond W. Bliss Chief of Operations, SGO Brigadier General Fred Rankin Surgical Consultant, SGO. Colonel B. N. Carter Surgical Consultants Division, SGC Colonel R. H. Kennedy Surgical Consultant, 2d Service Command Colonel Walter B. Wise Surgical Consultant, 3d Service Command Colonel I. M. Gage Surgical Consultant, 4th Service Command Colonel W. B. Parsons Surgical Consultant, 6th Service Command Colonel E. a. Noyes Surgeon, Fifth Service Command Colonel C. S. Beck Surgical Consultant, 5th Service Command Colonel D. C. Elkin Chief of Surgical Service, Ashford GH Colonel L. T. Peterson Orthopedic Consultant, SGC' Lt Col C. W. Cutler Surgical Consultant, 1st Service Command Lt Col Frank Mayfield Chief, Neurosurgery, Percy Jones GH Lt Col T. P. Shearer Halloran General Hospital Lt Col Augustus McCravey Chief, Neurosurgery, Wakeman GH Lt Col C. S. Stone Chief, Surgical Service, Wakeman GH Tt Col P L Preston Orthopedic Consultant, 5th Service Command Lt Col n! D. Hall ■ Chief, Surgical Service, Crilc GH Lt Col 0. E. Nadeau Chief, Surgical Service, Fletcher Gh Lt Col Franklyn Rice Chief, Surgical Service, Billings GL Lt Col Spencer Braden Chief, Surgical Service, Nichols Gil Tt Col E. A. Kahn Returned from ETC Lt Col W, H. McGaw Chief, Orthopedic Service, Walter Reed GH Major S. L. Raines Surgical Service, Thomas M England GN Major J. J. Joelson *sst Chief, Surgical Service, Orile GH Major F. C. Hamm Chief, Urological Section, Wakeman GH Lt Col Barnes Woodall Chief, Neurosurgery, Walter Reed GH Major G. C« Prather Chief, Urology Section, Ashford GH Major A. J. Leader Ward Officer, General Surgery, Fletcher GH Major Robert Kelly Chief, Orthopedic Surgery, Ashford GH Major M. P. Knight Chief, Orthopedic Sect-uon, Ciile GII Maior William Antopol Cnicf, Laboratory oerviee,- Billings GN mX R.T. Sauer Chief, Urology Section, Fort Knox F.cg Heap Major J. J. Roth Chief, Urology Section, Fletcher GH Major George Maltby Chief, Neurosurgery section, Ashford GH Major S. R. Hoover Urologist, Fort Knox Regional Hospital Captain J. H. Semans Chief, Urology Section, McGuire GH Captain G. Baumrucker Hines Veterans Facility . Captain Harold Lipshutz Asst Chief, Urology Section,■eakeman GH Contain H. A. Harper Nutrition Consultant, 5th Service Command Contain c! c! Miller Chief, Urology Section, Billings GH Captain W. C. Ward Asst Chief, Neurosurgery Section,Ashford GH Captain H. O.’.Ltpsky Chief, Urology Section, Nichols GH Dr*. W. H. Toulson University of Maryland, Baltimore, Md. Dr. John E. Howard Johns Hopkins University, Baltimore, Md. Dr. Hugh Jewett Johns Hopkins University, Baltimore, Md. Dr. V, E. Holcombe Charleston, W. Va. NEKTON D BAKER GENERAL HOSPITAL Colonel E. L. Cook Commanding Officer Lt Col J. B. Talley Executive Officer Lt Col D. H. Poor Chief Surgical Service Major F. W. Alexander Chief, Otorhinolaryngology Major C. W. Elkins Chief, Neurosurgery Major S. A. Fox Chief, Ophthalmology Major C. S. Hertz Asst Chief, Surgical Service Major G. M. Miller Chief, Medical Service Major W. H. Steffensen Plastic Surgery. Major H. A, Swart Chief, Orthopedic Section Major P. W. Sweetser Director of Reconditioning Program Major E. T. Thorsness Chief, Laboratory Service Major J. J. Michaels Chief, Neuropsychiatry Major J. M. Noeckcr General Surgery Major W. A. Lange Plastic Surgery Major H. E. Abel Dermatology Cnpt H. V. Agin Chief Neurology Section Capt D. E. Barker Plastic Surgery Cant R. P. Buckley Plastic Surgery . Capt J. E. Cameron Asst Chief, Neurosurgery Section Capt Norman Learner Chief, Cardiovascular Section Capt W. R. Minnich Asst Chief, Medical Service Capt 3. A. Molle Chief, Open Lard Section Capt R. L. Payne Plastic Surgery. Capt D. D. Pelliciari Plastic Surgery Capt G. G. Perry Plastic Surgery Capt B. P. Petroff Chief, Urology Section Capt J, Y. Phillips nsst Chief, Neurosurgical Section C fpt J L. Rothfeder Chief of Physical Therapy section Capt D. T. Shaw Asst Chief, Plastic Surgery Capt J. vV, Shuman Chief, Anesthesia Section Capt C. R. Sullivan Neurosurgery Capt B. R. Vincent EEMT Capt C. D. Wilson Chief, Radiology Section Capt Biagio Franco General.Surgery Capt R. J. Thomas Asst Chief, iuiesthesia Section Capt Jacob Rcber Asst Chief, Ophthalmology Capt R. E. Hanford Plastic Section Capt S. E. Turel Neurosurgery Capt C. M. Steer General Surgery Capt A. H. Kramrn Orthopedic Surgery Capt D. M. Kraus Radiologist Capt A. C. Naclerio Chief, Closed Lard Section Lt S. B. Fowler Asst Chief of Orthopedic Section Lt R. J. Holbrook Neurosurgery Lt 11. A. Jacobs Biochemist Lt W. B. Mi 11s Chief, EECG Section Lt Melvin Newman Orthopedic Surgery Lt G. P. Perakos Chief, Gastro-Intestinal Section Lt Samuel Rosner Neurosurgery Lt F. V. Lucas Bacteriologist Lt C. A. Young Ophthalmology Lt R. T. Porter Neuropsychiatry Lt C. W. Umlauf Neuropsychiatry Lt F. J. Gilbert Neuropsychiatry Lt J. D. Frazoni Neuropsychiatry Lt D. D. Mark Neurology • Lt W. B. Milton PROGRAM 11 May 1945 MORNING SESSION Lt Col Poer Presiding Speaker • Page Colonel Cook - Opening Remarks 1 General Rankin - Opening Remarks 1 Capt Lipshutz - "Non-specific Urethritis and Prostatitis in the Army" 1 Discussion of Capt Lipshutz’ Paper 6 Major Leader - "Tuberculous Epididymitis" 7 Discussion Major Leader’s Paper 9 (Meeting Adjourned to permit Visit to Urological Clinic and Ward) General Kirk - Remarks 11 General Marietta - Remarks 11 General Bliss - Remarks 11 Major Joelson - "Urinary Calculi in Recumbent Patients" 11 Major Hamm - "The Non-$urgical Management of Stones" 18 Discussion of Major Joelson's and Major Hamm's Papers 22 AFTERNOON SESSION Lt Col Mayfield Presiding Major Prather - "War Injuries of the Urinary Tract" 28 Discussion of Major Prather's Paper 34 Major Elkins - "Neurological Aspects" 36 Lt Col McCravey - "A,Plea for. Exploration of the Spinal Canal and Cauda Equina Injuries" 38 Discussion o.f Major Elkin's rand Lt Col McCravey’s Papers 40 Capt Petroff - "Urological Aspects" 42 Capt Ward - "Associated Complications in War Wounds of the Spine" (Paper presented was written in collab- oration with Major Maltbjr) 46 Discussion of Capt Petroffs, Capt Ward's and Major Maltby's Papers 50 Capt Barker - "Surgical Treatment of Decubitus Ulcers" 54 Capt Harper - "The Nutritional Aspects of the Care of the Paralyzed Patient" 56 Discussion of Capt Barker's and Capt Harper's Papers 62 EVENING SESSION Colonel Noyes Presiding Speaker Page Major Kelly - "Dermatome Grafts for Chronic Osteomyelitis" 65 Lt Col Knight - "Obliteration of the Defect in Bone in Cases of Osteomyelitis Closed by Dermatome Grafts" 67 Lt Col Preston - "Dermatome Grafts on a Production Basis in the Fifth Service Command" 71 Discussion of Major Kelly's, Lt Col Knight's and Lt Col Preston's Papers 73 Movie on the Paraplegic Patient Taken at Newton D Baker General Hospital 12 May 1945 ■FINAL SESSION Major Prather Presiding Capt Cameron - "Ambulation and Support” 80 Lt Col Poor - "Daily Care of the Paralyzed Patient" 82 Lt Col Stone - "The Future of the Paraplegia" 84 Discussion of Capt Cameron’s, Lt Col Peer's and Lt Col Stone’s Papers 88 Capt Rappaport - "Post-Mortem Findings in Six Cases of Traumatic Transverse Lesions of the Spinal Cord" 92 Major Hamm - "Urological Problems in the Convalescent Center" 96 Capt Miller - "Surgical Urology from the Viewpoint of the Army, Including Congenital Anomalies of the Urinary Tract and their Treatment" 97 Major Leader - "Extraction of the Law-Lying Urethral Cal- culi by Improved Catheter Loop Extractor" 102 Discussion of Capt Rappaport's, Major Hamm's, Capt Miller's and Major Leader's Papers 106 11 MY 1945 Morning Session Call to Order - Lt Colonel David H. Poer, Presiding. The first meeting of the Fifth Service Command Urological Conference wi3JL now come to order. It is our pleasure to have our Commanding Officer, Colonel Cook, address us at this time. j COLONEL COOK; It is indeejd a pleasure to have you with us today at this Uro- logical Conference and Symposium on the Paralyzed Patient sponsored by the Fifth Service Command. I want to welcome you to the Newton D. Baker General Hospital and hope that we have a nice and profitable meeting. I want to in- troduce at this time General Fred W. Rankin, Colonel E. A. Noyes and welcome all the officers and guests with us today. GENERAL F. W. RANKIN: Colonel Cook and guests. I suppose I speak in the place of The Surgeon General who is not here to speak for himself, but who will be here this afternoon. I am sure he would say that, if he were here now, he would be highly pleased with the program which has been prepared"for you and with the turnout. I have certainly looked forward with a great deal of pleasure myself to the program, particularly the treatment and care of the paralyzed patients in the Army. I think it has been one of the outstanding accomplishments. 1 know of no other place where it has been accomplished in a better way than the Fifth Service Command. I look forward to the program with a great deal of pleasure. COLONEL PC PR: Because of the fact that General Kirk and other guests will arrive later in the morning we have attempted to shift some items on the pro- gram in order to allow’ for a visit to the Urological Clinic and any wards you care to visit. We will go ahead with the program at this time with a break at about 0930 and reconvene here at 1100. There has also been a request that the arrangement of the papers be changed and I wonder if Captain Lipshutz would be ready to go ahead at this time. The first paper will be ’’Non-Specific Urethritis and Prostatitis in the Army" by Captain Harold Lipshutz of Wakeman General Hospital. CAPTAIN HAROLD LIPSHUTZ: It can probably safely be stated that the greatest number of cases seen in the Urological clinics of the Army General Hospitals are comprised of non-specific urethritis and prostatitis. These are, plebeian diseases, yet of vital importance from the military point of view. Wherein lies the importance to the Army? First - Loss of manpower hours from active military duty by the loss of the soldier’s time during the repeated and often unnecessary prolongation of attendance at Cut-Patient Clinics. Second - Loss of manpower hours from active military duty through the unnecessary hospitalization of cases that can, and should, be treated through the Out-Patient Clinic. Third - Loss of manpower hours from active military duty by the unnecessary prolongation of types of therapy where no results are being attained. Fourth - Lastly, the loss of efficiency. 'Here, with certainty, it might oe said that any individual affected with a urethral discharge, and in this respect a soldier is no different than any other individual, is a temporarily demoralized individual, whose main thoughts are constantly centered on the dis- ease of that part of the body, the normal health of which is so essential in the lives of each one of us. (Slide to Illustrate) What are some of the contributory factors involved in the above four premises? First - The lack of awareness, which exists in both civilian medical practice and in the Army, that the common underlying etiological factor in persistent and recurrent non-specific urethritis is not a chronically in- fected prostate, but chronic infection of the glands of Littre, situated along the floor of the urethra. (Slide to illustrate). Every acute infection of the urethra is accomplished in varying degree by involvement of these glandular structures. In many cases of urethritis, dependent on the severity of the .m- flamatory process, obstruction of these glands of Littre is a common sequel, and quite often, small, minute abscesses are present during the acute phase of the infection. Fibrous scarring of the urethral mucosa about the small glandular duct is the pathological explanation of the chronic residual retention of pus. Unfortunately, many cases of recurrent urethritis are kept under constant^and repeated prostatic1 massage whan at no time has a sound been passed to evaluate the pathology present in the urethra proper, nor, in many cases has therapy been"applied to the diseased areas directly involved. Second - "Sulfonamides and penicillin will cure the diseases under dis- cussion in many cases. However, there is a large percentage of cases, in which both sulfonamides and penicillin have absolutely no effect. Now, with both penicillin and sulfonamide therapy, result of therapy should be rapid and ob- _ jective, quickly discerned. Yet, despite this, many cases, under nospitalization for clinical care, are continued under either or both of these forms of therapy when failure to obtain a quick beneficial effect lias resulted. Parenthetically, it might be stated that we all know that the prostatic and urethral chronic infection may or may not be secondary to antecedent gono- coccal infection; but we do not know that some virus, filtrable or otherwise is not at fault in some of these cases. This possibility must be kept in mind in those cases, resistant to the more recent methods of therapy just described. What plan of therapy, in the Army, might be offered for the treatment of the diseases under discussion? The following plan is respectfully offered, having proven of value to the author in the therapy of non-specific urethritis and prostatitis in the Army. First - No soldier affected with chronic prostatitis or chronic urethritis should be hospitalized in a General Hospital, but should be treated on an Out- Patient status, unless there is a flare-up with an acute comp-Lication such as prostatic abscess, severe hemorrhagic urethritis or acute .epididymiu-uS. Second - And extremely important, a brief, stern and concise statement to the patient of the necessity of absolute cooperation in an attempt to avoid unnecessary sexual excitement. It has been of help to the auuhor to ask the soldier whether he would rub an acutely inflamed eye or a severe boil, on his arm, and what would happen if he did. Psychologically, tnis question has a good effect. Third - The insistence on the dietary avoidance of all spices and alcohol. Fourth - The management of the acute non-specific urethritis, and the acute phase of recurrent infection of the urethra, varies witn the preference of the individual urologist, who will usually employ that method of therapy which has given him the best results. The author's plan is to avoid any local treatment or instrumentation of the urethra during the acute fuare-up.. The guide for' local therapy is the presence of two glasses ox clear urine in a two glass specimen study, the presence of no shreds being no contra-indication to active local therapy. Fifth - ORAL THERAPY. Here sulfonamides receive prior employment. All cases are given an initial course of therapy with either sulfadiazine thiazole, but the use of the drug is not continued longer than v6 hours if im- provement is not marked. The plan has been to give 15 grains, 4 times dailj for a period of 5 to 7 days, and then 7J grains, 4 times daily for ar. additional 7 to 14 days, if improvement is continuous and no contra-indication arises. When the sulfa drugs have failed to produce a rapid improvement two (2) drugs have been of extreme value to the author over a period of years in the handling of non-specific urethritis, two old drugs, with the use of which many of you will probably not be in agreement. The two drugs are Oil of Sandalwood and methenamine; the latter in the form of a commercial preparation called Hexalet, produced by Biedel and Company. Oil of Sandalwood is given m aoses of minims XV,, 3 times daily after meals, with a glass of water. (Caution should bo given that a backache of no consequence is apt to be produced). The latter drug, Hexalet, has been used because of the greater tolerance shown by the digestive system, and because of the contained self-acidifier, sulfa-salicylic acid. Therapeutic use of either of these drugs is prolonged beyond a period of one week only when improvement is continuous. If one of these drugs does not help, then the other is used. Sixth - Penicillin. Since this therapeutic agent is needed for more serious cases, its use should be reversed for those cases which are disabling, and when all ether treatments have failed. Seventh - LOCAL THERAPY is necessary in a high percentage of cases in order to completely cure the infection present and to prevent recurrences. The treatment employed consists of antiseptic applications and astringents to the urethra, and sounding. Here, it has always been of value to the author to avoid the use of any strong medication. The preference has been for many years to make use of either aqueous Mercurochrome, Neo-silvol, or 5% sil- ver protein such as Solargentum applied throughout the urethral tract, under reducing pressure by injecting the solution through a Keyes-Ultzman cannula, injecting the solution as the instrument is being withdrawn, in order to avoid undue pressure in the region of the verumontanum. The most important medica- ment, and one that almost of necessity must be used because of its astringent action, to finally clear up resistant urethritis is Silver Nitrate, the percent of solution is not to exceed 2%, the optimal probably being 1%. Eight - Sounding. Herein lies the secret to prevention of recurrences. Unless severely scarred, contracted areas about- the glands of Littre along the urethral floor are stretched, and free drainage is given to the badly, chroni- cally infected glands, recurrence is usually the rule, rather than the exception. Sounding should be at weekly intervals for at least six (6) treatments, with as large a sound as can be passed, but not beyond the size of a #32 French. Ninth - Concerning prostatic infection. In civilian'- life, foci of in- fection should be searched for and cleaned up. In the Army, this is not al- ways too practical, especially as concerns tonsillectomy on a large scale, be- cause of the loss of manpower hours time to the Army. Abscessed teeth certainly should be removed. For the purpose of the Army, prostatic massage need not be continued forever. When, after a reasonable period of prostatic massage, aulxon-r amides or other oral therapy, and possibly a small amount of Penicillin, there remain a moderate quantity of i/BC’s in the prostatic fluid per high power field of the microscope, the soldier should be discharged, if he is symptom-free, with no evidence of urethritis. (Slides to illustrate point in discussion by review of cases) The following slides contain brief resumes of the histories of cases of. non-specific urethritis that have been cleared up by employment of the regime just outlined. Most of the cases, chosen from a large series of similar ones, are cases in which Penicillin and sulfa therapy have failed to effect a curs- or at least have failed to keep the soldier on duty, and not mentally disturbed. SUMMARY The prime purpose of treatment in the Army, of both chronic prostatitis and non-specific urethritis, is directed to keeping the soldier on full, active, military duty, free of any demoralizing influence. Hospitalization in a hos-r pital ward should be kept to a minimum, limited in prostatic disease to the. severe, acute parenchymatous prostatitis and prostatic abscess; in urethritis, to the severe, hemorrhagic type, or that accompanied with an acute complica- tion such as acute epididymitis or conjunctivitis. CASE #1 (Sulfa-Resistant Urethritis) Appeared at WGH GU Clinic 20 February 45 Diagnosis: N.S. Urethritis, Secondary to Acute Gonorrhea (July 1944) Duration and type prior treatment: FOUR MONTHS, including sulfadiazine. Therapy employed at WGH GU Clinic: oil of Santali orally, 1% silver nitrate locally two times, sounding one time (Palpable glands of Littre). Date G.U. clearance: 13 March 45. No symptoms, no Signs. Duration of urological therapy WGH GU Clinic: 22 DAYS CASE #9 (N.S. Urethritis Resistant to Penicillin) Appeared at WGH GU Clinic: 10 April 45 Diagnosis: N.C. Urethritis. Duration and Type prior treatment: ONE MONTH, including 200,000 units of penicillin Type of Therapy employed at WGH GU Clinic: Oil of Santaii orally. Date G. U. clearance: 17 April 45. No symptoms, no Signs. Duration of urological therapy WGH GU Clinic. 7 DAYS CASE #2 (Chronic Urethritis Arrested by Oral Therapy) Appeared at WGH GU Clinic: 30 January 45 Diagnosis: N. S. Urethritis, Secondary to Acute Gonorrhea (August 44) Duration and type prior treatment: FIVE MONTHS, including 800,000 units of Penicillin, 1 course sulfathiasole, 1 course sulfadiazine. Therapy employed at WGH GU Clinic: Oil of Santaii orally. Date G. U.’clearance: 15 February 45. No symptoms, no Signs. Duration of Urological therapy at WGH GU Clinic: 16 DAYS CASE #11 (N.S. Urethritis, Recurrent, Hemorrhagic, Severe, Complicated by Acute Conjunctivitis) Appeared at WGH GU'Clinic: 6 February 45 Diagnosis: N.S. Urethritis, Hemorrhagic, Recurrent. Duration and type prior treatment: EIGHT DAYS; present attack no treatment. (Previous attack July to August 44 cured by sulfadiazine orally and Argyrol locally) .Type.of.therapy employed WGH GU Clinic: Oil of Santaii, Hexalet, Sulfadiazine orally, (.improvement noticed with use of latter two drugs); b% Mercurochrome, Nitrate, 1% Silver Nitrate, locally, sounding, (palpable glands of Littre). Date G.U. Clearance: Patient still under treatment. No symptoms, CASE.#12. (N.S. Urethritis, Hemorrhagic, antero-Posterior, Severe, Resistant to Penicillin and Sulfathiasole). Appeared at WGH GU Clinic: 14 February 45. Diagnosis: N.S. Urethritis, Acute Hemorrhagic, Severe. I Duration and type prior treatment: NEE WEEKS, including 600,000 units of Penicillin, 5-day course of Sulfathiazole, Type of therapy employed WGH GU Clinic: Oil of Santaii orally, Mercurochrome and 1% Silver Nitrate locally, Date G.U. Clearance: .13 March 45. No Symptoms. No signs. Duration of urological therapy WGH GU Clinic: 28 DAYS CASE #13 (N.S. Urethritis, Chronic, Cleared up by Local Treatment) Appeared at WGH Clinic: 1? January 45* Diagnosis: N.S. Urethritis, Chronic. Duration and type prior treatment: TWO YEARS, type prior treatment unknown. Type of therapy employed WGH GU Clinic: Urethral Sounding, 1% Silver Nitrate locally (Palpable glands of Littre). Date of G.U. Clearance: 15 February 45. No Symptoms, few shreds in urine. Duration of Urological Therapy WGH GU Clinic: 29 DAYS CASE #8 (N.S. Urethritis Secondary to Acute Gonorrhea, Resistant to Penicillin and Sulfathiasole) Appeared WGH GU Clinic; 10 October 44 Diagnosis: N.S. Urethritis, Secondary to Gonorrhea. Duration and type prior treatment: TWO MONTHS, including 500,000 units of Penicillin, a 10-day course of Sulfathiazole. Type of Therapy employed at WGH GU Clinic: Oil of Santali orally. Date G.U. Clearance: 7 November 44. No symptoms, no signs. Duration urological therapy WGH GU Clinic. 14 DAYS CASE #3 (N.S. Urethritis Resistant to Penicillin) Appeared WGH GU Clinic: 20 December 44 Diagnosis: N.S. Urethritis. Duration and type prior treatment: TWO IQNTHS, including 600,000 units of Penicillin, one 5-day course of Sulfathiazole. Type of Therapy employed at WGH GU Clinic: Hexalet orally, instillation 1% silver nitrate, 1 time. Date G.U. Clearance: 1 January 45. No Symptoms, No Signs. Duration urological therapy at WGH GU Clinic. 