What Now?

0. JAMES HURT, M.D.


Jeff was born on Feb. 26, 1965. He came under the care of the Kentucky Com- mission for Handicapped Children in April 1966. The first recorded diagnosis was meningomyelocele and bilateral clubfoot ( Fig. 1 ). Since that time other prob- lems have been identified including hydronephrosis right, crossed ectopia of the atrophied left kidney, and congenital absence of the sacrum and the lower lumbar spine ( Fig. 2 ). It was discovered early that his lower limbs were anesthetic from the waist down.

Treatment was started and has continued to the present time. He has needed the services of numerous disciplines: pediatrics, neurosurgery, orthopaedics, urology, ophthalmology, neurology and plastic surgery. On May 31, 1966, the meningomyelocele was excised. Following this operation, he had multiple castings of the lower limbs in attempts to correct the foot deformities. These efforts were unsuccessful. On Jan. 20, 1967, a loop ureterostomy was performed and on Jan. 30, 1967, a ureterostomy was done.

Jeff's problems were studied and the possibility of reconstructive surgery of the lower limbs was considered. It was finally decided that he should be ampu- tated, so he had bilateral subtrochanteric amputations of the lower limbs on Mar. 30, 1970. He then came to the Amputee Clinic for some type of device which would permit maximum activity.

Until this time Jeff had been very inactive. His multiple deformities and inactivity had produced marked disability and weakness. He did have some assets. He is a bright individual and personable. In addition, he has an under- standing, patient, loving mother, without whose help he would probably still be totally dependent.

In the Amputee Clinic, Jeff was put in a plastic "bucket" with a colostomy opening and a trapdoor for removal of feces. The bucket was then placed on a platform with coasters ( Fig. 3 ). It was felt that he could propel himself with canes, and that he would develop physically in so doing ( Fig. 4 ). This postulated physical development did occur. As his tolerance to the "bucket'~ increased, he was able to travel longer distances and became stronger. Also, he started using a wheelchair part-time and enjoying it. He liked competition and responded to the challenge of wheelchair races. In his first year of competition he almost won. He was determined to win so he practiced and plotted his strategy and did come in first the next year. Needless to say, he is proud of his medals ( Fig. 5 ).

Considerations for the Future

Jeff is now eight years old and has outgrown his present "bucket." It has served its purpose. He gets about and is active in his wheelchair and "wild rider," a low-slung, hand-operated vehicle ( Fig. 6 ). We think he has attained maximum mobility. His physical development is now such that he can attend a special school. Considering his multiple disabilities, we think that he has done well to this point. The question is-what now?

Our Clinic naturally wants to help each individual become independent, achieve maximum function, and hopefully to be productive. How can these goals be achieved with JeW? At the lower educational levels special schools are available. He has considerable ingenuity and with ambition and proper motivation he should be able to manage later. His present attitude and activity level are fine. Hopefully he will mature mentally and emotionally as he matures chronologically. The emotional stability of his mother and her cooperative at- titude should support this development since he is responsive to suggestion and guidance.

Nevertheless we are aware that this process of transition from immaturity to maturity will strain the resources of our program. Academic training, guidance in choosing a career, training for that career, counsel and assistance in attaining maturity-all are needed. Since our program is not highly organized along these lines, we are sensitive to the needs involved. We would welcome any suggestions that would help us develop our program so that we can provide help for Jeff and others who may come to us with similar complex problems.

Descriptors: Amputation; lower limbs; meningomyelocele.

Kentucky Commission jór Handicapped Children Juvenile 4 rnputee Clinic Louisville. Kentucky