1. A clinical study has been made of heterotopic ossification in 273 patients with paraplegia of traumatic and non-traumatic origin treated at the Liverpool Paraplegic Centre over a period of twelve and a half years. 2. The literature is reviewed and theories of etiology are discussed. 3. Etiological factors have been studied. Prominent among these is inadequacy of early treatment leading to urinary infection and to the formation of pressure sores. 4. It is concluded that there is no effective treatment for established heterotopic ossification. 5. The importance of prophylactic treatment is stressed. Special emphasis is placed on adequate primary treatment, correction of hypoproteinaemia and early mobilisation.

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IN dealing with patients suffering from spinal injury it is extremely important to achieve, a? a final result, automatic bladder emptying. Every effort must be made to avoid permanent drainage of the bladder either by urethral or suprapubic catheter. Catheter drainage not only exposes the patient to great potential dangers but also handicaps him in his attempt to lead a reasonably normal life (already restricted by his motor and sensory paralysis). A patient should never be considered as fit for discharge from hospital until his bladder problems have been satisfactorily solved.We do not attach great importance to " bladder balance," that is, ratio of residual urine to bladder capacity, but a high residual urine inevitably leads to urinary infection and renal failure. To avoid these dangers the residual urine must be no higher than 4 to 6 oz. at the most.One of us has described elsewhere (Ross, 1951) the routine investigations carried out in these patients, but we have found in practice that the urethro-cystogram is of especial value. Expressed in the most simple terms the problem is to determine the ratio of the expulsive forces, that is, detrusor tone plus abdominal straining plus manual compression, to ths resistance at the bladder neck. If the expulsive forces are efficient, and, in spite of this, the patient has a high residual urine, then there must be either a mechanical or spastic obstruction at the bladder neck or in the urethra. As a corollary to this, it is obvious that even jf the expulsive forces are weak, satisfactory evacuation of the bladder may still be achieved by diminishing the degree of resistance at the bladder outlet.Reference was made to the pudendal nerve in a previous communication (Ross, 1951), but at that time only nerve blocking had been attempted. In our hands pudendal nerve block with procaine was unsatisfactory as we failed to achieve a complete paralysis of the nerve. This fact was shown by the failure to abolish the anal and bulbo-cavernosus reflexes. Although sometimes used in obstetric practice, we believe that the paralysis obtained is only relative and is rarely complete. For these reasons we discarded the nerve block in favour of neurectomy.In carrying out this work we have received the greatest help and encouragement from Ernest Bors (1951, a and h), whose pioneer work at the Veterans' Hospital, California, is well known. At first we confined the operation of pudendal neurectomy to patients with spasticity limited to the external sphincter, but more recently we have extended its use to those with spasm of both sphincters. Successes in the latter group suggest the possibility that motor impulses, carried by the pudendal nerve, reach the internal as well as the external sphincter muscle. It has been pointed out that striated muscular fibres are also found in the region of the internal urinary meatus (arcuate muscle of the vesical orifice of Young and Wesson, or the external vesical sphincter of McCrea). Much investigation into the physiology of micturition is still required b...

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