12 DAYS CASE #10 (N.S. Urethritis Resistant to Sulfa) Appeared at WGH GU Clinic: 5 January 45 Diagnosis: N.S. Urethritis, Chronic, recurrent. Duration and type prior treatment: SIX YEARS, numerous courses of sulfa drugs. Type of therapy employed WGH GU Clinic: Hexalet and Oil of Santali orally. Date G.U. Clearance given: 10 February 45. No symptoms, no signs. Duration of urological therapy WGH GU Clinic: 36 DAYS CASE # 5. (N.S. Urethritis Resistant to Penicillin and Sulfa) Appeared WGH GU Clinic: 5 December 44. Diagnosis: N.S. Urethritis. Duration and type prior treatment*. TWO MONTHS, including 1.00,000 unies of penicillin 1 course of Sulfa. . ••••■ * • Type of therapy employed WGH GU Clinic: Hexalet orally, 1% Silver Nitrate into the urethra, sounding one time (Palpable glands of Lrttre). Date G.U. Clearance given: 12 January 45. No Symptoms, No Signs. (Except few shreds in urine). Duration of urological therapy at Y/GH Gd Clinic: 28 DAYS CASE #4 (N.S. Urethritis, Resistant to Sulfadiazine) Appeared at WGH GU Clinic: 20 February 45 Diagnosis: N.S. Urethritis Duration and type prior treatment:' TIP MONTHS» including 6-day course of Sulfadiazine. Type therapy employed at WGH: Oil of Santali orally. Date G.U. Clearance: 13 March 45. No Symptoms. No signs. Duration of urological therapy WGK GU Clinic: 22 DaYS LT COLONEL. P0£H: Capt Lipshutz* paper is noxv open for discussion. MAJOR JOSEPH J RGTH: Gentlemen. I have had the opportunity for several months to see a great number of these cases at Camp Campbell. At that time, we had two divisions of troops, including some detachment troops from the 2nd Army. We ran a GU Clinic three times a week. There was never a time while those troops were there that we saw less than fifty or sixty cases of non- specific urethritis and prostatitis at each clinic. So you can readily see what the loss of manpower is. I am in perfect agreement with Captain Lipshutz that these patients should not be hospitalized because they do not ordinarily get daily treatment, except drugs by mouth. Furthermore, we do not want to * totally disable them. I have found that these cases come under three categories: (1) Residual prostatitis and urethritis resulting from acute gonorrhea. ne find a fair number of cases that have a chronic urethral discharge, giving the appearance of gonorrhea and some of these last a long time. (2) We find those cases due to bad sex hygiene. These cases usually start with a simple, ordinary con- gestive type of prostatitis where the patient complains of mild frequency and occasional burning, and on examination we find nothing. These cases, if allowed to go on, become secondarily infected. (3) We have the third group that we can divide into two classes — where foci of infection exist elsewhere in the body or the*,cause unknown. There is just one drug that I would like to add to those mentioned by Capt Lipshutz. In these urethral cases, the azo dyes, such as pyridium or perenium have helped where other drugs have failed. Dr Walters of New Orleans recommends them and I have tried them in several cases. They have helped in a great number of cases. Occasionally, where the urethritis is ultra-resistant and apparently will respond to nothing, and we have seen such cases, I thin): ii would be advisable to fulgurate the glands of Littre endoscopically. LT COLONEL POER: Any further discussion? CAPTAIN B P PETROFF: I would like to ask Captain Lipshutz where he gets sandalwood oil? CAPTAIN LIPSHUTZ: I am glad that both of these subjects were brought up. About the azo dyes. Azo dyes are very fine. In urology we ail know that 3rou cannot depend on one drug, and the azo dyes are good. It is a problem to get these drugs in the Army. I am certain that I can make the statement that we have saved alot of manpower hours by the method that we have employed in our clinic. We have been getting the sandalwood oil through our Medical Supply Officer on a non-standard drug requisition. I am sorry to say that recently the use of both oil of sandalwood and Hexalet was turned down absolutely by the Office of The Surgeon General in Washington. We will probably have to resort to the use of the Methenamine, and hope the results will be good. - I know that I can safely say that we have saved many manpower hours for the Army and are willing to have our records checked to prove this. COLONEL C. S. BECK: This has been a very important problem in our hospitals, almost every General Hospital has a number of these patients. I think the policy of treating these patients on an outpatient status is to be recommended. LT COLONEL PQER: I will now introduce the next speaker, Major Abel J. Leader, who is speaking on '‘Tuberculous Epididymitis’1. MAJOR A. J. LEADER: The declining incidence of genital tuberculosis for the last two or three decades has paralleled that of other forms of the disease. For this, credit is due to a prophylactic consciousness that has resulted in improved hygienic standards, the tuberculin testing of cattle and dairy herds, ana early recognition and prompt and vigorous treatment of the disease when it does occur. Despite this we still see enough of genital tuberculosis to know that it is not a rarity, and the problems it presents are as perplexing as they were 20 or 30 years ago. The epididymis is now accepted as the primary focus of tuberculous disease in the genital tract by most urologists, consequently tuberculous epididymitis is almost synonymous with genital tuberculosis since it is almost always assoc- iated with tuberculosis of the seminal vesicles and the prostate, Hugh Young and his followers, who are in the minority, spoke of the disease as tuberculosis of the seminal tract, since it is their view that the early lesions are in the seminal vesicles and in most cases the epididymis is secondarily involved. Young therefore advocates removal of the seminal vesicles, portions of the pro- state when involved, the vas deferns, and the epididymis. When the disease is unilateral he believes that the opposite side does not often become involved following this treatment. Barney, whose views are shared by most urologists, believes that the disease usually begins first in the epididymis and that the lesions in the seminal vesicles and prostate improve and become quiescent when the epididymis and the distal portions of the vas are excised. In light of results and burden of proof rests with the proponents of the Young theory. Over 70 percent of the cases of epididymal tuberculosis are encountered in the age group which in most common to the army - that of 20 to 40 years. With more than ten million men in the services, it appears almost as though most new cases of epididymitis might be expected to come to our attention sooner or later. In'spite of the gravity and chronicity of the disease, these patients can be helped, and it is believed that a restatement of what we know concerning the operative and non-operative methods of treatment will be helpfulc. Some of these problems require discussion from the Army standpoint. What are we going to do with these patients after they have been operated? Should these patients be carried in isolation and how far should we go in isolating them? What should we do with these patients after their wounds heal? What should be the Army policy with respect to the treatment of sinuses developing postoperatively, and should hospitalization be continued during this period? First, it is known that genital tuberculosis is rarely, if ever, a primary disease. The mediastinal and broncho-pulmonary nodes, the lungs, the kidneys, or the bones are actively involved in most cases,and in some several active foci may be recognized. Consquently the prognosis depends largely on the general condi- tion of the patient and the extensiveness and activity of the tubercular lesions elsewhere, Epididymal tuberculosis is a local manifestation of a systemic di- sease and a thorough work-up of the patient generally is always indicated before any surgery is contemplated. One must be especially alert for a possible renal focus. Braasch in 1920 reviewed a series of 234 cases of renal tuberculosis and found that 171, or 73 per cent of the cases, had genital infection. In this con- nection too, Bumpus points out that dysuria, usually described as one of the symptoms of genital tuberculosis, is in reality a symptom of renal involvement, for he was able to show that renal tuberculosis existed in 72 of 79 cases of genital tuberculosis presenting this symptom. Where a unilateral renal focus is demonstrable in conjunction with genital tuberculosis, nephrectomy is always indicated as a prelude to surgery on the epididymis, for it eradicates the reservoir which otherwise continues to feed infection into the genital tract. Most authorities advise against performing nephrectomy and epididymovasectomy at the same operation, and the latter is generally left for a later time. As to whether surgery should be done for genital tuberculosis in the Army, it is our opinion that it is justified in every case in which the condition is considered to have developed in line of duty. It is true that once the diagnosis is made the soldier with epididymal tuberculosis has no'further value.to the service, and on theoretical grounds, the surgery should properly be left to the Veterans* Administration Facility, but as with traumatic paraplegias, cases of genital tuberculosis require ’’stabilisation” and a good start is made toward stabilizing these patients by the surgical elimination of the active focus, whether it is in the kidney or the epididymis, or both. The only possible con- traindication we are apt to encounter in the Army is the presence of a na?f.comit'a-rfV bilateral renal tuberculosis, in which case surgery is out of the question and medical management is all that is possible. In civilian practice far-advanced pulmonary or bone lesions and well advanced tuberculosis of the en- tire male genital tract on both sides constitute further contraindications of surgery. Bilateral tubercular epididymitis, even with moderately advanced in- volvement of the prostate and seminal vesicles, is operable, for it has been conclusively shown that in a relatively large number of such cases the condition of the prostate and seminal vesicles will improve following surgery. Epididymovasectomy in the manner described by Cabot appears to be the pro- cedure of choice in surgery of the tuberculous epididymis. This operation in- cludes a-careful' dissection of the epididymis from the testicle, preserving the testi-cle, and removing the vas deferns well above the internal ring. The opera- tion is most satisfactorily done under spinal anesthesia. Because of the almost constant involvement of the vas, this is separated from the cord up to the ex- ternal ring. The vas is doubly clamped with curved Kelly clamps, divided a short distance above the epididymis and the cut ends are carbolized. The point of the clamp.holding the upper end is guided into the external ring and carefully pushed along the canal until the tip of the forceps lies at the internal ring. The handle of the clamp is then depressed and an incision about half an inch long is made directly over the tip of the clamp, which is thus exposed. The end of the vas thus exposed is grasped by another hemostat and the original clamp re- moved. The vas is then gently withdrawn and by continuous gentle traction and finger dissection as much of the vas as possible is withdrawn. It is then clamped deep in the wound, ligated, divided, its end carbolized, and it is per- mitted to drop back to the depths of the wound. The inguinal wound is closed with a single catgut stitch in the aponeurosis and another of silk or dermal closes the skin. Conservatism is the general rule with respect to the testicle unless its blood supply has been compromised in the dissection or unless the involvement of the testicle by tuberculosis is at all extensive. In such cases the testicle should be removed. Small superficial areas 01 involvement may be curetted and carbolized with excellent chance of preserving the testic3.e for its valuable internal secretions. Bleeding is carefully controlled and a small rubber tissue drain inserted to the surface of the testicle, to be removed in three days. The wound in the scrotum is closed with interrupted matress sutures of dermal, following which a snug suspensory dressing applied. The foregoing method offers excellent chance for primary healing. This is rarely the case when the epididymis is marsupialized as advocated by Keyes. As to the treatment of the uninvolved epididymis, although it has been shown that 45 to 64 percent of these will become involved subsequently, usually within a year, here too the treatment should be conservative. Ligation of the unin- volved vas does not prevent extension of the process, this being due to extension via the reticulated lymphatics or recurrent hematogenous dissemination. Those who favor bilateral epididymovasectomy argue that azoospermia occurs in 35 per- cent of all cases of epididymial tuberculosis, even when one side is clinically unirwclved. Bilateral epididymovasectomy seems justified where azoospermia is shown to exist since this usually means that the - apparently uninvolved vas is already occluded by a tuberculous lesion that cannot be palpated. Now that we have operated on our patient, what plans are wo going to make for him both as regards to his convalescence from surgery and for the immedia•■e future? It must be emphasized that surgery represents only a start in treatment and that these patients must continue hospitalization for at least six months and preferably a year following surgery. During this time they must be kept in bed and given the benefit of heliotherapy, high vitamin, high caloric diet, ultraviolet therapy and the best medical and nursing care. A sad experience of ours, in which an apparently healed incision broke down and commenced to drain immediately after the patient had inadvertently been given a furlough, brought home to us how important it is to divorce ourselves from sentiment in these cases. Regardless of how long a soldier has served overseas before he is sent to us, and how long it has been since he has seen his family, it is our duty to the patient to keep him at rest, in the hospital and in bed. The formation of chronic draining sinuses is one of the major complications of surgery for genital tuberculosis. These sinuses usually result within a few weeks after surgery when as a result of abscess formation the line of incision breaks down more or less completely resulting in the formation of a deep wound with profuse drainage which may continue for years. For such cases heliotherapy and local irradiation with the air cooled mercury vapor quartz lamp are inval- uable in promoting early healing, especially if the interval of time between the formation of the sinuses and initiation of this form of treatment is not pro- longed. Wang has demonstrated that the closure of these sinuses can be effected in about 4 months. This is in contrast to the much longer periods required in most of the cases not given the benefit of ultraviolet therapy. He emphasizes the importance-of regularity in treatments and of early treatment in obtaining the best results. The treatment of genital tuberculosis is a long-term proposition and one • to which the Veterans' Hospital is better adapted than is the Army General Hospital. -It has been stated that these patients require a minimum of 6 to 12 months of bed rest, heliotherapy, ultraviolet therapy, good food and excellent medical and nursing care. It is our opinion that such cases should be trans- ferred to a Veterans' Facility without delay following recovery from surgery.- *• Where the case is complicated by sinus formation shortly after surgery, we be- lieve that discharge should not be effected prior to closure of the wound by ultraviolet therapy. Overseas cases which have been operated on but in which sinuses have developed subsequent to operation should be carefully evaluated in an Army General Hospital for. possible renal involvement. If this work-up. is' negative the patient should be discharged from the service and sent to the Veterans' Hospital for further treatment. Current directives make an exception of officers and enlisted men of the first three grades, as well as enlisted men of long service. These patients are eligible for transfer to the Fitzsimmons General Hospital. * • Most General Hospitals do not have tubercular wards, since the incidence of cases does not warrant this. The question as to whether or not patients suffer- ing with genital tuberculosis should be isolated is one that deserves some con- sideration. 'While it is known that most of the purulent material discharged by the chronic tuberculous sinus does not contain the acid fast organism, still in a sufficiently high percentage of cases the discharge is infectious. The danger from the care3.ess handling of dressings saturated by the discharge lies, in the possibility that the pus may dry out and the organisms inhaled in sufficient concentration by those previously non-infected to start up the disease. For this reason re believe that care should be taken that all dressings should be immedi- ately burned, and that the clothing of the patient which has been soiled by the discharges should be specially treated. Inasmuch as these patients require con- stant bed rest, it is generally advisable to keep them in a separate room where such precautions as given above can be most easily followed throughout. Gf course if active open lesions in the lungs are demonstrable, the usual precautions as are taken with all cases with pulmonary tuberculosis should be strictly observed. A few words may be added concerning the use of tuberculin in the treatment cf genital tuberculosis. Opinion is divided as to its value, but some authori- ties feel that it is helpful but that it is by no means the most important factor in producing results. In closing, it appears from ail information available to us that early surgery and prolonged postoperative treatment as we have outlined offers the best hope for the successful treatment of genital tuberculosis, LT COLONEL PC Hi: The paper of Major Leader is now open for discussion. CAPTAIN G. 0. MILLER; I just wish to congratulate Major Leader on his splendid paper and presentation. There are two points that I think should be driven home. I think these patients dc markedly improve following surgery. We had a patient sent in from the 12th General Hospital in the Pacific. This boy had a tuberculous epididymitis that had been removed. The pathologist stated at this time that there was marked caseation of this organ and that he had marked involvement of the right lobe and right seminal vesicle. He was draining from an old sinus in the scrotum and I could not find any involve- ment of the prostate, clinically. Urine was repeatedly examined, I.V. check plates taken and to date we have not been able to find any evidence of tuber- culosis in this boy. He is now getting well. I also feel that this patient should not be left on the ward as it is impossible to teach these patients to properly handle their dressing if they are having a lot of discharge. There is always the danger that they will cause infection of other patients. LT COLONFT. POUR: There are several visiting civilian doctors to whom we wish to extend the provileges of the floor, xre there any further comments? COLONEL C. 5. BECK: Several of these patients with tuberculous epididymitis are on the Urological Service of practically every General Hospital that I have visited. How should they be placed on isolation precautions or should such precautions be disregarded? Major Leader recommends a modified isolation regime, in that, each patient should be placed in a side room off the ward and that the dressings be burned. I think these precautions are to be recom- mended. These patients are discharged from the Army after the wound is healed and drainage is stopped. I question the advisability of placing a drain in the wound at the time of operation. A drain might allow the entrance of secon- dary infection and this in the presence of tuberculosis might become chronic. DR. LT. H. TOULSON: In regard to this question of surgery in tuberculosis, a few years ago there was a symposium connected with a meeting of the American College of Surgeons, and it was generally agreed that tuberculosis of the urinary tract was a manifestation of the general disease and that all of these cases should have, if possible, presurgical therapy in the up-building of the patient. Everyone seemed to feel that the pathology would fibrose the lesion . or bring it a very rapid fulminating condition, and would prove in a short time whether this patient had a surgical chance or not. You don't see much tuber- culosis and I understand that in the service you see little or none. I am re- minded of a patient I had some time ago. This patient of mine had a unilateral renal tuberculosis, had complete genital tuberculosis, and after about six months of sanitorium care he gained thirty pounds in weight, his resistance improved tremendously and we went ahead with a successful nephrectomy. He was can in- telligent young lawyer, and the question*came up about the risk if married. He did that very successfully. He has a lovely, healthy daughter. There has been no evidence of any recurrence. In closing, I would like to say that I think we ought to regard surgical tuberculosis as a local manifestation of a general- ized infection. MAJOR J. J. JOELSON: In regard to drainage, as a general principle, it is wrong to drain tuberculous lesions. In the scrotum, however, it is safer to put in a drain for the first twenty-four hours to avoid the danger of getting a hematoma. Our cases of tuberculous epididymitis at Crile General Hospital have been kept in bed for some time before operation in order to give the sub- acute inflammatory reaction a chance to subside. MAJOR G. C. PRATHER: The discussion so far and the presentation of the problem has made the diagnosis appear fairly simple. As Dr. Toulson and I were just saying privately, we sometimes have difficulty in regard to diagnosis if no scrotal fistual exists. The individual who has a thickened epididymis may re- present a chronic non-tuberculous infection or a chronic tubercular one. This raises the question as to how far one is to go in the military to prove or dis- prove the diagnosis of tuberculosis. Let us assume that we have ruled out the upper urinary tract and that the prostate is not abnormal to palpation, but the thickened and irregular epididymis is obvious. I would like to ask those who determine policy, which is rarely the urologists themselves, as to what the military wishes us to do and how far we are to go in this matter. If one is able to make a probable clinical diagnosis do they wish us to pursue a period of bed rest in a named general hospital, is the patient to be transferred to Fitzsimmons General Hospital with simply the clinical diagnosis, or should epididymectomy be performed. Dr. Toulson and I are in agreement as to certain ways of handling these cases, namely by non-surgical measures if possible, but others may think differently. Re usually receive instructions, and I would like to ask what those instructions are in regard to this problem. GENERAL F. U. RANKIN: I do not know anything about policies of this type except common sense. Major Prather has made it seem a lot harder than it may be. As a matter of fact, we do not have much of this in the Army that is h , Injection of draining sinuses with lipiodol has helped in determining the extent of the cavities, their locations, and frequently the indicnt?d treatment. LT* COLON ML PRANK MAYFIfLP: .These two papers are now open for discussion* Discussion on paper presented by Captain Lilliam C* Ward, Ashford General Hospital, on '’Complications and Causes of Death,” and paper presented by Captain Doris potroff, Newton D. Baker General Hospital, on ’’Urological As- pects* ” COLON.TL IPYS MIMS GAGD: The tiro urological complications thr.t we have seen are infection and stone formation. The majority of all these cord cases have urinary infection of varying degrees with several types of bacteria, both cocci md bacilli, proteus being one of the most difficult to handle. However, the urologists have accomplished excellent results in treating these oases, and their treatment in its various phases is established uponsound urological principles. Urinary calculi, however, is a serious menace to these ccrd cases. About of the cord cases in our three Neurosurgical Centers in the Fourth Service Command have kidney, ureteral or bladder stone forma- tion. It has been repeatedly demonstrated that recumbent patients develop • urinary calculi. This is due. to increased absorption of osseous calcium and its excretion. It has been demonstrated by Flock that calcium phosphate is precipitated out in the kidney in a similar manner as the sulfonamides. Flock stated that by repeated X-ray examination, one could find early pre- cipitation in the calyces. He reported cases where he had demonstrated early precipitation of calcium and had removed same by washing out the kidney pel- vis with l/4fo acetic acid solution, I feel confident th*t are are having the* same calcium precipitation in our cord cases and should take steps for their early recognition and treatment. He have established a routine regimen mobil- ity, diet and copious fluid intake. However, 1 would recommend that repeated X-ray examination of the urinary tract of the cord cases be done, from their arrival to their discharge. This should also apply to the Orthopedic Ser- vices in the cases of prolonged immobilization of the patients with fractures. If wo do this I believe stone formation and its sequelae can be prevented, A most interesting observation in these cord cases is that even though they have all of the environmental requisites for the development and pro- pagation of phlebothrombosis, there has not been a single instance of this complication in over a hundred cord cases in our Command, This is true both from the local and systemic effects of phlebothrombosis, ,ro -have had no infarcts of the lung in any of our cord cases, - This, to me, is a most in- teresting observation and should be investigated thoroughly, as it may throw considerable light on this most interesting pathologic phenomenon which is so little understood from the etiological standpoint. Another complication which is not oncommon is for a simple decubitus ulcer to develop into one which rapidly destroys all of the integument down to the osseous tissue. I have seen the neck of the f-3nur, acetabulum and ilium exposed by ulceration, as well as extensive gangrenous sloughs over the sacrum in these cord cases. I feel that these complications of simple decubitus ulcer are due to the symbiotic relationship between the strepto- coccus and staphylococcus as recorded both experimentally and clinically by Meleney. The hemolytic streptococcus that produce skin gangrene as des- cribed by Meleney has been present in a few cases. Therefore, we should sus- pect either one or both of these clinico-pr,t hoi ogic states when a decubitus ulcsr takes on a rapidly spreading destructive process. The energetic treat- ment of these decubitU3 ulcers from a bacterologic standpoint with early skin grafting will prohibit ulcer complications and promote rapid healing. I feel confident that the majority of all complications that occur in these ’’cord cases” can be prevented, CAPTAIN HAROLD LIPOIINTZ: I know I can speak for Lt. Colonel Stone and Major Hamm in congratulating Captain Petroff for the fine work he has been doing here, I realize sono of the difficult situations that must have arisen, par- ticularly in getting adequate equipment. I want to comment on the use of cystoscopy in treatment of paraplegics at Vakeman General Hospital, Ira have found that cystoscopy is a necessary procedure. This has been impressed on us because of the great number of cases arriving at our hospital from over- seas with bladder calculi present on arrival. Recently, five out of seven cases presented multiple bladder calculi at the time of admission to the hospital. For this reason, we believe cystoscopy should be done as soon after arrival of the patient as is possible, and preferably within 48 hours. There is a point that should be stressed concerning the time of removal of all catheters. Cystonetric readings, although valuable, cannot be depended on, because the most important factor is the presence or absence o:"1 spasm of vesical sphincters, 1lion the sphincters are fully relaxed, the Cunningham incontinence clamp suffices for urinary control. In tho presence of good dotrussor function, accompanied with refractory spasm of the vesical sphincters, it is possible that electric destruction of the sphincteric control will bo the answer. I would like to ask one question of the neurosurgeons: Me have alwavs been taucht that automatic bladder function or voluntary bladder control cannot bo attained in the* presence of destruction of the third sa- cral nerve supply to the urinary bladder (llervi Srigontes), yet our best results with return of voluntary bladder control have boon in thoso cases of recovering partial paraplegia where these nerves have been damaged. "'ill the neurosurgeons please explain? LT. COLONX CONDICT hr, CUTLNR: Urological Aspects - All cases except one have shown'fYnecid typo of bladder paralysis on admission. Eighty percent have shorn no bladder or rectal sensations. The vast majority of cases are now appearing with suprapubic bladder draining. Only three_oases vrith perine- al indwelling catheters. Of sixty-seven cases, forty-two have had supra- pubic tube drainage, twenty urethral indwelling catheters, two had catheters through a perineal urethrotomy and three no catheters at all. The supra- pubic drainage cases closed spontaneously. In two of these urethral catheters were substituted for a short time. The perineal urethrotomy cases closed spontaneously after removal of the catheter. Two of the. twenty indwelling urethral catheter oases had developed periurethral abscesses requiring supra- pubic cystotomy. Only two of the sixty-seven cases have had full return of normal bladder function. The remainder have automatic bladders which -epipty periodically approximately every hour to one hour and a half. These patients have little or no control* Three cases admitted without catheters were found to have distended bladders with residual of 300 to 400 cc. end one with over- flow and incontinence. Tidal drainage treatment was instituted for the cases with suprapubic drainage in which the wound was fairly tight around the. tube. Following a week of sulfadiazine by mouth and boric irrigation, nandolic acid salt (cal- cium mandolate) by mouth and acetic,acid solution for tidal drainage wore used in the earlier cases. A large number of cases, however, tolerated this regime poorly. The present pi? n, which is more effective, employes boric acid solution five-tenths percent for tidal drainage. Sulfadiazine is used one gran four tines daily for seven days, with a similar quantity of sodium bicarbonate, fluid intake is kept at 3,000 cc, as long as tid? 1 drainage is used. If sulfadiazine is not well tolerated, twenty-five thousand units of penicillin is given every three hours until the infection is under control. Continuous drainage with irrigation is used in those caso-s in which the supra- pubic sinus is wide open and for those who .do not tolerate tidal drainage w well. The irrigating solution is 1 to 8,000 potassium permanganate. JTo complications other than a r are pyelonephritis have been observed. These 'cases have been fewer under the present system than when the mandelic acid therapy was employed. Four cases in which indwelling catheters through the urethra had been used developed epididymitis. Conclusions: That indwelling urethral catheters in these cases ere undesir- able) because of complicating infections and epididymitis. Bladder function has not returned more rapidly "where urethral catheters have been employed than with suprapubic drainage. Drainage through perineal urethrotomy wound has proven satisfactory in that is provides a good drainage and is not associated with conploations. Such wounds have closed rapidly after re- moval of the catheter. The number of cases in this group has been too small to draw conclusion. Tidal.drainage has succeeded, where appropriate, in keeping the bladder clean .and free of infection. It has' been.the general ob- servation that the development of automatic bladders is rather slower .in these paraplegic cases than in civil practice* It has been proposed that better and more rapid results might" attend the use of a .perineal urethrotomy with inch-rolling catheter permitting .the ..secondary surgical closure of supra- pubic cystostomy wounds, once infection has been controlled. It is be- ‘lieved that the automatic bladder would develop more rapidly under these conditions. * . CAPTAIN G. BAUIIkHCHNR; Captain Petroff has made a very complete summary of the urological complications of spinal cord cases. I vrould like to discuss some of our results on these cases from my services at the Gardiner Gonerhi Hospital and the Hines Veteran Hospital in Chicago. I would first like to show an unusur1 complication in one of these para- lyzed cases resulting in death. The bullet that tronssected the spinal cord, f-.lso cut the right uretoro-pelvic jf)nation and lodged in the diaphragm.' Shiodan injected into the bladder refluxed back up into both kidpeys ex- plaining his pyelonephritis. Dye injected into the right flank fistula showed extravasation into the right flank and made a pyelogram of the right kidney* Both trochanters vrero protruding through his largo hip ulcers. Excision of these made nursing care easier, hut his course vras rapidly down- ward and ho expired in spite of plasm, blood transfusions and sulfa drugs, Tho new information that we have now regarding the large amounts of serum protein loss from these bed sores may bo the factor in pro- longing the lives in similar cases and preventing this severe emaciation that too often occurs in these cases with large bed sores. Tie do not use tidal drainage. 'To use a closed system of bladder lavage set up with a special two way clamp. It is fool-proof, simple and needs no specialized care. It can be easily taken care of by both patient and nurses. Simple pressure of the fingers allows bladder to be filled, release of the pressure, allows fluid to run out of the bladder. The height of the urinary drainage tube can be elevated to the level of the bladder, thereby keeping a certain amount of dilating bluid in the bladder in those oases which are extremely spastic. The believe by this technique to be able to correct the spastic and snail capacity bladder so that when automaticity does set in, the bladder will have a bigger capacity and be more elastic. Tre use a cystoneter which registers full bladder pressure and volume simultaneously. It has been our experience that those bladders with 100 to 150cc volume that can exert a pressure of over 40mm Hercury pressure either reflexly or by intra-abdominal pressure, will sueessfully empty to a low residual and need no further catheter drainage. Vie find that urethral catheters get along about as well as suprapubic and sometimes better if the? suprapubic catheter leaks, providing the urethral .catheters are changed frequently and kept clean and irrigated. Otherwise, .of-course, if neglected peri-urethral abscesses are common. For the most part,.the cystostomy tubes inserted overseas are properly placed and located and fit well. However, those very few- that vrero found unsatisfactory were so because of three reasons: . . (1) Too low an insertion in the abdominal wall, causing pressure of tube against symphysis pubis with, of course, the pot entail danger .of* bone i n vo 1 verhont. • ' • . , ■ (2) Too low an Insertion in the bladder itself, causing pressure of tho end of the catheter against the trigone which often produces spasm and • discomfort and, lastly, (3) Lack of support of the bladder to the rectus msuole causing a false pocket of urine between bladder and abdominal wall, making replacement of the .suprapubic catheter very difficult. This problem of spinal cord injuries is one of the few problems of Varld.H nr II and one which is a challenge, to almost every medical s-pecialty. *.re will all have to learn from the other’s experiences. Therefore, .meetings of this sort aVe most valuable to all of us. CAPTAIN JA1F3S H. oHLi/dJS: At McGuire General Hospital we have over "thirty paraplegic pf tients vrith catheters in place. Twenty of those have supra- pubic drainage. .. I would liko to make two remarks about suprapubic cyst ostomy. . First, suprapubic cystoscopy has proved, to be a valuable-procedure. By passing the cystoscopo through the suprapubic tract, it is possible not only to examine tho interior of the bladder, but also to remove encrusted mucosa and stones. Our impression is that-the patient has less cvstoscopic reaction than by the transurethral route* The second remark concern's the drainage of tho bladder with suprapubic catheter. This has boon improved a great deal by rolling the patient on to his abdomen - while irrigating the catheter. The gravitation of the exudate toward the suprapubic catheter facilitates its removal. In the supine posi- tion only the supernatant exudate is removed. I can see a problem - namely, whether or not it is preferable to allow the sinus tract to close early and to treat the bladder transurethmlly or to treat the bladder suprapubically until it is permanently free of exudate and stones, and then to allow the sinus tract to close, reasonable expecting to have no more difficulty afterward. I,T. C0L0II3L ITtbJIK JIAYFI3LD : I hate to close the discussion on such an in, ort- ant subject as the bladder* Captain Petroff - CAPTAIN BORIS P^TTRO.FP: I would like to answer Colonel Gage about thrombo- phlebitis. ’ re have two cases - one came from overseas with a terrifically big thigh; the othoi* had a swollen leg vrhidh ur.s assumed to be thrombo- phlebitis. I an surprised that there has been no question of suprapubic cystotomies, because when these patients first came in with supr? pubic tubes in them* it was mainly on Major 51kins* suggestion that they were changed from suprapubic to urethral drainage* Major 31kins did a firm bit of .insisting* I was all for leaving the suprapubic tubes in but Major Tlkins said to go ahead with the removal of suprapubic tubes. Mo rxde the change, the first patient developed epididymitis, and Major Tlkins said to let it stay in - that it wouldn’t hurt him. He is now one of our prise patients, voiding with an automatic reflex bladder. Now for this business of peri-urethral abscess, we end up with a fistula and when the patient begins to void, everything runs out over the floor like a watering can. This is a groat problem to us, end I would like the visiting urologists to suggest some way of repairing this peno-scrotal type of fistula, LT. C0L0N3L ffllAlfK MaYFIISLD: • The next two papers by Captain Barker and Captain Harper will bo presented as a group and then discussed if time permits. It is necessary in deference to our hosts that we close this meeting by 5:15, 1 now call upon Captain Barker whose subject is, "Surgical Treatment of De- cubitus Ulcers." CAPTAIN DONiiLD 3.' RAPJN5R: A review of previous literature reveals little success j.n the surgical treatment of bed sores, Honroe in-a personal, conmun- ication stated skin grafting had boon tried in those without success. Laman and have reported one case of back ulcer treated by incision f nd closure. The type of patient dealt with in this paper besides being a pro- blem of bed ulcer is also one in which there is complete or partial denerva- tion to the area affected by the ulcer. .There ar.e tiro questions which cane in mind at the start of the work, (l) ’Jhethor the ulcer could be closed or grafted with success, and (2) whether donor sites would heal after surgery. This paper presents results of a series of 30 operations done at this hospi- tal. Host of the paralysed cases were admitted with one or more bed sores. Of the 21 patients in this series, 10 or 50/o had only 1 ulcer. 5 or 25/ had 2 ulcers, 4 had 3 ulcers, and one case had 5 ulcers. The ulcers hanged in size from 1x2 inches to 6x8 inches, covering the entire area over the sacrum. Seven cases had ulcers over one or both hips, Pro-Operative liana geraent As soon as a definite line of demarcation became appnrnnt, the necrotic tissue was dissected away with a pair of scissors. From that time until grafting the ulcers wore dressed with either boric ointment, urea ointment, or an emulsion made by nixing A- cc. penicillin in 1 oz. of vaseline. The appearance of the ulcer was not affected greatly b; the type of ointment used. 'Then the ulcers had a. clean base, the operations were done. No attempt was made to get areas bacteriorologically cleqn. Operative Procedure Split thickness skin grafts, 12/1000 of an inch in thickness, were used on 16 cases. The granulating area was shaved down to a yellow base when possible and the graft sutured into place. In a number of oases the ulcer was so close to the bone that no incision of the granulation tissue was possible. All of the cases received wet dressings for 4 days post operative, •The principle problem net here was the inability of the patients to remain in one position for any period. In the constant changing of position by the ward personnel the dressings- were moved about and accounted for the loss in some grafts. One patient with five largo sores was grafted three tines with- out success. His daily protein loss from the sores was 50 gm/day, and there was reversal of the a/G ratio. 50;? of the cases were healed after the first operation, 40;? had a take •f oo *t 50c/i of the graft, and there were 3 complete failures. The apparent P'-or .-’Qsuits of the grafting can be attributed to the debilitation of the concerned. One fourth of the cases had ulcers 4x0 inches or larger* (R.D.) Plate 1 shows preoperative ulcer 6 x 8"; plate 2 shows seme ulcer 14 days postoperative. Plate 3 sho\vs same ulcer 2 months postoperative* Plate 4 shows another healed graft 5 months postoperative. (Deriv.) Seven primary closures were done by excision of the. scarred 'area and closure of the skin edges with 000 silk suture* Only the smaller ulcers wore closed by this method. All over 4 inches in diameter were closed by grafting or rotation flaps. Of the seven cases, 5 healed after one operation* Twd of the seven cases opened up partially after the seventh day postoperative. Some of those cases have been healed five months to date and withstand trauma well. In no . case did infection apparently play any part. (Sii) Plate 5 shows a bed sore pre-operative. Plato 6 shows same oationt four months postoperative. (St) Plate 7 shows pre-operative ulcer, plate 8 shows same ulcer postoperative. Rotation flaps were used in five oases of ulcers of the hip. It was ob- served early that the rotation of the hip when the foot moved caused a tear- ing along the suture line of closures of the hip and cases in which .grafts were used. Those cases were closed by rotation of the full thickness flap of skin from the adjacent area to the ulcer, and either closure of the donor area by grafting with split skin graft or extensive undermining and closure. (aP) Plate 9 shows ulcer of the hip pre-operative; plate 10 shows same ulcer immediately after closure; plate 11 shows ulcer four weeks postoperative. (BA) Plato 12 shows hip ulcer pre-operative; plate 13 shows same ulcer 3 months postoperative. Discussion A total of 30 cases have been operated on to date. Sixteen of these were skin grafts; 7 primary closures, 2 operations by basket weaving, and 5 operations by rotation of a flap. Of the 30 cases, 19 or 63;? are healed at the present tine. 27/? of the ulcers have about 50v? closure and but of the 30 cases there were three complete failures. In the rotation flap and the primary closure series the results were better than those in which split grafts were done. This probably due to the fact that the split skin grafts were used in large ulcers and also in cases in which the condition of the patient seemed too poor to permit ex- tensive radical surgery. Of the primary closures and rotation flaps 80m healed after the first operation. The following types of closures are recommended: In large ulcers of the back; i.e., those measuring about 4" in dia- meter and also in cases in which there is extreme debilitation, split thick- ness skin grafts is the method of choice. In small ulcers measuring from 1 to 3” over the back the method of choice is excision of the ulcer and clos- ure at the time of operation. In ulcers of the hip, skin grafting is not recommended. - Tven in the smaller ulcers of the hip it is recommended that a rotation flap be done. In ulcers from 1 to 2" in diameter a rotation flap with primary closure of the donor are.a is the method of choice. In large ulcers a large rotation flap to the ulcer area with split thickness skin graft of the donor area should be used. It is estimated that the time saved in these ulcers varies from six months to two years, and in some of the larger ulcer areas it is probably a life saving measure to use split thickness skin grafting. ‘ An ulcer about 1” in diameter may take six to nine months to heal, where* as, ulcers of the back such as some shown in this series without surgery would probably not be healed after five years, I believe that the excision inclosure'of even as small clears as three-quarters of an inch in diameter that have penetrated to the subcutaneous tissue should be done. The following conclusions are presented: 1. Primary excision f nd closure of small ulcers of the back is the method of choice, • 2. In largo back ulcers or in patients who are very poor risks surgi- cally skin grafting is successful and the recommended method. 3. In hip ulcers a rotation flap is a quick method of a permanent clos- ure. . - (1) L&non, John B., Jr., Lt. Col., MC, and Alexander, Then, Jr., Capt., HC, Secondary .Closure of Decubitus Ulcers with the Aid of Peni- ‘ cillin. J.n.H.A. 127:396 (Feb) 1945 LT. CQLQUUL 1 IAYPIHtP: The next paper is entitled, ’'The Nutritional .as- pects! of The Care of The Paralyzed Patient", .presented by Captain fibroid A. Harper, SnC., nutrition Consultant, Fifth Service Command. CAPTAIN HAROLD A. HjJT'Pl: • It is now becoming well recognized that nt 1 nutri- tion may readily occur as a result of disease or injury. In addition to in- adequate food intake there are various factors which decrease the efficiency of utilization of ingested food while increasing the rate of destruction stored energy in its various forms, ’/hen the patient is in asatisfactcry nutritional state at the time of the injury or operation, a relatively brief period of starvation or malnutrition is probably of no serious consequence. This, is very definitely conditioned however by the state of the- individual’s reserves. The case’s with which we have to deal are for the most part those who have been grounded in overseas combat'theatres. Their nutritional history during the period immediately preceding the injury is frequently characterized by a period of subsistence on cembat or emergenc ■’ rations- and difficulties of supply and transport may have resulted in an impaired food supply. Ai-' though the rations in use are n-rbritionally adequate, various envir oimenta 1 factors may result in the consumption of a diet which is only borderline. It is.reasonable.to assume therefore that many men have a diminished nutritional reserve at the itime they sustain their injury. Accelerated depletion of these reserves enhanced by the anorexia secondary to surgical.procedures nay therefore be sufficient to produce an acuto-malnourished' state, ... ; The paralyzed patients illustrate well the pheonomena described. The .majority of such patients have lost a considerable emount of weight, particu- larly In the atrophic paralyzed extremities, Ife.fiy also .present, evidences of generalized emaciation.- The nutritional deficiency *of these patients are obviously due to a number of factors. On admission to hospitals in the zone of interior nearly all have large, oozing, decubitus ulcers which are- a. source of considerable loss of protoin, Infection is a common complication with the result that depletion of reserves is accelerated. It is most important therefore that immediate attention be directed to an evaluation of the state of nutrition of these patients and that methods for correction of the -malnourished’ state and the maintenance of .an optimum level of nutrition be instituted. Attention has been properly focused on the protein nutrition of these patients. As has already been noted protoin losses by exudation may be ex- tremely large, -*. up to 50 grams in some casesv The so-called ''toxic" des- truction of protein which is concomitant of disease or injury may account .'"'or considerable loss and togother with the wear and tear quota, one may find that more than 150 grans of protein per day will be necessary to achieve nitrogen bal nee. Re-establishing and stabilizing protein balance in these cases is usually a rather arduous procedure. It is believed that the situa- tion is complicated by the fact that the underlying injury or pathologic pro- cess may markedly influence the mechanisms responsible for blood and tissue protein synthesis. A stucty of the blocd proteins of these patients frequently reveals in- creased globulin and decreased albumin levels* This may be the only objective evidence of protein malnutrition but it is to be considered rs indicative of extensive depletion of protein stores. It may be presumed that the tissue stores have been called upon to maintain the normal plasma levels as long 6s possible. As hippie has pointed out, the tissue proteins are in dynamic equilibrium with those of the plasma, and plasma protein is part of a balanced system of body proteins; a steady sta.te of ebb and flow exists between the plasma proteins and a portion of the cell and tissue proteins* Recent studies have indicated that there is a definite -metabolic par- tition betweven the plasma and the r est of the body* Specifically, it is stated that each grdm loss of plasma protein is accompanied by a loss of about 3Q grams of tiesue protein, Alien regeneration takes place, only 3* r5% of the nitrogen retained is used to replenish serum albumin while 96*3#> is allocated to replace tissue protein stores. This explains why large quantities of pro- tein may produce relatively little improvement in plasma albumin levels* Ulrian has supplied a formula which gives some concept of how large the daily' protein intake must be to restore plasma albumin levels to normal* "Protein need = (• A - SA ) ( Tf ) (30) (Ki) (Fp) (d) ~ioo“ * 20 A - Normal serum albumin concentration in gnu per 100 cc (taken as 4.6)* SA' - Actual serum albumin concentration of patient in gnu per 100 cc* IT s Patient’s body weight in grrams, Kp : The reciprocal of the fraction of ingested nitrogen retained. Ko = The minimum daily endogenous protein need (usually 25 grams o'* protein) . • d = The number of days in which it is proposed to correct the protein depletion. .*• .Protein need * total amount of protein in grams which must.be ingested during the regeneration period of "d'1 days. The' factor, 20, in the denominator converts body weight into plasma vol- ume, while the factor, 30, represents the rationbetweeri plasma and tissue loss* a convenient nomogram for computation of the daily protein requirement in hypoproteinemia has been published by the Arlington Chemical Company. I • . . The formula is valid only in cases of chronic hypoproteinemia incident to prolonged dietary.deficiency of protein since when hypoproteinemia follows hemorrhage, burns, nephrosis, or liver disease, the 1:30 relationship be- tween tissue and plnsme proteins does not hold. To use a determination of the total plasma protein as a diagnostic aid for assay of the state of protein malnutrition, one must take into account two important factors. For under "certain conditions a normal value will be reported when there is actually protein depletion. Those factors are (l) the effect of dehydration and (2) the presence of decreased levels of albumin accompanied by an increased globulin. As plasma protein diminishes, the water retaining power of the blood is also decreased. Fluid is lost to the tissue spaces and increased concentration of the plasma will occur with a. consequent decrease on total plasma volume. Quantities of protein which -would be low in ft normal plasma volume would then appear normal or even elevated. Con- versely when the concentration of the serum albumin is raised there will be an increase in the plasma volume, averaging about 17-18 cc. per gran of al- bumin retained. One clinical study reported increased in- plasma volume of 600, 800 and 000 c’c. in patients receiving 50 grams of albumin* Therefore as one replenishes plasma protein stores thoro will be a shift in fluid bal- ance so that, for temporary periods at least, an increasing volume will have the effect of reducing the actual concentration of protein. Again, one nay find that total protein is normal but actually there is hypoalbuminemia which is masked by an increase in golbulin. This is parti- cularly true where there is chronic infection, most of the increase.occurring in the gamma globulin fraction, rich in antibodies✓ To obviate those pitfalls red cell counts and hematocrit determinations dhould be obtained simultane- ously with the plasma albumin and globulin in order to estimate the probable degree of dehydration. Although much emphasis has been placed on albumin globulin ratios the plasma albumin content is actually the significant factor involved* Correction of nutritional deficiencies in these patients may be expected to greatly enhance the success of all aspects of their care* Healing of the decubitus ulcers will bo favored as will the success of grafting procedures* As the extensive losses of protein from this source abo deminished it will become progressively easier to restore and maintain nitrogen balance. The patient can be expected to more successfully combat the chronic infection to which he is exposed. ' The efficacy of chemotherapeutic agents will be en- hanced and wound healing materially improved. The basal diet of theses patients can ordinarily be the regular high • protein diet of the hospfcal if there is no obvious impairment in their ability to digest or assimilat'e it. It is obvious that food offered to a patient is of no value unless it is eaten. All too frequently it is observed thr t no professional notice is taken of the fact that those patients refuse rather large quantities of food. Jvory effort must be made to assure the serving of a palatable and attractive diet. In some cases it may be desirable to use six smalie? feedings per day until appetites is restored. If the diet is pro- perly consumed one can probably depend on a daily nutritional intake of about 2800 calories find 100 grams of protein. From the preceding discussion one notes however that a much larger daily intake of protein will often be necess- ary to compensate for the losses in exudates as well as those of normal and abnormal metabolism. Additional protein must be allowed for the synthesis and replenishing of body proteins. One should set a protein objective to *be attained daily by these patients - possibly 150 to 175 grams, or more if tolerated. The other components of the diet are depended upon to supply as much energy aspossible in order to spare protein to a rw xinum degree for use in anabolic reactions. It nay be desirable to increfse vitamin supplementation. The poly-vita- min capsule ordinarily supplied contains exactly one half the current National Research Council recommendations for the daily intake of the norme 1 adult* The use of tiro such tablets three times a day should be adequate in the ab- sence of frank deficiency symptoms. Larger doses of the vat or soluble vita- mins are very inefficiently utilized, much of the material being immediately excreted in the urine. It is apparent that the provision of largo quantities of protein becomes a prominent feature of the nutritional management of those cases. Conse- quently considerable attention has been directed to this problem. In the presence of an anemia most of the administered protein is diverted to the synthesis of hemoglobin and it is not until the anemia has been corrected that satisfactory tissue and plasma protein regeneration will occur. It is of course in these situations that the use of whole blood is of value. To cor- rect an acute deficiency of pin sma protein especially where there is frank edema, the administration of plasma or plasma albumin is ideal. But in a chronic hyponlbuninenia due to malnutrition, plasma is of value but nay be disappointing. For every gran of plasma protein which remains in the blood possibly 30 grans are removed by the rest of the body. To supply 2000 grams of protein for the entire body requires 30 liters of plasma (120 donors). From a nutritional point of view it would seem more physiological to supply good quality protein in a more economical and assimilable form. This can be achieved by the use of certain protein concentrates or hydrolysates, several of which are commercially available. Two are hydrolysates of casein, the protein of milk, and a.re .available for both oral and intravenous use, A third is a mixture of wheat, beof, milk, and yeast proteins, for oral use only. It is usually possible and, in fact, desirable in all of these cases to confine alimentation to the oral route. In additional to the advantage of providing as normal a regime as possible, one must consider the fact that in- dividuals whose plasma protein levels are dangerously law cannot tolerate intravenous fluids with impunity. To administer 100 grams of protein as a fivo percent Anigen solution, for example, requires the introduction of two liters of fluid. Such a procedure will not bo well tolerated if continued for some time. There is appended a series of recipes . for the use of Amigen and Aminoids, ns well as certain other formulae which use untreated or natural prot ins. The palatibility of Anigon and Aninoids is the principal disadvantage in their use. The relative efficiency of a hvdroloyzed over an unhydroloyzed protein in the present of nornal gastric ana pancreatic function has not boon determined. It is advisable that patients requiring intensive nutritional care be recommended to the attention of one Dietitian who will be specifically assigned to the task of supplying adequate nutrition to these cases. In the jcuto phase of malnutrition a daily record of the food intake should be kept. During this period of high protein level should be set and attained. This can be done by judicious use of all tho nbtkods at the disposal of the Dietitan. The various formulae suggested nay be varied from day to day and administered in such quantities and at. such frequency that together with the protein of the basal diet, the, protein standards required for tho patient will be met. Addi- tional high protein dietary supplements are being developed and will be made available. The successful application of the principles of adequate nutrition re- quires constant individual supervision in' every case but a sound nutritional plan is all important in the supportive management of these patients if they are to attain maximum benefit fpon surgical and medical treatment. miWTLAZZmi PHOT 3111 STIPPLHIC3HTARY F33DIIIG IE. AHIGUJ F0Ilt1ULA3 (x) Formula No. Ingrodients Am’t C P F Calories 1 Ifelch’s Grape juice 100 gms. 15.1 0.3 — Lemon juice 10 gms. 1.0 - — Sugar 10 gms. 10.0 - — Anigon 10 gms. - 10.0 — 146 Tg7I~ 10.5 -- 2. Tomato juice 200 gns. 7.2 2.0 0.2 Lemon juice 10 gms. 1.0 - - Anigon 10 gms. - 10.0 - Salt - - - - 8.2 12.0 0.2 So 3. 111 lk 200 gms. 10.0 6.6 8.0 45 gms. - 6.0 4.7 Sugar 10 gms. 10.0 - - Anigon 10 gms. - 10.0 - 20.0 22.6 12.7 ' 285 4.Custard: 3gg 45 gras. 6.0 4.7 Sugar 10 gras. 10.0 - - Hi Ik 120 gms. 6.2 4.0 4.8 Amigsn 5 gras. - 15.0 - Vanilla (tablet) - - - - Salt, nutmeg - - - - * 16.2 15.0 9.5 210 5 Junket; Milk 120 gms. 6.2 4.0 4.8 Anigon 5 gms. - 5.0 - Junket Powder 11 gms. 10.3 - 17.0 9.0 4.8 147 6. Prune juice 200 gns 57.6 1.6 - Anigon 10 gns * 10.0 - 57.6 11.6 - 2 77 7. Orange juice 200 gras 26.2 1.2 - Lemon juice 10 gns. 1.0 - - Anigon 10 gms. - 10.0 - 27.2 11.2 - 154 Formula Ho. Ingredients Am* t C P •Z Calories 8. Can Pineapple J, 200 gras. 25.6 0.6 0.6 Anigen 10 gns. - 10.0 - ft o • b Aw a O —TOT 150 9. , * Milk 150 gms. 7.5 5.0 6.0 C/ioc, Syrup 50 gras • 28.8 2.5 2.5 Amigen 10 gms. - 10.0 - a 36.3 17.5 8.5 292 10. Ice Cream 60 gms. 13.5 2.7 * 7*2 Milk 100 gras• 6,0 3.3 4.0 Anigen 10 gms. - 10.0 - Choc, Syrup 50 gms. 28.3 2.5 2.3 . - » . - 47.3 18.5 Ts.'f 387 11. * Ice Cream 50 gms. • i—! i—1 2.3 6.0 Milk 100 gnS. 5.0 5.3 4.0 Choc. Syrup 60 gras. 34 • 5 6,0 3.0 Anigen 10 gns. - 15.0 0 • 50.8 2376 13.0r 415 . The Amigen must be dissolved in a warm fluid. In the fruit beverages the 10 gns. of Amigen should be dissolved in l|r tablespoons warm water. In the milk beverages, a portion of the3 milk nay be warmed and the Amigen dis- solved t'iier in. .II. AMINOIDS FORMULAS (x) 1, Thole MilM 200 grams Aminoids 20 grams Food Value: C-17 P-15.6 £-6.2 ffal,204 . 2, Skim Milk 200 grans Anihoids 15 grams Food Value: C-15.3 P-U.2 F-0.6 Cal.123 , 3. Milk, whole 130 grams Egg 1 each Sugar 10 grams Aminoids 15 grams Feed value; 0-24.3 P-19.4 F-12.6 Cal.-287 4. Custard: baked Egg _ 1 each Thole milk 120 grans Sugar 10 grams Aminoids 10 grams Food Value: 0-19.5 P-15.2 F-lC)". 1 Cal-231 5. Naked Custard Same as IV, but substitute skir milk for whole Food Value* C-19,5 P-15.6 F-5.5 Cal,-190 6. Grape juice 200 grans Aminoids 10 grams . * • ♦ Food Value. C-33.7 p-5.1 F-0.1 Cal-156 7. Pineapple Juice 200 grans Aminoids 10 grans pood Value: 029.1 P-5.1 F-0,7 Cal.-145 8. Pear Neotar 190 grams Lemon Juice 15 grams Aminoids 10 grams Tatar - 200 cc Food Value: C-16.0 P-4>5 F-0I1 Cal.-84 9. Lemon Juice, clear 25 grams Sugar 10 grams Aminoids 10 grams Tatar - 200 cc Fo#d value: C-16.0 P-4.5 F-oa 0al 84 10. Tomato juice 2nC grans Lemon juice 10 grams Aminoids . 10 grams Food Value: C-11.7 P6.5 F-0.5 9a1-75 11. Cooked Oatmeal 150 grr ns i Aminoids 10 grams (Should be served vrith cream or milk and sugar) Food Value: C-15.5 P-7.5 F-l.5 Cal-106 12. Hot clear broth 200 cc Aminoids 10 grans Food Value: 0-4.1 P-9.7 F-0.3 Cal.60 111 * CAoEC FORMULA (x) Milk - ‘ 250 gms. Eggs - 2 Casec - 20 gms. Total Protein - 44 gms. Ice Calories - 563 Cream - 80 gms. Cocoa - 5 gms. iV. IIIGli PROTEIN, T0BLT0 SOUP (xx) CHO Fro. Fat Thiamin Riboflavin kinoin t Grams Milligrams Butter 35 pu................. - - 28 • • Casein 15 gn - 13 - - - Wheat gem (Viobin) 15 gin.... 7 66 - 0.495 0.120 1.035 Soy Flour 10 gm 5 5 2 0.055 0.0,4'J 0. Milk 240 gm 12 d 10 0.120 0.500 0.700 Bouillion h cube . ~ - • - .. Tomato-puree 2 tbsp. 3 2 - - - - Salt to flavor (omit in patients with edema or ascites) * 27 34 40 0.670 0 • 660 2.135 ' Total Calories - 612. Total Protoin - 3*4 grams. Vail yield one bov/1 of soup. In making the soup- Melt butter in the top of the double boiler. Stir in the casein, wheat gem, and soy- flour. Mix in tl.e tomato puree and bouil- lion cube (for variety other flavorings nay b e us ad.) Add m i Id gradua 1 ly • Cook for 10 minutes. If 2 cups a day. are given at approximately 09GQ and 1500 a total of 03 gm of protein will be furnished. A third feeding could be given at 2100. V. TUBS FEEDING FQIIMULA (xnQ Total volume about 1500 co. should be made up fresh daily, and kept in a closed container in refrigerator. Mixing in good mechanical mixer is neces- sary in preparation, (rive feedings of approximately 100 ml., conveniently spaced throughout the day and/or night. Material is most readily given with a 50 or 100 co syringe through u small nasal tube which may be left down for three weeks to four weeks, use alternate nostrils at weekly intervals. The mixture map’ be given just as it cones from the refrigerator -- it is not necessary to warn it. 1 Calor Pro- Ca Fe Vit. Thia Ascor Ribo Ma ies tein A Mine bio acid flavin gm. •gra. ng. I.U. mg. mg. mg. ng. Milk - 1 pt 350 16.8 0.56 1.0 8.6 00.19 . 5 0.86 0.53 1 pt. 1 • to • 2Q« •. •. Raw liver*(freed of tendons) 998- 14.0 0.43 1.0 5760 0.14 0.62 — 4 oz or 120 grams....... 158 25.0 0.01 9.8 33000 0.58 37 3.00 17.00 Raw eggs - 4 . •. •. 316 25.6 0.11 5.4 1980 0.28 - 0.74 0.12 Dried yeast*5" 2 tbsp or 20gns Glucose or Lactose or Sucrose 72 10.0 0.02 4.0 - 3.20 0.80 8.00 or Karo Svrup, 225 gm or 7?;-oz 'Tbole milk powder-4tbsp or22 900 • ** M* gr-ns . 10S 5.6 0.21 0.4 310 0.07 1 0.35 0.15 Casein-4 tbsp or 50 gm. Applesauce, Apple Powder, or Pectin (4 tb’sp, or 60gm. 120 25.0 apple Salt - 10 g 49 0.1 ■ 0.1 30 - ' 0.02 TOTALS FOR APOJE 3052 119.1 1.33 21.7 41896 4.26 43 6,57 25.82 Orange juice - 4 oz or 120 ec. (Give half with one of A.H. feedings and half in P.M. ..... 59 1*1 QiOo- 0.4 300 0.09 64 0.03 0.26 CO.’-SPLETE TOTALS: 31 lT WL20T2 I.oo.22.1 V42l96: 4'.33 IPHf.ToTg'j* ' Salt Concentration about 12 g. * Ground beef or pork nay be alternated with liver ** If considerable distention or diarrhea develops, substitute with equal amount of wheat or com germ. *** This ingredient is added to prevent diarrhea and must be adjusted to bee individual ("x) Courtesy Gardiner General hospital, Chicago, Illinois (xx) Stare, F.J. and Thorn, G.W., J.A.M.A. 127, 1120 (1945) Amigen•'- Enzymatic casein hydrolysate: Mead Johnson Company, Evansville, Ind Manufactured for intravenous use as a 5% anigen, dextrose solution, in liter flasks and for use as a soluble powder in one pound cans. Ami gen powder is protein. Casoc - Calcium caseinate, 88f3 protein, ilead Johnson Company, hvansville, Ind. Aminoids - A mixture of wheat, beef, milk raid yeast proteins, 45;! protein, the Arlington Chemical Company, Yonkers, hew York. LT. COLOIILL CONDICT W, CUTLER: Forty-five of sixty-seven patients admitted to Cushing Hospital had bed-sores. Two of the sixty seven had slight pro- gression of their bed-sores after admission. No case has developed a bed-sore following entry. The bed-sores are characteristically multiple, thus there have been 130 decubitus ulcers in the forty-five patients. Important considerations in treatment have been found to Be: Constant and repeated turning of the patient every two hours day and night. The use of small kapok pillows to prevent local pressure on sensitive areas. (Sup- porting the chest arid pelvis on pillows in a prone position makes for com- fort and better breathing.) Keeping patients dry at all tines. Adequate nutrition and attention to avitaminosis and protein deficiences. In local treatment various applications have been tried, including vase- line gauze, penicillin jolly, granulated sugar, and a preparation of concen- trated rod cells with penicillin and agar. Of those the granulated sugar has proved particularly effective in diminishing pyocyaneus infection and slough. Bpitholization seems to be rather more rapid under this treatment. Cleansing of the wound and rapid development of granulations of a healthy character has followed the use of a paste composed of concentrated rod blood colls thickened with agar and containing penicillin. Associated with this type of preparation secondary closure has been used in seventeen oases and has proved most satisfactory in deep penetrating bod sores measuring not more than seven centimeters in diameter over the sacrum and five centimeters in diameter over the trochanter. In performing this closure, penicillin is given forty-eight hours pro-operatively and twenty“one days postoperatively. The wound is cleansed witn saline, the edge of the de- cubitus trimmed away with complete undermining of the entire skin and sub- cutaneous tissue over the sacrum and low back out to trio flanks for a distance of eight to ton inches, superficial to the gluteus muscle. Closure of the circular defect is performed with tantalum .010 suture in two layers, one for the deep fascia and one for the skin. Ho drain is employed. The wound is filled with penicillin solution and the sane solution is injected through the suture line into the wound area twice a day for ten days. Stitch; s are left in placo for twontypone days. In trochanter decubitus the treatment is the same. Three layers are usually required in the suture, as the sore fre- quently extends through the fascia lata and the gluteus maximum fasci il« .1 i iC o ') are closed separately from the sub-cutaneous and skin layers. a plastic ex- tension is always necessary. -Where complete suture closure has been effected, there has boon no case of reopening or breaking down. Slower her.ling ocourr d in those cases which could not bo complete closed. istLIEUTENANT HARK A. JACOBS: Wo have boon most grateful to Cnptfin Harper for his valuable advice and helpfulness in suggesting diets for our patients here, but from our work it appears that diet is only a partial answer to the problem* Protein studies have shown the impoverished nturitional state of many of these men who have just returned from overseas. The fact that wo have no opportunity of observing those patients until they have , spent some time in the hospital overseas does not permit us to appraise their actual status in the real acute phase of their pathological condition. But as they pass into the sub-acute or chronic phase, it i s apparent that there are many factors involved, Piet, lack of appetite, infections and even their node of transportation to this hospital have an effect upon the patient’s nitrogenous state. Those that travel by air seen to be in much the better shape* Host of these patients have come to us in a poor state of nitrogen bo.1-- once, and in mild acidosis. They have a hypoprotoinemia with a reversal of the normal albumen-globulin ratio,.and further laboratory studies showed many other things of importance. There wera avitaminoses, calcium metabolic changes with the formation of renal and cystic caluoli, infected kidneys and bladders, and varying sizes of necrotic skin ulcers. The kidney and bladder stones were found to be almost entirely of the alkaline typo, including cal- cium carbonate, calcium phosphates and triple phosphates. On arrival here we found that the skin ulcers that these patients had were a large possible source of their inanition and introgen imbalance. Those decubitus ulcers varied in size and number but in all cases were infected and oozing. The material that oozed from these sores appo? red to us to be such an important factor in the nitrogen blance, that we attempted studies on thorn to show the actual loss from this source. Little previous work had been done on this importance subject, and the results obtained were startling in some cases. Through the use of cellucotton dressings of these ulcers we; were able to obtain sufficient material for our experiments. By covering these ulcers with the pads for twenty-four hours, then doing a micro-Ejeldahl detorminatior on the material contained on the pads, we found that these ulcers did have an important bearing on the nitrogen balance, hypoprotoinemia and albumen- globulin ratio. In fact, one patient with five ulcers of varying sizes and shapes was found to have a total protein loss from just those of over 40 grams in twenty- four hours. Others showed loss in protein loss, but most proved to bo im- portant in nitrogen waste. Thus you can readily see the tremendous increase in pertain intake that is necessary to even attempt to obtain a zero balance, much less achieve a positive one, since to this ulcer loss must be added ni- trogen loss through the usual sources, suchaps urine, feces and perspiration. Also add to this the anorexia and the indifference to food itself and you can see hour our probolm becomes increasingly difficult of solution. As infection from all sources was brought under control, the nitrogen balance gradually tended toward zero and the albumen-globulin ratio showed improvements, but maintenance of infection control was almost impossible. However, we believe that a partial solution to the problem was found in the use if skin graft coverings for the decubitus ulcers. There and when this was done, the protein loss through these ulcers became negative, the patient tends toward and approaches a positive balance and the- albumen-globulin ratio itends toward normalcy. Ve have no data yet on its permanency as far as maintaining such a balance is concerned. vro are attempting to clear up all sources of infection so as to elimin- ate an-/ stimulus that night still exist. But there still remains the quest- ion of how to get enough proteins, enough calories and enough vitamins into those patients that do not want food. There is still v good deal of work to be done before definite conclusions can be reached, but t/g are increasing our store of data and material. The question is still posed: How can we get these patients into posi- tive nitrogen balance and maintain them thus by diet, with the difficulties and complications that face us f t present? CAPTAIN HAROLD A. Il/J’PISt: The study conducted here at Newton D. Baker Hospi- tel' on the losses of nitrogen in exudates is a valuable source of evidence to support out ideas on the greatly enhanced nutritional requirements of the diseased state. Prevention <>f losses by this route make it much easier to control the high degree of negative nitrogen balance which otherwise exists. But in any case one must often take heroic measures to increase protein in- take in order to reduce the amount of negative balance. Anorexia must be regarded not as inevitable but as a challenge. The objective in my present- ation has been to outline workable methods to reduce if not entirely com- pensate for these nutritional inadequacies. These methods have been found entirely satisfactory in practice but they require constant individual super- vision of the nutritional management of each case. It is therefore helt that we do have adequate means to control the nutritional aspects of this problem and it is hoped that they will find much more general application. LT, COLOITdL PRaNT IIAYFITIP: I wish to commend both essayist for excellent presentations on important phases in the care of the paralyzed patient. Mhe healing of decubiti greatly promotes nutrition, and adequate nutrition is ne- cessary for the prevention and cure of ulcer. I am sure that all of us have gained many valuable points from these two papers. Before I close this session I would like to express again my thanks to Colonel Bee]: for his invitation and Colonel Cook and Colonel Poer and his Staff, Major dikins and all the Staff at Newton D. Baker for the program that has been arranged and for the cordial hospitality that has been extended us. PROCEEDINGS OF THE CONFERENCE 11 May 1945 Evening Session COLONEL E. A. NOYES (Presiding): Tonight w.e have run into the program something a little foreign to the main subject .of the meeting, but personally, I foel it is just as vital as the treatment of cord cases, and I say to the visiting officers that we are just as proud of it as we are of our cord cases. It concerns treatment of osteomyelitis by dermatome grafts. 'There will be three papers with discussions after all throe papers have boon presented. The first paper will be presented by Major Robert Kelly of Ashford General Hospital on "Dermatome Grafts for Chronic Osteomyelitis". Following these papers and the discussion there will be a movie on the paraplegic patient. MAJOR ROBERT KELLY: Colonel Noyes, distinguished guests and members of the staff of Baker General Hospital, the treatment of osteomyelitis by skin grafting procedures following saucerization is not now. It was described (Slido) by Neuber in 1895, some twenty years before publication of Orr’s monograph (Slido). A few years later, in 1902, ,J. ,P. Lord, then professor of surgery at Creighton University, reported (Slide) with this illustration the result of treatment of a case of osteomyolitis of some fifty years’ standing by saucorization and Thiersch grafting. Reid, in 1922, published a report in the Johns Hopkins Hospital Bulletin on the healing of chronic osteomyelitis by Reverdin grafts. Doubtless, he used this type of graft under the influence of Doctors Halsted and Davis. (Slide) Here is shown an illustration of- one of his cases so treated. (Slide) Here we have another, two weeks after application of Reverdin grafts. (Slide) This is one of 46 years’ duration, (Slide) and here, the result follov/5.ng saucerization and Reverdin grafting. (Slide) Here is shown another, throe weeks after Reverdin grafting,'and (Slide) this represents an osteo- myelitic process just above the ankle extending through-and-through the tibia, after saucerization and Reverdin grafting. This case was of 30 years’ duration. Why such reports did not lead to widespread adoption of the procedure is- not clear. Armstrong & Jarman, in England, and Quick, in Australia, have employed this form of treatment, the latter for over 20 years. More recently, Converse has included osteomyelitis among war wounds of extremities for which he advocates early skin grafting. Lord again, and Beekman have advocated other forms of plastic procedures for the healing of chronic osteomyelitis. In January 1943, we began to treat osteomyelitis by this method at Ashford General Hospital. We were fearful of recurrence, of local extension of the infection, and of systemic complications. We have with- held formal report of this treatment until recently when, after treating more than 100 cases over a 2 year period, we have felt that appraisal of these factors from our experience could be made. Technique A saucerization is performed, which we have come to regard as anala- gous to debridement of a fresh wound. All devitalized tissue, including scar, is removed. The contour of the wound must approach but need not duplicate that of a saucer (Slide). As boon,as we are satisfied.the wound will permit of the proper application of pressure, we sacrifice no further good tissue. When a vascular ligament, or tendon denuded of its sheath is loft exposed in the wound, it is excised and subsequent reconstruction planned. Major arteries and nerves, of course, are pre- served. The surface of the wound is then covered with a single layer of plain fine mesh gauze, made as wrinkle-free as possible. (Slide) Mechanics’ waste packing is applied over this and packed in carefully to produce firm pressure as uniform as possible to all areas of the wound. Over this, when available, is wrapped an ace bandage. Lacking this, some other form of pressure bandaging is employed. The firmer the pressure which can be made without embarrassing circulation, the better the result. It is technically difficult by circular wrappings of any form of pressure agent to maintain uniform pressure extending to tho base of the digits of the extremity. For this reason, in extremity work we have employed the pressure agent locally and often made the plaster immobilization unpadded distal to the pressure agent. The plaster is then split from top to bottom through its entire thickness. Little difficulty has been encounter- ed from swelling, none from decubitus. Our interval between saucerization and grafting while our earlier cases were being done varied from zero to more than thirty days. Now it is usually in the range of four days. For skin grafting, as largo a donor area as possible is prepared, and the plaster is bivalved. In the operating room the bivalved plaster is removed and the packing withdrawn from the wound. Split thickness grafts are obtained with a dermatome and fitted accurately to the surface of the wound. It is imperative that the graft fall of its own weight into the most remote recesses of the wound, and that it be free of wrinkles. Along the lines of suture necessitated by trimming the graft for fit, untied running sutures may be placed, to be withdrawn following "take” of the graft. The graft is sutured to the adjoining skin edges and a pressure dressing applied similar to that previously described, sometimes omitting the layer of fine mesh gauze. Dakin’s tubes may be incorporated in the mechanics’ waste of those pressure dressings after both saucerization and skin grafting, and through them local chemotherapeutic agents instilled. An ace bandage is more imperative at this stage in that swelling is permitted with less increase in pressure. Hie pressure now made in the initial wrapping of the ace bandage is less than that made following saucerization, being the same as for any other skin graft. Over the pressure agent a fairly thick layer of sheet wadding is built up so that expansion of the pressure dressing Will not be limited by the walls of the plaster. Again the plaster may be made unpadded distal to the pressure dressing and handled as before. The smaller the amount of drainage, and the cleaner the odor, the longer the dressing is allowed to remain. Many of our dressings are removed after four days, and practically all after six days. Following removal of tho dressing, appropriate immobilization is maintained. The wound is loft exposed as much as possible, still providing for protection from mechanical irritants. It is kept moist with boric or acetic acids in weak solution, or with penicillin, depending upon the culture report. The greater the amount of necrotic material present, the greater the necessity for moisture by these agents. Local penicillin has seemed disappointing in its effectiveness, perhaps because B. proteus and B. pyocyaneus may have been present when it was used, though not revenle,d in routine cultures. Healing from this point has not been rapid. Of course, we do not consider healing complete until the entire area is covered by epithelium, and no drainage, exudate, seepage, or other type of moisture emits from the wound. By the end of two months, healing is usually complete. Commonly there is a high percentage of apparent followed bv a period during which maceration results in considerable apparent loos of 'graft. . Many interesting things have happened during the period following removal of initial skin grafting dressings. On several occasions results which appeared worthless at first dressing have proved highly gratifying within three weeks. Detailed enumeration of these interesting occurrences would be of no value at this time. Results The x-ray criteria on which a diagnosis of active osteomyelitis may be based are unsatisfactory. We have considered osteomyelitis to exist where a granulating wound is found in continuity with a process present- ing by x-ray, evidence of bone damage with one or more of the following,.: (1) Necrotic fragments. (2) Periosteal reaction. (3) Hazziness of trabocular detail. (4) Evidence of localized decalcification. Six months ago a group of cases was selected purely on the basis of most strikingly meoting these criteria. Forty-five osteomyelitic processes were present in 43 patients on whom 47 skin grafts were performed. We evaluated our results (Slide) on these criteria. The results were: Excellent 24$ Good 28$ Fair 24$ Poor 24$ Several of the cases evaluated as poor at that time have since proved quite satisfactory. COLONEL NOYES: The. next paper, "Obliteration of the Defect in Bone in Cases of Osteomyelitis Closed by Dermatome Grafts”, presented by Lt. Colonel Marvin P. Knight and Captain George 0. Wood of Crile General Hospital. LT. CODDNEL M. P. KNIGHT: A major problem in the reconstructive surgery incident to war wounds is bone infection or osteomyelitis with resultant distortion of bone contours and loss of substance due to sequestration. Many new methods of therapy resulting in shortened periods of disability are being constantly introduced (especially since widespread use of the newer chemotherapeutic aids) presumably because the current and accepted method of treatment of traumatic osteomyelitis by sequestrectomy and saucerization, chemotherapy, adequate drainage and prolonged plaster cast immobilization has well known disadvantages such as inconvenience to the patient, the total period of disability and the ultimate functional result.. Surgeons dealing with these problems are aware of the fact that, with this method of treatment of osteomyelitis, bone cavities with or without non- union are very prone to occur. . These bone cavities with their rigid bounding walls are reluctant to heal and even though eventually healed by granulation tissue are not only subject to recurrences of inflammation and suppuration, but because of loss of bone substance, so weaken the bone that full use of the extremity may not be possible. Thus, the bone may be "united” but with grossly inadequate union for full utility and, therefore, subject to refracture at a later date unless carefully guarded. One is not infrequently con- fronted by a patient whose "bone is healed” but whose joint and muscle function is so impaired and the possibility of osteomyelitic recurrence so great that it is open to question whether the patient would not be benefited if the extremity were amputated and a prosthetic limb fitted. We have developed procedures which, we feel, expedite healing and in many cases circumvent the complete develqpment of these cavities with eburnated margins within the substance of the long bones of the extremities. During the past year we have performed in the neighborhood of 200 sequestrectomies and saucerizations in the course of this development of procedures which seem superior to the usual methods surgical management of infected, compound fractures. Many of those cases are now nearing the terminal phases of their reconstruction and the present preliminary report includes those cases on whom' the entire series of reparative procedures have been performed. These procedures consist of early and complete saucerization of the involved osteomyelitic bone, followed in from five to twenty-one days by the application of split-thickness grafts as "dressings” into the depths of the saucerized areas. This effectively converts the infected wounds into closed fractures so that the wounds remain healed and dry but, by this technique of radical saucerization and the application of split grafts, large lacunae and bone defects remain which seriously weaken the bone as a supportive structure. Bono does not regenerate beneath these adherent split grafts to any appreciable degree and the lacunae remain essentially the same in spite of a- tendency toward contracture beneath the grafts which decreases the volume capacity of the saucerized area .but does not represent an increase in the amount of bone present. The split- thickness graft is notoriously unstable when exposed to trauma, and in this respect, these grafts on bone are no exception even though they are depressed beneath the skin level and thus protected somewhat from trauma. Thus, in most instances, it has been found necessary toreplaco the split- grafts with full-thickness skin by some plastic method, both for epithe- lial stability and.. to . permit further reconstructive surgery on the involved bone. " The large skin-line bone cavities resulting from these extensively saucerized wounds present quite a>surgical problem relative to closure and obliteration of the cavity with restoration of bone contour. In the past, attempts have been made to obliterate septic bone cavities by the intro- duction of antiseptic paste or waxes, fat grafts (either free or pedicled) and pedicle grafts of muscle into the unlined, infected cavities. Similarly, pedicles of skin and fat have been introduced into the cavities in an effort to secure an epithelial covering without any attempt at obliteration of the cavities. Success has been variable and uncertain, and little attempt has been made to increase the amount of bone present. In the present series, an attempt has been made to obliterate these clean, skin-lined cavities in such a way as to provide for increased osteogenesis in the region of the lacuna by bone graft and at the same time to supply a stable, epithelial covering by the immediate closure of adjacent skin margins or by the shift of pedicle flaps. DETAILS OF THE STAGE PROCEDURES The First Stage: The Saucerization and Preparation of the Osteo- myelitic Cavity. This important and necessary stage in the treatment of an osteomyelitic, compound fracture is planned and carried out with the thought in mind that the resultant wound should be adaptable to the early application of a split thickness skin graft dressing and that the final scars following recon- struction should be advantageously placed. All non-viable bone and bone of questionable viability should be removed and the fracture site well saucerized so that granulations will cover the bone surfaces in the shortest possible period. An attempt is made to preserve any union which may bo present but occasionally minimal fibrous union may have to be sacrificed. For obvious reasons all cicatricial soft tissue in the region of the fracture is excised as completely as possible and in the event that a joint is involved in the osteomyelitic process, the cartilage is similarly removed. The wound is packed open in the conventional method with vaseline gauze, and the operated limb is provided with temporarly immobilization pending subsequent operative procedures. After five to seven days the wound is inspected and its suitability for skin graft determined. Usually it is healthy with a very thin layer of granulation tissue overlying the bone surfaces, but occasionally in those cases in which suppuration has been allowed to continue over a sufficient length of time to produce extensive soft tissue fibrosis and bone sclerosis, the outward growth of granulations over the eburnated bone surfaces probably will be slow. In these cases grafting must be deferred until the bone is covered with the minute granulations necessary to a successful skin grafting. With the gradual accumulation of clinical experience and judgment, the saucerization 6tage can be so modified as to obviate this difficulty. Those cases in our series in which an unusual period of time has elapsed between stages may be explained by the length of time the osteomyelitis had persisted before this method of treatment was instituted, the degree of osteo-sclerosis about the fracture site at the time of primary operation and the lack of accumulated experience necessary to adequately determine the proper method of dealing with osteo- sclerotic bone in this type of plastic repair. The Second Stage: The Split Thickness Skin Graft Dressing. With the Padgett dermatome making the procurement of large split thickness grafts of predetermined thickness possible, little difficulty is experienced in obtaining enough graft material for covering the largest saucerized areas. This thin graft ( .010-.016 inches in thick- ness) is obtained from the most convenient source, perforated, and its rubberized epithelial surface dusted with sulfathiazole powcler. The recipient area is then prepared by curettement of the granulating surfaces with removal of any tissue which appears edematous or avascular. The graft is then applied to the saucerized areas and tailored to fit the depressed, irregular bone cavity by shaping the thin sheet of split skin into an irregular, blunt cone. The graft margins are sutured to the skin edges and pressure dressings of ordinary machinist waste are meticulously placed from the bottom of the cavity outward as all recesses must be completely and tightly filled to insure intimate contact between the parasitic graft and recipient area. The entire extremity is wrapped with an elastic bandage, temporarily immobilized, and chemo-therapy administer- ed over a two to three day period. The initial dressings are routinely removed at the end of six days and ordinary vaseline gauze dressings instituted* At this dressing it is usual to- find that from 80 to of the skin graft has "taken'' and not infrequently one finds the entiro surface completely epithelialized. Subsequently, the wounds are treated in much the same manner as any skin graft surface with proper attention to the underlying bone pathology. Immobilization is continued in accord with established principles with physiotherapy as indicated. Surface care of the now epithelium is administered daily through windows in the casts or bivalved casts, depending upon the degree of union of the fracture, ’When the grafted surface is completely epithelialized and the des- quamative process has diminished so that the graft is relatively stable, further surgery is indicated for the obliteration of the bone cavity. The Third Stage: The Obliteration of the Bone Cavity with Autogenous Bone Chips. The principal factors in the success of this stage are: 1. The planning of suitable epithelial covering for the lacuna. 2. The complete excision of a split thickness graft from the depth of the saucerized area. 3. The procurement of a sufficient amount of bone chips to fill the cavity. 4. The covering of the chip-filled cavity with the skin and sub- cutaneous tissue in such a manner that tension is avoided. In planning the epithelial covering for the lacuna, it is frequently possible to undercut the margins of the skin adjacent to the cavity so that viable full thickness skin may be closed over the cavity without tension. It has been found advisable, when possible, to plan the closure so that the suture line does not overlie the cavity as it has been found that the incision apparently heals better when not "floating" over the recently filled cavity. Therefore, it is frequently necessary to elevate a double pedicle sliding flap in the region adjacent to the cavity and shift the flap to relocate the suture line. These flaps may usually be shifted without delay .and their viability will usually be satisfactory if the ratio of length to .width does not exceed 3 to 1. In most cases one flap is adequate but occasionally it is necessary to raise flaps on both sides of the cavity. Rarely, after the flaps are elevated their cir- culation may not seem adequate, so that it becomes necessary to "delay" the procedure by returning the flaps to their original bed and not proceed with the remaining operation until two or three weeks later. Occasionally when an extensive, loss of surface covering has occurred, it may be necessary to migrate skin and subcutaneous tissue by the pedicle method from more distant sources. With satisfactory full thickness epithelial covering of the lacuna assured, it is safe to proceed with the excision of the split thickness lining of the saucerized area. The marrow canals are then reopened and the bone surfaces scarified throughout. Autogenous bone chips are then procured from; any convenient source' in quantities sufficient to fill the cavity (the wing of the ilium has proven an excellent source). Those chips are transferred to the prepared cavity and the flap or flaps over the filled lacuna. A split thickness graft obtained from the thigh is utilized to cover the denuded area representing the former location of the pedicle flap. Pressure dressings of machinist waste are again utilized. Post-operative chemotherapy is instituted over a period of three to five days with the inspection of suture line and flap covering of the lacuna on the third day. If any tendency toward accumulation of fluid is noted, it is aspirated and the region.irrigated with penicillin through the aspirating needle. As soon as the sutures are removed, • the extremity is treated in the orthodox manner as indicated by’ routine orthopedic judgment. SLIDES LOZON- Fracturo, compound, comminuted, complete, proximal third, left tibia, sustained 30 May 1944 as a result of high explosive shell fragments. Operative procedures: 1. 19 June 1944 - Secondary closure of wound medial aspect, left tibia, overseas. 2. October 1944 - Sequestrectomy and sauceri- zation, Crile General Hospital. 3. November 1944 - Split thickness skin graft, lacuna, left tibia. 4. Secondary closure of skin over defect in bone, in December. 5. April 1945 - Application of bone chips. "v. ROMANOWSKI- September 1944 - Incision and drainage, left leg. November 1944 - Sequestrectomy and saucerization, left tibia. November 1944 - Application of split thickness graft to saucerized are' March 1945 - Plastic obliteration of bone cavity, left tibia. DeGOOD- October 1944 - Sequestrectomy left tibia, proximal third. September 1944 - Split thickness skin graft. January 1945 - Shift of pedicle over lacuna with application of split thickness graft, lateral aspect of the knee. March 1945 - Bone graft, chip type from wing of ilium, left tibial cavity. ARMEN I - 6 March 1944 - Split thickness graft applied overseas. 8 November 1944 - Plastic repair of cicatrix, left tibia and osteo- periosteal graft from right tibia. SKIBA- October 1944 - Sequestrectomy and saucerization, left tibia. 18 October 1944 - Split thickness graft to saucerized area. November 1944 - Plastic repair of bone cavity with bone chips from wing of ilium. WELLAR- December 1944 - Sequestrectomy and saucerization femur. January 1945 - Split thickness graft, saucerized area. April 1945 - Plastic obliteration of bone cavity with bone chips from ilium. HORNER- February 1945 - Sequestrectomy and saucerization. 27 February 1945 - Split thickness graft to saucerized area, left femur. 16 April 1945 - Plastic obliteration of bone cavity with chips from left ilium. DRUESCHEL- January 1945 - Sequestrectomy and saucerization. February 1945 - Application of split thickness graft. 15 April 1945 - Obliteration of bone cavity with chips from wing of ilium, tibia. DELLI BOVI- January 1945 - Sequestrectomy and saucerization, right tibia. 23 January 1945 - Split thickness graft, bony defect, right tibia. February 1945 - Removal of split thickness graft; obliteration of bone defect with bone chips from wing of the ilium. SUMMARY A method has been presented for the obliteration of bone cavities by autogenous bone graft and plastic skin closure. Itoelve cases are presented in xvhom these methods were clinically employed in the treatment of traumatic osteomyelitis with cavitation. Since the first two cases were operated, the time intervening between saucerization and the application of the split thickness graft has been decreased to seven to ton days. The final procedure, that is filling in the cavity with bone- chips following in three to eight weeks when epithelial covering is adequate. In the first three cases treated the skin flap was transferred over the bony defect leaving a large hole underneath the flap and it was necessary in two of these cases to carry out aspirations of the hematoma for several days post-operatively. From this experience it was observed that progress was more satisfactory when the bone cavity was filled with bone chips at the tine the flap was shifted, rather than shift the skin and follow this with filling of the defect some two or three weeks later. This seems to be a more reasonable method of dealing with this problem than methods previously employed in that not only is infection eliminated at an early date but also an attempt is made to promote osteo- genesis by bone graft and a stable epithelial covering is provided by surgleal methods. We express our gratitude to Hr. L. R. Johnson of Cleveland, Ohio, for his untiring effort in toking and producing the photographs. COLONEL NOYES: Lt. Colonel Robert L. Prpston, Orthopedic Consultant from the Fifth Service Command will discuss /"Dermatome Grafts on a Production Basis in the Fifth Service Command". LT. COLONEL R. L. PRES TON: Colonel Knight and Major Kelly have discussed their experiences with dermatome grafts for chronic osteomyelitis wounds. I would like to summarize the results we have had with this method in the Fifth Service Command and to mention some of the impressions I have received from, the observation of this work in our hospitals. A year ago, after seeing the excellent results of Major Kelly, at the Ashford General Hospital, I passed the word around and began to urge that the method be tried in the other hospitals. At that time the Orr-Trueta treatment, with or without local penicillin or sulfa drugs, was the treatment of choice for mos t of the cases. Disadvantages of the Orr-Trueta Technic. It has long been recognized that there are many disadvantages to the Orr-Irue ta trea tment. The prolonged immobilization results in considerable residual soft tissue disability. Considerable impairment of function of the extremities may result from the freezing of the joints, fascias and muscles during tho period of immobilization. During the long period these wounds are packed open a large amount of protein is lost in the wound discharges making it difficult to maintain the patients in nutritional balance. Many of the wounds heal with dense scar which must be excised before function can bo restored. Areas of sclerosis and areas of soft tissue scar usually develop in the bone as it heals under the influence of the Orr-Trueta treatment. When the patients treated by the Orr-Trueta technic are compared with those treated by adequate saucerization and the early application of dermatome grafts it is apparent, that in the cases treated by skin grafts, the texture of the bone usually has a more normal appearance on X-ray, there is less residual scar, the function of tho extremity is bettor at the completion of the treatment and tho patients remain in better general condition during the course of the treatment. 8econdary Closure. The question arises as to whether these wounds can be closed by secondary suture of the skin over the saucerized bone der.-ct so as to save one step in the reparative process ,• .The cases we are discussing this evening have had purulent discharge from infected bone cavities'for. four to five months so that conditions are not suitable for secondary closure. The situation is entirely different in the cases on which secondary closure has been used so successfully in the overseas hospitals; the cases in which the infection-has not had a chance to become established. It has been demonstrated that a very high percentage-of split thickness skin grafts will survive in the presence of infection. The secondary closure of these badly infected wounds is not compatible with accepted surgical principles and I do not believe that the percentage of good results can be expected to compare with those which follow the use of split thickness grafts. We have used secondary closure on en occasional, exceptionally favorable, case. I believe that v/e should continue to reserve this procedure for this type of case and use the dermatome graft for the routine cases. Our principle objective is the elimination of the infection as soon as possible so that definitive plastic or bone surgery can be done. The wounds seem, to remain closed once healing has taken place. Of course, in many of the cases,-: the dermatome* grafts must be replaced after healing by more suitable full thickness grafts but it is my impression that this secondary procedure is not required as frequently in these cases as it is in those treated by the Orr-Trueta technic. During the past year f>50 cases -have been done; most of ihem by Colonel Knight at Crile; Major Kelly at Ashford; Major Rizzo at Fletcher and Lt. Burgess at Billings, with a few cases in each of the other hospitals. Slide 1 - Statistics Number of Cases --------------- 550 Cases which can be evaluated- -------- 498 Interval Between Saucerization and Graft- ------------- 0-30 days of-Cases - -- -- -- -- -- - 4-9 days Completely healed in One Month ------------ 52% In Two Months- ----------- 89% Failures (not healed in two months) ----- Saving of Hospitalization In 89 per cent of the cases the wound has healed within about two months after saucerization. This is about two and a half months earlier than can be expected with the Orr-Trueta treatment, as the average healing time with-that method *is about four and a half months. A considerable saving of hospitalization is effected by the use of the dermatome grafts. In Conclusion: After observing the results of this work, done by a great many surgeons in the Mi’+h Service Command during the past year, I believe that the technic is suitable for the production line methods which are necessary in a busy general hospital, that the end results are better than those with other methods that hospitalization time is saved, and that the method is now well enough established to be adopted as the standard treatment for chronic osteomyelitis resulting from compound fractures. COLONEL NOYES: We will now proceed with the discussion. Wo would like very much to hear from the Surgical Consultants from other Service Commands. Papers as follows: Dermatome grafts for Chronic Osteomyelitis presented by Major Robert Kelly, Ashford General Hospital. Obliteration of the Defect in Bone in Cases of Osteonyelitis Closed by Dermatome Grafts presented by Major M. P. Knight, Crile General Hospital. Dermatome Grafts on a Production Basis in the Fifth Service Command presented by Lt. Colonel Robert L. Preston, Fort Hayes. COLONEL IDYS MIMS GAGE; I wish to congratulate Majors Kelly and Knight and Lt. Colonel Preston for this real contribution to the treatment of localized osteomyelitis of the osseous system. When Major Kelly stated, that he saucerized the bone, I immediately thought of the saucer izatior.s recommended years ago (first in Germany) for the treatment of chronic osteomyelitis. This saucerization was the removal of two-thirds of the circumference of the shaft of a long bone involved in an osteomyelitic process of a chronic nature. I was always against such an insult to an uncomplaining bone. (The osseous tissue is just as sensitive to trauma as the conjunctiva and should not be mistreated as though it was a concrete pipe.) I have never done a saucerization of a bone for chronic hematogenous osteomyelitis, and, God willing, I never will. The operation for chronic osteomyelitis (localized form) is not a true sau- cerization but is comparable to a localized debridement of the osseous tissue, and I think the word debridement should be used instead of sau- cerization. The results shown here tonight in the cases of Localized traumatic osteomyelitis are most noteworthy. The question of removal of all devitalized and infected bone with skin grafting within 9-10 days is based on sound surgical principles. Its superiority over the Orr treat- ment of these cases is unquestionable. The Orr treatment is one that is prolonged, costly and questionable. Review of the cases treated in Spain that migrated to France where they were evaluated, demonstrated the inadequacy of accomplishing bone healing and the elimination of infection. The method advocated tonight produces rapid healing of both the osseous tissue and soft parts. The osseous tissue which showed sclerosis before debridement and grafting reveals a dramatic change, i.e., rapid decrease of sclerosis due to revascularization of the entire cir- cumferential bone edge of the cloaca. The time of hospitalization has been shortened almost 50^. The addition to the procedure as reported b2/ Major Knight, the use of bone chips, and a sliding graft, accomplishes two things: heals the osteomyelitic process and restores bone continuity at the same time. This will overcome subsequent grafting and again shorten hospitalization and prevent chronic toxemia with all of its undesirable complications and sequelae. Dickson of Kansas City in 1940 reported, I believe it was 13 cases of chronic osteomyelitis thdt he had debrided, applied sulfanilamide to tho wound with skin closure with primary healing. This was quite a step forward in the treatment of these cases. Therefore, we must give tho sulfa drugs, and especially penicillin, credit for making it possible to treat the cases of osteomyelitis by the methods advocated by the essayist tonight. I would like to congratulate all the surgeons of the Fifth Service Command, who have taken part in this contribution in the treatment of traumatic osteomyelitis. I consider it one of the real advances in surgery of the osseous system of World War II. The only regret that I have tonight is that the surgeons and orthopedists of the Fourth Service Command are not here tonight to hear these contributions and to see the remarkable results that have been obtained in the treatment of osteomyelitis. COLONEL NOYES: Thank you, Colonel Gage. COLONEL Yf. B. PARSONS: Colonel Cook and Gentlemen: I would like to. indorse heartily Colonel Gage’s congratulations on this splendid piece of work. I was glad to hear hira speak about saucerization and agree with him that this is a bad word. Another word that I hate is the word pack- ing. It is too bad we do not have better words to describe what we do when we dress a wound. I do wish someone would find a nice short word to describe the right way to place gauze into a wound. Perhaps the younger ones here do not have any misunderstanding, but I am sure that most of us older ones think of saucerization as being different from what was done in the cases reported. This was really sequestrectomy. There is a great difference between osteomyelitis of the hematogenous variety and the osteitis occurring in military compound fractures and there is also a great difference in the military cases between the problems presented by the shaft as compared with the end of the long bone. In the lower leg, if for some reason or other, a wound has not had secondary closure at an early date, it will be wide in relation to its length, or deep in relation to both width and length by the time it has arrived in one of the general hos- pitals in the states. Even so, such wounds involving the shaft of the humerus or femur can be satisfactorily closed by shifting soft tissues after removal of minimal amount of diseased bone. There is a nice series of such cases being done by Lt. Colonel Horwitz at Vaughn General Hospital. By covering the defect by plenty of soft parts one has produced the ideal conditions for a subsequent reconstructive procedure. Cavities in the upper end of the tibia and in the sacrum represent perhaps the two most difficult problems to solve. I think this method as reported here is a very sound one to hasten healing in the bone, that it will be particularly useful in the closing of cavities in cancellous bone and should be used whenever it is impossible to bring soft tissues together over the defect. LT, COLONEL C. Wi, CUTLER, JR: These cases at Cushing General Hospital have been managed by Captain Richard 3. Dodge, under the supervision of Major fobin of the Orthopedic Service. The following principles of treatment have obtained: 1. Maintenance of the most advantageous position of fracture fragments until bony union occurs or surgical fixation is indicated. 2. Elimination of active infection. 3. Fortification of the patient’s natural defense mechanism. 4. Reduction to a minimum of a period cf disability, Consistent with maximum restoration of function. 5. Reduction of the incidence of recurrence of infection. Genoral systemic measures and supportive therapy are consistently pursued. Penicillin has been utilized systemically prior to any operation undertaken and for an indicated period following it. Complete and meticulous removal of necrotic tissue, both bone and soft tissues, have been carried out, at the appropriate time in each case. Four groups of cases have been followed for the purpose of comparing different -typos of local treatment of the resulting wound. Sixty cases were treated by the following method: After sequestrectomy, gauze saturated with penicillin solution, 1500 units per cc, was placed in the wound. This was changed daily under operating room conditions of asepsis. Seventy-one per cent of these were closed in an average time of two weeks without further intervention. The sequestrectomies in this group wcre not of the wide excision type, but consisted of exploration and careful clearing out of the sinus tract and fracture site with removal of minimum healthy uninvolved tissue. Twenty-two cases wore treated, following sequestrectomy, by closure of the wound by suture with a rubber catheter inserted to the depths of the cavity* Local penicillin was instilled into this catheter at four- hour intervals for an average period of two weeks before the catheter was withdrawn. Twelve or fifty-four per cent were healed in an average time of three ana one-half weeks. Fifteen cases have recently been treated on the saucerization program. At the time of sequestrectomy wide excision and saucerization of the wound was done, with subsequent skin grafting on the surface of the wound, about eight days later. This groups has been too recently undertaken to permit evaluation. The general observations on these groups of cases have given the following impressions: Those cases treated by penicillin gauze and repeated dressings apparently clear up early. An optimum condition of the wound and a minimal amount of discharge is noted at approximately two or three weeks. From that period on, tho progress of the wound is much slower and the general appearance less healthy. The method of incasing the part in plaster following elimination of culturable bacteria seems to involve a longer period of treatment, with no apparent benefit. Those cases in which closure with the injection of penicillin through a catheter was employed hav© tended to show the presence of an unobliterated continuing deadsspace in the depths of the wound. Even though skin healing results, reopening of the wound has occurred in some instances. The technique of this procedure has not been well worked out ant it may have possibilities which are not yet realized. Hie saucerization method of treatment followed by skin grafting seems to be applicable in the wounds where the bone is superficial. Closure by flaps or secondary soft part suture is appropriate where the wound is deep. The cleaning up of the wound adequately-, to permit either of these pro- cedures depends on complete sequestrectomy, systemic penicillin, meticu- lous aseptic technique in dressings and avoidance of too much interference. It has been found that the gross clinical aspect of the wound is a better guide to its condition and readiness for further surgery than are culture to determine the pathogens in the wound. A development of considerable interest at this hospital has been the undertaking of obliterative osteotomies, and in some instances, even arthrodeses in the presence of open granulating wounds, as proposed by Dr. M. N. Smith-Peterson, civilian orthopedic consultant to S.G.O. This has been undertaken in a few cases, with, so far, satisfactory results and without untoward complications. In such wounds, penicillin has been used locally in the depths of the wound, introduced through the Smith- Peterson cannula and under the guidance of its originator. No conclusions or report are possible at this time because of the relatively small series of cases thus far treated. COLONEL N. B. WISE: I don't want the 3rd Service Command to be left out of the congratulations that are due Colonel Beck, Colonel Preston, and others who have done such wonderful work in this Command and. added such a contribution. The answer to these problems, I think, is going to be a combination of the things we have heard tonight. This war has brought out many new procedures and we go on step by stop* This is certainly a great step but along with it we should take full advantage of some other things done under the protection of chemotherapy and penicillin. While mentioning penicillin, I should like to ask the essayists to give a little more detail about their methods of using this drug* One said that these cases were treated two or three days after operation. I wonder that treatment is not begun before operation to prevent reactivation of the osteomyelitis or other infections and continued for a rather good length of time after operation, in the light of knowledge as to how penicillin works. As to other measures to bo used in reparative surgery of soft parts and bone, I would like to stress particularly the pressure dress- ing. The differences between the results of inadequately applied pressure dressings and those carefully applied are. very striking. We see in plastic surgery great liberties being taken about the face, eyes, nose, mouth, and other parts that cannot readily be sterilized. Careful applica- tion of pressure dressings seems to be a sort of magic that lias beneficial effects in prevention of infection. A combination of all available measures should give a comprehensive program from which to select, using secondary closure in certain instances as recommended by Churchill, not, of course, in the expanded part of the tibia but perhaps in the femur and other deep lying bones that arc better adapted to this procedure, using thin o,r dermatome grafts in the types of cases that we have been so well exhibited tonight. There will, no doubt, be areas where sliding grafts cannot be done and pedicle grafts will have to. be used, I, likewise, would certainly have had some of our orthopedic surgeons hero if I had known in advance that such outstanding orthopedic advances were to be presented on the program. We have no Orthopedic Consultant in our Service Command, and I am anxious for our orthopedists to attend such mootings as this. After I saw the program it was little too late to get orders, but if permitted, I will send some of our ortho- pedists around to visit you. COLONEL NOYES: I see Colonel Peterson here - COLONEL L. T. PETERSON: I would like to add a word of emphasis to what has already boon said. Iho work shown here tonight is a real contribution and is comparable to the reparative surgery being dono overseas which we have all heard about. I visited a number of convalescent hospitals recently and had an opportunity to see cases with scars that were breaking down. We should practice excision of scars and application of skin grafts even more freely than is now being done. Major Kelly has made a real name for, himself at Ashford in this type of work. Colonel Knight has shewn us a solution to what has appeared to be an unsolved condition, that is, large defects in the upper end of the tibia. It appears that he has actually answered some of the questions which Colonel Cutler has raised. Whore the knee joint is intact, it should be preserved and certainly it is better to fill the defect and maintain length rather than to shorten the tibia if the former can be done. Ihis preserves the knee, although the shell might be thin. The procedure which Colonel Knight has dene, filling defects with bone and covering with full skin, is preferable to any collapsing type of procedure. Where the knee joint is destroyed b£ trauma and infection there is little choice and arthrodesis is indicated. Colonel Noyes, I think your Service Comma.nd has made a distinct contribu- tion in the work discussed here tonight. We have seen a certain reluctance on the part of the orthopedic surgeons to do early sequestrec- tomies and proceed as boldly as Colonel Knight and Major Kelly have done in actually covering defects with skin. I wish that all Chiefs of Ortho- pedic Sections and Plastic Sections could see this work, and I hope the consultants who are here will carry this message to other hospitals. It is a special pleasure for me to be here tonight to make a comment because I initiated Colonel Knight and Major Kelly into the service and want to personally congratulate them on their papers and also to congratulate Crile and Ashford,General Hospitals on having them on the staff. LT. COLONEL W. H. McGAW: I would like to ask Major Kelly and Colonel Knight some questions on their excellent papers. First, I wish to state that my interest in free skin grafting to bone infections and cavities began in Melbourne, Australia. There I had the privilege of seeing some of Balcombe Quick’s cases. One case particularly impressive had severe osteomyelitis of the os calcis. A large, irregular, through and through cavity had been successfully healed by free skin grafting, maintaining full tendo-achilles function. Mr, Quick accomplished this by using two dental wax molds introduced into the defect from both sides of the os oalcis. He used one little trick for introducing and maintaining the graft in place. The Tiersch grafts were fixed on the molds by frosting them in place with ethyl chloride spray. On returning home I had the luck to see Major Kelly’s work at Ashford General Hospital. By careful work he has been shortening the convales- cence and hastening complete healing. I find he is a very modest man. He hasn’t mentioned the definite improvement as shewn by serial x-rays of the bone itself after his method of skin grafting. It was apparent to me that the sclerotic bone around a cavity gradually changed its dense character to more normal looking texture and bony trabeculation. Like- wise the cavities gradually became filled in and definitely smaller. I wish to ask him about his experiments on keeping excess skin in the re- frigerator to fill in possible small areas lost at the initial grafting. Colonel'Knight has made valuable contribution to the treatment of these difficult cases with marked bone loss. It was not clear to me when he advocated introducing the bone chips under the skin flap. Was this done at the time the flap was shifted or after it had completely healed in its new location? I also wish to ask if any of the bone chips sequestrated later and if they did, were they all lost? COLONEL NOYES: Major Antopol. MAJOR v/ILLIAM AN TOPOL; I just happened to be on the side lines watching these amazing results. The laboratory at the Billings General Hospital was asked to make a bacteriologic survey of their cases of chronic osteo- myelitis on the day before application of the split thickness graft, usually the seventh post-saucerization day. A method was applied bjr which the numbor and -type of organisms on a unit surface could be determined. 210 cases were treated by this method on the orthopedic section of Billings General Hospital, of which 150 consecutive cases were taken after the bacteriologic method was standardized, (Table 1); 67 healed in 25 days or less, and 69 were successful between 25 to 50 days. In the former group there were 10 cases which had over 400 organisms per square centi- meter, of which more than ZQff0 were staphylococci; in the latter group 14. Only 14 of these 150 cases, or less than were failures. Of these failures, 7 or had staphylococci in the same order of magnitude as the successful takes. Applying tho chi square formula, these figures are of great significance; from this it might be concluded that if more than 400 organisms are present over a square centimeter of the wound, of whitfh more than 2CF/o are staphylococci, there is at least a 1 to 5 chances that skin graft will not be successful. It was also found that the presence of great numbers of other organisms, even more than 100,000, have no effect on the success or failure of the skin graft if staphylococci are not present in significant numbers. TABLE 1. Bacteriologic Surgery of 150 Cases of Chronic Osteomyelitis Treated by Saucerization and Split Thickness Skin Graft. NO. CASES .-STAPHYLOCOCCI*. SUCCESSFUL 25 DAYS 67 10 SUCCESSFUL 50 DAYS 69 |4 FAILURE 14 7 *Over 400 Organisms of which more than 20% were Staphylococci. COLONEL NOYES: In closing, I would like to ask the speakers to answer the questions that were put to them. Major Kelly, if you will. MAJOR ROBERT KELLY: I would like to thank the discus so rs for their remarks. I would like to point out the fact that although the operation may not be a saucerization, more tissue is removed than in a sequestrec- tomy. The chemotherapy is usually started one day in advance of surgery and continued for several days. We have used ’’icebox” skin in two cases. The third one is being done during the few days of this meeting. There has been, I v/ould say, about fifty per cent take of skin on the wounds. We have allowed the skin to freeze, and that should not be done. The icebox skin probably has helped. I would like to add one thought in regard to secondary closure and skin grafting of wounds. Might it not be true that when we have a wound vh ich cannot'be secondarily closed without tension or dead space, or both, that then is the time we should apply a skin graft, the initial surgery being the same in either case? LT. COLONEL H. P. KNIGHT: I think the first question asked me concerned abscesses iSo 1 lowing closures of full thickness skin over these bone defects before the application of chips. As X tried to bring out, the first two cases were treated by skin flaps from the lateral aspect of the skin-lined cavity,, the chips not being inserted at that time. We found it w.as necessary to aspirate these lacunae. In a desperate effort to prevent this, it was decided to fill in this defect with bone chips from the wing of the ilium three weeks following the transfer of full thickness skin over the hole. In the second case treated in this manner, also before any had been filled in with chips, it was necessary to aspirate this defect many times, each of these cavities being clean and well covered with skin. Each aspiration was carried out somewhat like one would aspirate a tuberculous abscess, filling in the lacuna or hole by in- stallation of penicillin following the aspiration. The second case finally healed enough so that it was not necessary to aspirate the lacuna, but X-rays three months later showed no reproduction of bone, although the skin .had been well healed for four months without reaction to skin or bone. This soldier had been on a furlough 30 days, the lacuna being at the upper end of the tibia. During the procedure to fill in bone chips, there was found a small abscess which resembled the Brodie's abscess which usually has a sterile culture. This area was completely saucerized, filled in with bone chips and closed, and has remined closed' since this .procedure. This is the only abscess which we encountered during these cases either early or late. Since the filling in of bone chips in this particular case, there have been no ill effects. Vie have in the severe cases of osteomyelitis used a definite routine, using penicillin and sulfathiazole nine days previous to sequestrectomy and saucerization these patients were given 100,000 units of penicillin daily. The use of penicillin and suIfathiazole‘definitely has its effect. From another aspect it has definitely given us courage to do more radioal procedures andthis is especially true previous' to the application of a split thick- ness skin graft over these large saucerized areas. However, we have in several instances not used penicillin or sulfathiazole and carried out the same routine, that is sequestrectomy and saucerization followed by the application of a split thickness skin graft dressing seven to ten days later without ill effects. We have also encountered some individuals who have been given penicillin four or five days post-operatively that have had severe urticaria and some slight elevation of temperature. We noted that when the penicillin was discontinued each cleared up from a few hours to a few days. As Colonel Gage mentioned, the treatment of osteo- myelitic cavities with sulfanilamide in 1940 by Dr. Dickson of Kansas City, closure of skin over these defects preceded the closure by complete excision of scar in that area and especially in hematogenous osteomye- litis in children. I have noted also in these osteorayelitio bones from war time injuries, it is definitely indicated to excise enough scar tissue to good bleeding surfaces, but split thickness skin grafts take or heal in inverse proportion•to the scar tissue remaining. .When Dr. Dick- son's article first appeared I used his method in closing some small sinuses which were definitely draining and it appeared to me at that time that the most essential thing was thorough sa'ucerization and thorough excision of scar as much if not more so than the sulfanilamide itself. In the series of 18 skin flaps, 12 of which were shown here, wo have found it far better following excision of split thickness grafts, unless it was definitely contra-indicated which we encountered in only one case that was not thoroughly saucerized, to fill in the defect with bone chips, and to cover the area and chips with, a full thickness skin graft in one procedure rather than removing the split thickness skin graft dressing, transferring the flap to cover the defect, leaving that flap floating as we did in the first two or three cases'. In other words, in four to eight weeks following the application of this split thickness skin graft dressing, it is better to have one final procedure than to divide it up into -bwo procedures. The hole is then filled in with bone rather than hematoma or serum - in other words, eliminating dead space. Another question asked was as to the failure of these grafts. Thus far, I cannot say we have had a failure. One patient, tho first one in which this procedure was carried out, has completely healed. The femur is solid and he was transferred to a Convalescent Center. There has been in two cases superficial Ooze of serum in one area of the skin flap but no infection in the region of the bone chips. I do not think we have had time enough following the first group of procedures to estimate or definitely say whether we have had a failure or not, but we have been, enthusiastic concerning the first group of cases which have been treated in this manner. I can safely say we have saved joints in at least of these patients by this method of treatment which, if they had been treat- ed in the Orr treatment of osteomyelitis, would definitely heal with painful or arthrodesed joints. This method of treatment is definitely • heefuitiih thantreatment of osteomyelitis near joints. COLONEL E. A. NOYES; I want, to thank the discussers for their remarks. It is gratifying "to have the work discussed and accepted in this way. Wb ' will call on Colonel Beck to wind up the evening session. COLONEL 0. S. BECK: I am gratified to hear the remarks made by the surgical consultants All those surgeons are close personal friends of mine and their remarks mean a great deal to me. I should like to congratulate Major Kelly for starting this work in the 5th Service Command. I also want to congratulate Colonel Preston for instituting this procedure in the other hospitals. While this pro- cedure is not original, it does seem to me that we have put this proced- ure on a production line in all the general hospitals of the 5th Service Command. At the present time, the operation is being done in large numbers in each of our general hospitals. Some of the general hospitals have one or two wards of dermatome grafts in patients with osteomyelitis. A great deal will be said in the future about this method of treating • osteomyelitis. It certainly seems to me that this method has many advantages over the Orr method. The method provides a skin cover to the wound and the skin cover keeps bacteria and dirt out of the body and keeps hemoglobin and blood plasma in the body; it prevents the leakage of protein from the wound; the patient’s nutritional condition improves, inflammation in the soft part subsides and as this occurs, tenderness leaves the wound. The soft tissues become pliable again, whereas, with an open wound these tissues become frozen together. The patient is very much more comfortable v/ith the wound covered with skin. These surgeons who have done this work have gotten a great kick out of it. A plastic surgeon is not required to place the dermatome grafts, any good surgeon can do this. Saucerization of the' bone sometimes requires judgment and skill, especially if the lesion is close to a joint. I think I have seen lesions so close to a knee joint that one would expect the osteomyelitic process to enter the joint. This method might prevent extension in the j>int and thereby preserve a joint. Further plastic work will be necessary in some of these patients. Later on the dermatome grafts may have to be replaced by a pedicle graft. We have been making these pedicles in each of our general hospi- tals and we have not been transferring these; patients: to plastic centers for such operations. I have discussed this matter with General.Rankin end Colonel Carter and it is their opinion that a general surgeon can go ahead and do these pedicle grafts, COLONEL E. A. NOYES: There will' be a five minute break and then Colonel Cook has-a movie taken at this hospital that he would like to show you. PROCEEDINGS OF THE CONFERENCE Saturday, 12 May 1945 Final Session Major George C. Prather, Ashford General Hospital, Presiding.—Tfye Symposium on The Paralyzed Patient will be continued with a discussion on /’Ambulation and Support” by Captain James E. Cameron. ' Captain J. E. Cameron;- Ambulation or locomotion is generally conceived to mean the ability to stand and walk unaided. In the treatment of paraplegia we must modify this definition and consider that we start with the patient unable to voluntarily move a muscle below the spinal cord level of D-10, we feel justified in defining ambulation as the ability to get about by means of braces and crutches proficiently enough to care at home; to carry out the necessities of ordinary life without constant help from another personi We should, perhaps, call such a patient mobile rather than ambulant. We feel that the following expected results justify the initiation of an early and vigorous program of ambulation in each patient with a spinal cord injury; 1. The morale factor. Patients with spinal cord injuries and paraplegia have an extremely low morale which influences their appetite and general health adversely. This is, of course, derived from the prospect of being unable to walk; any advance in their ability to get about either in a wheel chair or on crutches causes an immediate improvement in their general outlook on life, their appetite and general health. 2. Therapeutic exercise. In our 70 cases, 49 are incomplete or recovering, as manifested by gradual downward progression of the sensory level and return of function in previously paralyzed muscles. In many cases the prognosis cannot be given, even after direct inspection of the lesion at the time of laminectomy and it may be many months before any recovery takes place. It is in this group of cases (which in our series represents 10%) that the very early initiation of a program of ambulation is of immeasurable benefit. This benefit is derived from the passive exercise obtained in the swinging movements of otherwise paralyzed lower extremities. No amount of artificial or assistive physical therapy can make up the equivalent of such exercise. 3. Neurologic changes. For some unexplainable reason weight bearing on the feet seems to overcome marked clonus and in- voluntary mass movements seen in recovering cord injuries. We have had two patients who made no attempt to stand or walk because of marked clonus who improved remarkedly and 'went on to complete recovery upon a program of forced weight bearing. 4. Improvement in general nutritional vasomotor functions. We feel that the resumption of the upright position is a great benefit in the general bodily tone and cardiovascular status. We have nothing new to offer in ambulation except a program which cofisists of the following: - 1, Exercises to strengthen the muscles of the upper extremities used in crutch-waIking with particular attention to the triceps and muscles of the shoulder girdle. These exercises are commenced as soon as the patient enters -the hospital and are continued throughout his stay. They are given by the Reconditioning Service. 2. Braces are ordered on the patient while his bed sores and bladder are being treated. In cord lesions with little or no function in the abdominal musculature, a thoraco-pelvic girdle is necessary. This consits of semi-circular padded steel bands engaging the rib margins above and the pelvic crests below. The legs are attached by free hing.es at the hip with the joints placed opposite the tips of the greater trochanter. The encircling thigh bands consist of a wide metal band posteriorly and wide canvas or leather straps anteriorly. An important point in the construction of the brace is to make the upper border of the upper-most posterior band parallel to and at the level of the gluteal crease. Drop-locks are used on the hinges at the knee but the ankle - motion is free. This allows flexion at the hip and knee while the patient is sitting in a chair and locking of the knees while walking. The toes of the shoes are turned in- ward about 10 to 15 degrees in order to shorten the arc of travel that the foot must go through with each simulated step. 5. Walker. The standard army walker is used with a crutch type arm support. 4. Crutches about which nothing need be said. ' > Patients with high lesions require prolonged and tedious instructions in the art of paralytic walking. Normal walking is a complicated process in any biped animal. Steindler (l) describes the normal human gait as a constant alternating play between the two lower extremities in which they alternately assume the function of support and of propulsion. The only phase of the normal gait seen in a paralytic is that which takes place as the non-weight bearing extremity is allowed to swing, like a pendulum, forward; the paralytic gait is, therefore, fundamentally a succession of alternating pendular movements. Propulsion is obtained by the triped action of each of the two crutches and the braced lower half of the body. It is impossible to take up all the be- ta i Is of paralytic crutch walking but this much may be said at this time. Such walking involves swinging the pelvis and lower extremity by either the thoracic cage or the abdominal musculature, the force being transmitted through the braces. Since the gluteus medius muscle is paralyzed, it is necessary that the patient lean far to one side in order to raise the opposite extremity off the ground. This makes a grotesque over-movement at first which requires long practice before it is eliminated. These patients are frequently in- hibited by a strong fear of falling and it may be necessary to deliberately allow the patients to tumble. When he finds that his sensory organs in the paralysed region are no longer functioning, he will get over a great deal of his fear. We feel that any patient with a cord lesion at or below D-10 should be gotten into braces promptly and without waiting for recovery of muscle function below the lesion. We feel that we can extend to such a patient the hope of ambulation with crutches provided his upper extremities are intact. We further- more feel that patients with cord lesions as high as D-2 (provided their upper extremities are intact) may with prolonged practice and instruction be able to get around in braces, but to these patients we give a more guarded prog- nosis as far as walking is concerned and at the same time get them into braces and walker. It may be that in the future, some as yet undeveloped operative proced- ure (such as thoraco-pelvic fascial slings) and the application of knowledge gained from the treatment of poliomyelitis may make it possible for these higher cord lesions to get about with crutches. As yet none of these have been used to our knowledge. For those patients with high lesions unable to use the walker, we initiato a prompt wheel chair program. We feel that the simple change of posture and the additional exercise incurred in moving a wheel chair are a great benefit to the patient. The question of amputation of the lower extremities for irrecoverable loss of function as in paraplegia has been raised; the Library of the Surgeon General contains no references to such treatment. The Council on Physical Therapy of the American Medical Association (2) advises that amputation be performed only if simple amputation will offer a better prognosis in terms of a ppearance, comfort and function and if a sufficient part of the extremity possesses enough useful function to work well in a prosthesis. Certainly very few, if any, cases of paraplegia would meet these requirements unless compli- cated by extensive bone or vascular damage. In summary, therefore, early initiation of a program of ambulation in paraplegic patients raises their morale, furnishes involuable physio- therapy, may overcome clonus and mass-movements in partial lesions, im- proves the nutritional state and vasomotor tone. Such a program consists of exercises for the upper extremities, the early fitting of braces, and supervised instruction in paralytic ambulation, starting in a walker and progressing to crutches. Bibliography: 1* Steindler, Arthur: Mechanics of Normal and Pathological Locomotion in Man. Baltimore, Charles C. Thomas, 1935. 2. Council on Physical Therapy, J.A.M.A. 116: 19 - pp 2159-60, 10 May 1941. Major Prather - The next speaker will bo Lt. Colonel David H. Poor who will speak on f,Daily Care of the Paralyzed Patient.” Lt Colonel D. H. Poer:- The days when the patient who had received a spinal cord injury with resulting paralysis was treated as a troublesome and hope- less invalid, waiting for a kind, benevolent and perhaps desirable death, are definitely and irrevocably over. The men of the Army Medical Ccr ps can point with pride to the fact that they have led the way in bringing about such a complete reversal of this attitude, and action, and that they have met the issue with all the resources of the entire medical profession. Nothing has been spared to give these unfortunate individuals the best opportunity to live their lives in' some degree of comfort and happiness, based on their ability to get about and to perform some profitable occupation. This performance has not been carried out by such a relatively easy metho as sending out a generous check each month with assurance that it will con- tinue throughout life. It has been brought about by developing and following a plan which is adaptable to the needs of each individual patient and is also capable of inclusion of all improvements that have been found to bo of value. The basis for the everyday routine in caring for the paralyzed patient in this hospital is the purposeful development of a strong patient-doctor rela- tionship, the value of which to all soldiers having been emphasized by recent Army directives. All matters of every nature, all decisions whether profess- ional or otherwise, all supervision and management is directly the responsi- bility of the one doctor-officer under whose care these patients are placed. All personnel responsible for the care of these patients work directly, inso- far as is possible, under his authority and certainly he must, at all times, be familiar with everything that is being done for his patients, regardless of relative importance. Every single thing, however small it may seem, that happens to this patient is vital concern to him and he must be kept well in- formed at all times. This relationship becomes of inestimable value to the patient himself in that he finds that he has a firm fixed post to tie to and a ctually to spring from, on his road back to a reasonably satisfactory mode of living. The time and method by which the doctor establishes,‘fosters, builds up and cements this relationship is during the daily ward rounds. These must, first of all, be regular and systematic, meaning at least once daily, includ- ing Sundays and holida ys (perhaps even more important on such off days). Such rounds are necessarily time consuming since each patient must always feel that you have plenty of time to listen to all his complaints and to make and carry out any required changes in treatment promptly. Other rounds made in thar evening have proven of immense value since those hours are usually free from the hurry, bustle and rush of the average hospital day and it is during these periods that the patient soon learns to know that his doctor not only knows his problem but also knows the solution. The complexity of the problem of the paraplegic requires this unusually time-consuming program but it pays large dividends in a manner not to be obtained otherwise. In sponsoring, such an inclusive arrangement, we would not for one moment presume that such a doctor holds the entire responsibilities in his hands for the many details of the professional, nursing and reconditioning care of these patients. The reverse would be more true, Certainly in no other condition are so many services of trained specialists r equired in each and every field of therapy involved. For that reason, wo have started with the most important member of this treatment team who is the hospital corpsman or ward attendant, v/hose work takes him so close to the patient and who cares for the most per- ■sonal details of ones daily life, including the movements of the bowels and the funtions of the genital organs. To do this we have given these men and women special training in the handling and care of paralyzed individuals. By such a method the doctor can rest assured that every detail of the daily care is not only carried out well in itself but also in a sympathetic and cooperative manner with the many other branches of treatment required. For example, in giving an enema, the corpsman bears in mind the position usually required, the location of decubitus ulcers, the usual time for meals, visitors and amultitude of other details. With such a schooling he knows the needs for satisfactory results from an enema, and what will happen if satisfactory elimination is not obtained. The duties of these attendants are chiefly concerned with the proper care of the bladder and bowel, changes in position of the patient and aid in ambu- lation. Assistance is also given in the changing of bed linen and mattresses, and in feeding the patient. The use of special frames for turning the patient (Stryker) have not been found necessary when the attendants carry out their duties properly in shifting the areas of pressure on the body. Much more could be added about the extreme importance and value of the work done by these men, and after proper performance of duty they should not and will net go unnoticed or without thanks. The next in this important therapy group are the technicians and now the separation into specialties begins. It would seem that there are spec- ially trained men and women to do practically everything beyond the daily care mentioned above. Technicians carry out proper physical therapy and all this work blends readily into a reconditioning program consisting of such exercises that will give the individual the necessary massive shoulder girdle to substitute for leg motion. Special urological technicans or male nurses carry out all but the simpler procedures necessary to keep the urinary tract free from infection, draining properly, and to aid in the development of auto- matic bladder function. The functions of the dietitian have been enumerated by others and can be repeated for emphasis. Brace makers, Red Cross social and recreational workers, librarians, education and vocational instructors are some of the many workers- needed. This brings us to the nurses who share very closely with the doctor in the daily cure of the patient. She also shares with him the responsibility of carrying out the necessary details of treatment, must be his listening post and intelligence department to acquaint him with all information, to advise and to make suggestions as are needed in order to obtain the desired results. Medications must be given on schedule without favor and with an eye on the de- velopment of drug habits of one form or another, particularly opiates. She must supervise the work of the attendants and technicians to see that vital points in therapy are carried out properly. In addition to the important social and recreational program carried out for these patients by trained Red Cross personnel, attention must be paid to their religious needs. Daily visits by the chaplains are made and every effort is made to take the patient to the various chapel services where he mixes with so many other people. Personal guidance and counsel aro provided to take care of all legal business matters as well as domestic problems where adjustments must be made b. wife, children and other family members. An educational program is set up to fit the needs of each individual and this must fit into the voational plans to provide a livelihood after discharge. We now return to the medical profession to complete the circle of ther- apy originally outlined, and we turn to the many specialists whose services are required to give a patient suffering with such a complex condition the best opportunities to obtain the most rapid conversion to comfortable and independent living. This entire symposium has been made up of discussions by these men so that one scarcely needs to repeat their part in the program. Since the original injury is to the spinal cord, it is with the neurosurgeon that the launching of the original plan must rest. Nearby, the urologist has more actual daily contact with the patient until an automatic function of the bladder has been established and infection brought under control. The internists, especially the nutrition expert, has 'his important .function, the results of which are hastened by successful plastic surgery by closure of the decubitus ulcers. The orthopedic and the general surgeon likewise have their part in the treatment of associated conditions or complications, the more important of which have been discussed this afternoon. Practioally nothing has been said about the field of research "which has opened by the study of the results of this type of injury to the individual. The control of decubitus ulcers, has been partially solved by increase in our knowledge concerning protein and nitrogen metabolism and attempts are being made to control or prevent infection in the urinary tract. The sulfa drugs and penicillin have certainly been of inestimable vlaue, but the problem of the gram-negative organisms remains. Further information concerning calcium metabolism is required, as well as.all metabolic processes in paralyzed tis- sues. The problem of ambulation must be studied to provide mechanical methods more adaptable to needs of the patient. The question of amputation of help- less paralyzed limbs has been raised, and may require trial in the patient with the necessary degree of thigh flexion remaining intact. Many improve- ments in wheel chairs and mechanical walkers are certainly to be expected when American genius turns to the problems. Little has been said purposely about the special morale program required to initiate and bring about the most successful results in the treatment of these unfortunate individuals. Misinterpretation of such a program might result in too much of a Polly Anna attitude and all of us know the viewpoints of the average "G.I. *?oe” to such a program. It is our viewpoint that good morale in a paraplegia ward can best be obtained by treating patients in groups and perhaps later in a specially con- structed and equipped colony where they can become selfsupporting and by fol- lowing scrupulously the outline given above. This will readily convince the patient and his family that everything is being done to (1) cure his immediate ailments,, (2) to get him to walking again, (3) to develop a degree’ of bladder and bowel control, (4) to teach him a gainful occupation and (5) to discharge him promptly, and after that the morale factor of the paraplegic becomes no factor whatever. PRATHER?- ”The Future of the Paraplegia” will be discussed by Lt. Colonel Caleb S. Stone. LT.' COLONEL C., S« STONE:- On the first of May 1945 there remained on the para- plegia ward at YJhkoman General Hospital, 36 patients with paraplegia result- ing from spinal cord injury. These patients were all admitted subsequent to"the first of August 1944 and most of them between August 1st and Decom- ber 1st. Of this total, 26 will remain paralyzed in one or both of their lower extremities (71$); 22 will remain paralyzed in both lower extremities (60$). It is the group of 22, who will remain completely paralyzed in both lower extremities, that this discussion is most concerned with. AH of this group of 22 were underweight upon admission to the hospital, all had catheters in place, most of them suprapubic, all showed alterations in serum protein levels and AG ratios of greater or less degree. Most of them had bed sores and all were discouraged, despondent and forlorn. Some of these patients were received as little as three weeks after being wounded, some were received as much as two to two and one-half months after injury. The general plan of treatment oarried out on these patients has been outlined in principal by previous speakers on this program. These patients have been under observation now for a period of time varying from nine to three months. In addition to the details of treatment and specific procedures that have been carried out which have mainly to do with the immediate care of the paraplegia, we have made certain observations that have to do with the, late care and the ultimate disposition of this group of patients. What we have learned about them can be listed under four headings; a. Physical condition. b. Mental attitude. , c. Domestic adjustment. d. Economic adjustment.' Under the heading of physical condition, we have been impressed'.in our group with an apparent leveling off of improvement after about 4 to 6 months in the group of patients received without bed sores, In'rthe group of patients who had bed sores upon admission to the hospital, this leveling off has apparently come about 2 to 3 months after the’healing of bed sores. It is our feeling that the general physical condition, the de- gree of muscular development, particularly of the shoulder gird.lb, at this ; time is completely‘inadequate to permit these patients to enjoy tripod walking except for short distances and then only at intervals. Their phys- ical resistance and their muscular strength needs to be greatly increased if they are to become sufficiently ambulatory for crutches and braces to'" be worthwhile. * We have been also interested in the ability of these patients to ' withstand sitting up in a wheel chair for long periods. It is our impress- ion, based upon observations in this group, that these individuals can re- main up‘in wheel chairs for periods of 8 hours or more, day after day, pro- vided they are not engaged in any endeavor which absorbs- their interests .’’ When sitting about the ward or at the movies, visiting-at the bedside of a fellow soldier, these men are observed to be constantly shifting their buttock, frequently shifting the weight and relieving the pressure of con- tinued sitting. After starting a work program on the paraplegia ward, the patients interested in this activity who sat in a wheel chair at a‘work bench, became interested in their labor, they concentrated on production and in their effort to meet a production level per hour, they sat without shifting their weight and in two instances, superficial lesions developed on one buttock. It is true that in each instance, these superficial lesions may have been precipitated by the patient having bruised the buttock on the arm of his wheel chair in moving himself from the bed to the chair. Never- theless, the patients themselves state that they find it more comfortable and they consider it necessary when at work to stop at frequent intervals to shift their position and relieve points of pressure. We have been interested in the patients ability and willingness to be- gin to care for himself. Wo have accomplished little in this regard, at the time when the leveling off of his improvement occurs. As muscular de- velopment increases, patients have been encouraged to move themselves from' bed to wheel chair and from wheel chair to bed. This requires, in many instances, particular muscular development in the shoulder girdle and it will require especially further consideration of the relative height of the bod and the wheel chair and overhead frame which the patient can use to grasp as well as modification of the type of wheel chair now in general use. Pa- tients have been encouraged to take their own shower baths, using a specially constructed chair which can be rolled under the shower. Proper facilities are not available for the training of these men to take tub baths, even though this ability is desirable. Further, it would seem desirable not only to developo the muscles of the shoulder girdle and upper extremities to a sufficient extent, but also train the individual so that he might enjoy some form of locomotion in the event of necessity which would not require braces, crutches, wheel chair or the assistance of some other'indi- vidual. If the patient suffering from paraplogia over hopes to return to a ” productive life, it might be well to institute a sufficiently long program designed to determine how long ho may safely sit at work and by training, increase to the fullest extent his ability to sit at a bench. An attitude expressed by many of these patients is that they would never consider'going to their homes so long as they are unable to care for them- selves, with regard to bowel and bladder requirements. It would seem, therefore, that every opportunity to’develop an automatic bladder should be offered these individuals, that every opportunity also be offered by means of close dietary management, the development of habit, the training in the'; art of administering their own enemas and the supply of proper equipment ' : necessary so that these men can care for their bodily needs without the'as- sistance of other individuals. ' We are apprehensive that Certain individuals, now able to maneuver themselves in braces on crutches, will lose this ability because of too great an increase in the weight of the body incident to the deposition of fat. It would be advantageous therefore to instruct these individuals properly to their choice of diet and proper exercise in order to prevent occurrence of this limitation in the future. Mental Attitude - All of the patients in this group soon learn that they will not only remain paralyzed in their lower extremities but will remain without sexual ability. In the beginning, their outlook upon the future is bleak. These patients can be divided into two groups: a. A group of younger patients - 19 and up - many of whom left high school to join the Army; they are unmarried but most of them have an im- mature attitude toward the problems of life. The main thought in the minds of this group is that they want to go home. These men have few, if any, responsibilities and in view of the pension policy of a generous government, they seem little concerned upon the future. b. The other group is an older group - 16 of our 36 patients - are married, 9 of the 16 married men have children. All the men in this group also want to go home, if possible. They are very concerned less they be an undue burden upon their families. None of them wish to be dependent and those with children are concerned that the bounty of the generous government will not be sufficient to meet the responsibilities of a married man with children. We have noted that as time goes by and function does not return, these men become fretful and critical. They are relieved when the truth of their future is explained to them. Their mental attitude responds best to a sym- pa thetic personal interest in their individual problems; they respond best when they are given something to live for, something productive, something that they may use later on as a means of meeting their responsibilities. In the group of men that arrived in our hospital of September 44, an interesting development was noted. After about five months, those men without bed sores became restless rather suddenly. It was noted that poker games were frequent occurrences on the ward, the patients turned out their lights at a later hour, they slept poorly and they were irritable. About this time, a work program wras begun on the ward and an opportunity was offered every man to work at piece work which paid 60 or 70 cents for an a mount of work judging to be a fair production for an hours labor. As this pr ogram developed, it was noted that poker playing fell off remarkedly, patients began to go to bed early, they volunteered the information that they slept better. These changes were spontaeous and may well be cue to the simple fact that productive improvement was offered in place of idleness. It might be interesting to state the reasons why different men in this group are in- terested in working for money: one man wants to buy a tube metal collapsible wheel chair for himself; another man needs money with which to help his wife and child; another is sending his meager earnings to his children; some work merely to pass away the time; one or two are interested in the game of in- creasing the work output and the monetary income of the ward each week; others, who held good positions in plants and factories, are working hard and at a salvage job primarily to impress employers that a man consigned to a wheel chair is capable of turning out excellent work; some claim they are only interested in helping to create a better situation for others who are to follow; one man refuses to work in the program but does work in the occupational therapy shop each day, his reason being that he is only inter- ested in work that is creating or in a job that when completed, leaves him with an object that he has made that can be used as it is. The overall picture is that productive employement has added tremendously in meeting a problem of mental readjustment of recently paralyzed individuals. Economic Adjustment - We have learned much from out small group about the economic adjustment that will be necessary. It may be plainly stated that some of these patients, particularly the younger untrained and unmarried individuals, feel that the pension of $150 per month, plus the $100 a month allowed for an attendant that will be paid by the Veterans upon discharge from the Army, will always be adequate to meet their needs; others are a nxious for work because they need the additional income. Among our small group, there are three men who have been promised jobs by their old companies, provided they are ambulatory in wheel chairs; two men come from families who own a business in which the soldier can be productively employed in a wheel chair. It seems therefore that further efforts to rehabilitate and re-educate the paraplegia, is a responsibility that should be met because a reasonable percentage of them can, if rehabilitated, adequately return to gainful em- ployment. Domestic Adjustment will be difficult. Obviously single men in this group will rarely marry unless they are picked up by someone seeking a meal ticket. Doubtless many of the married men will separate from their wives. Some of the married men who have children will not separate from their wives because of the children. In any event, this is purely a personal problem. The responsibility of a governmental agency could only go so far as to provide a man with the necessary physical reconditioning and training so that he may meet his responsibilities in this regard and thereby be best prepared to settle his personal problems in whatever way the parties concerned most desire. We have not yet had the opportunity to discuss this problem with the wife of a paralyzed soldier and perhaps we should never attempt it. Plan - Since the subject given to me for this discussion is "The Future of the ParaplegiaM I may be justified in offering a suggested plan for the care of the paralyzed soldier, based on our observations with a small group of patients but a group which may well be considered-a cross section of the total number of paraplegias. It would seem therefore pertinent to suggest that the Army create a center fo.r the rehabilitation of the paraplegia. If ajjl adequate number of beds could be made available and an adequate staff, it might well’ bo that patients yet to sustain injury of the spinal cord could also be best treated during .the early stages of their disability, in such a center. The primary purpose, however, of a center for the rehabilitation of the paraplegias should be:. a. To accept patients after initial definitive care has been conpleted. One might estimate that the av.erage* stay in such a center would run from 8 to 12 months. The purpose of such a center would bo: . ✓ • a. To complete the physical reconditioning of these individuals, to equip them with the muscular development of the trunk and shoulder girdle so that they might become completely ambulatory in braces or wheel chair, so that they might withstand the strain of continued physical effort while seated. b. Re-educate. To educate these men so that they may become able to care for themselves in every respect possible; to give them vocational train- ing suited to their ability, their past experience or to opportunities awaited them, or to give them the education and training necessary to open up for them riew fields of endeavor, for which they have talent or desire, field of en- deavor, which in the past have not been available to them, and finally in the overall to so rehabilitate and re-educate the paraplegia, that he may . be able to return from the military service to a civilian status in his home without the necessity of being dependent the rest of his life upon insti- tutional care, which at best doesnot give an•individual any reason or purpose for remaining alive. Such a center could it be established, should be placed in a suitable, climate, one that permits outdoor activity pretty much the year around, where extremes of temperature are never encountered. Such a center should be housed in one story structures to permit easy access to the outdoors to men in wheel chairs or on crutches. The housing; facilities should be fire-proof, unless they are all one story structures close to the ground. If a multiple story structure is usod, it would of necessity require adequate elevator facilities to permit moving rapidly many patients confined in wheel chairs. Such a center should .certainly be on • the main line of a railroad, it should be in a community where adequate and suitable housing facilities are available for the many visitors who sho.uld come to patients of this type. _ The necessity for a work program might well demand that such a conter be placed with reasonable proximity to industry and also somewhat removed from a locality where labor is super-abundant. Such a center, could it be established, would certainly require ade- quate personnel, both in training and in quantity. Neurological Surgeons, Urologists, Internists, and a General Surgeon would all be required in ade- quato number in proportion to the number of beds occupied. In addition, properly trained physical reconditioning men would be necessary, an adequate brace shop, a large Physiotherapy and Occupational Therapy department, nu- trition officers and dietitians would be equally necessary. When one considers the vast number of questions raised by this group of patients, the answers to which are unknown, it becomes obvious that such a center should have associated with it an expensive, comprehensive research program. The key personnel referred to would necessarily be men with an interest in and an appreciation of the'problem of the paraplegia. Above all, such a center would require sympathetic, imaginative, and understanding direction fr om its Commanding Officer. COLONEL R, H. KENNEDY:- Again let me say how pleased I am to be able to be present and hear the discussion of the particular subject of the Symposium. It has been of great interest to me throughout the war. I have been Chief of Surgical Service at two hospitals which were neurosurgical centers. I have seen the development of the program which has been planned to maintain the physical condition and morale of the patient. 'When we first received these patients, they came in rapidly and their morale was bad. Since the program was developed, I feel that, in general, the morale of the paraplegic ward' is better than in any other ward in the hospital. It is the place which can be made the show place for distinguished lay visitors simply because of the morale of these men. It is a result of the work being done by all, from the enlisted men on up. I went on a two months’ mission last fall. When I left, the neuro- surgical center had just been organised. On my return it had received about 600 patients and among these was a group of 39 paraplegic enlisted men and two officers. Their morale was bad, and it was hard to go into that ward. I was told by the Assistant Chief of Service that a youngster, a Lieutenant, had recently been placed in charge of this ward and he did not think he would be mature enough to handle it. The urologist worked along with him. We went through the ward and made out a list of two typewritten pages of suggested improvements. For a man from whom we did not expect a great deal, he immed- iately blossomed out in getting things done. One incident was the talk of the hospital. I went on a Christmas leave and found on my return that this youngster had gone to the Commanding Officer a few days before Christmas and said,, "We've got 39 men over there on the paraplegic ward. Christmas is coming and many of these men have their families here. I don’t know whether they’ll be alive next Christmas or not but they’re here this Christmas and I want every one of these men to have their families here for Christmas dinner." You can imagine what this did to a Regular i*rmy Commanding Officer. The first answer was, "No". This ward officer was a First Lieutenant who had been in the i%rmy four months. He said, "I demand that these men be allowed to have their families here for Christmas dinner. These men deserve it. They have given everything to their country. They deserve to have their families here and damn it, they're coming to dinner". I learned that they had 140 on that ward Christmas day for dinner. The Red Cross arranged for bridge tables at each bedside, with candles, fancy table cloths, comfortable chairs. Whan it' came time to serve dinner, many of the enlisted men, WAC's and nurses from other wards volunteered to come over and help serve the dinner. It did a great deal for the hospital morale for this officer to insist on this being done. The most pleased person in the whole group was the Commanding Officer, who presided over the whole affair. When you need more rubber tubing, irrigating bottles, walkers, etc., and are told they cannot be obtained, there is no such answer. These men have given everything andebserve more than any other men in the Army. Every- one should take the attitude that there is no such answer as "no" to their noeds. I think the changing of personnel on the ward is the most difficult thing wo have to deal with. The enlisted men, nurses and officer sin charge should be left to continue in the same place. But don't forget that this is a terrific job that these people- are doing and we have to mention the ward- master and the nurses to let us know if they are feeling the strain. Some may stand it for six weeks, others six months. These people will stick be- cause they have learned to love the cord cases so. We have to pull them out because they break themselves doing the job. There has been little said about the dressing of wounds. Personally, I feel that it should be put in charge of some one person who will take an in- terest. The medical officer usually can’t attend to all these cases and should make the ordinary dressings the responsibility of some one nurse. Make it a contest among them to take it as a personal thing, that it is up to them to get the wounds clean. I feel that patient officers sometimes do not get as good treatment as enlisted men. It is the same as in civilian life* You know that a patient on the ward often gets better treatment than a patient in a private room. It is the same in the Army. I believe that the officer paraplegic should be put on the paraplegic ward and see what the other men are doing. It is a big morale builder. You can't move these patients once they are in, but if its taken for granted that, “This is the paraplegic ward, here you go", there’s nothing thought about it. I wonder if it would be possibleto keep in the service certain men at eaoh one of the neurosurg- ical centers who arc paraplegics themselves, who have been kept in the ser- vice as discharged hospital patients and who can stay around and train these men and be a morale builder among them, - somebody who has graduated from tho course and knows the whole routine. Thera is more to be said on the subject of closing decubitus ulcers. I wish Colonel Shearer might be asked to say something. LT. COLONEL THOMAS P. SHEARER: - Regarding the treatment of decubitus ulcers, I would like to congratulate Captain Barker on the beautiful results he has had at N. D. B. G. H. It is very interesting to note that there is little in the literature on the operative treatment of decubitus ulcer. At Halloran General Hospital, Captain Croce, Chief of GQneral Surgery, has devised a scheme for closing these ulcers by rotating full thickness grafts from adjacent areas. Our pre-operative management is much like yours, and seeks to obtain a cleanly ganulating wound free from infection, and slough with fixed edges showing signs of epithelial invasion. Some of those ulcers are 12-15 cm wide and 10-12 cm long. At operation the ulcer is excised, then curvalinear incisions are made on either side both above, along the iliac crest, and below into the buttock. The largo flaps so outlined are thus raised from the gluteal fascia. By rotating these four flaps toward the middle of the defect and approximating them to each -other, the defect may be completely closed with a layer of skin and normal subcutaneous pad which thus far has seemed capable of withstanding all the abuse of the normal skin of that area. We have used a fine silk technique throughout with 000000 black silk. * We have had no experience with Thiersch grafts because we have felt that the- treatment, as above outlined, is universally applicable, although some of the larger ulcers at first had to be closed in two stages. Moreover, we have felt that tho end result is more durable than that of split thickness grafts applied directly over the sacrum. Some of the latter have broken down repeatedly until wo covered them with sliding full thickness’: grafts as I have.outlined. We have come to conclude that operative wounds in these paraplegics will heal fully -as well as they will in other young adults whether the wound lies in an anesthetic area or not: By the simple closure of tho docubitus ulcer the nursing care is greatly reduced, the patient is ready for a more advanced program and his morale is greatly elevated. COLONEL CLAUDE S BECK: - I should like to congratulate the medical officers who have taken part in the symposium on the paralyzed patient. What we have heard on this symposium should not be regarded as the last word. I would rather regard it as the first word on this subject. Yio are really only at the threshold in the care of these patients and I don't think wo are going to 'st»p whore this symposium ends today. I think the subject has been covered in almost every detail. There are one or two points I would like to have addi- tional information on. I would like to have a picture of what happened to the group of paralyzed patients in the last war; I would like to see graphs on the duration of life and the causes of death; I would like to know how many of the patients were taken care of in the Veterans Hospitals and how many were, able to be taken care of at home.' After they arrived at their homes, I would like to know what,they were able to do, how much care they needed, whether any of them were able to earn a livelihood; I would also like to know something about the composite picture of experiences to date in this present war. I understand that there are about 100© paraplegic patients in this country at the present time and that there are also additional patients abroad. We ought to have a composite picture of the course these patients have taken up to the present time. I think we have all been favorably impressed by the progress that has been made in the care of these patients. The picture, impressive -s it is, is not as good as I would like it to be. I am disappointed in the matter of ambulation. These patients really do not get around very well. If they were to be discharged to their homes, I am very doubtful whether they would get around well enough to go out on the streets. Colonel Gage and I have been wondering about the advisability of bilateral amputation of the legs. Could the patient ambulate himself better if he did not have his legs? I should estimate the legs weight, 40 to 50 pounds. With complete transec- tion of the cord, the legs are absolutely useless in ambulation. What they actually do is to elevate the center of gravity from the ground, a distance of about 4 feet, they act like a pair of stilts and the patient is in con- stant fear of falling. Should we not amputate the legs? If this were done, the patient could get around much better, he 'would have less weight to pull after him, ho could sit on a platform which has wheels under it nc ambulate himself by means of his arms, he could