Abstract 1. 1. Pilonidal inflammatory disease is common in the Navy. At our Naval Hospital, 7.5 per cent of operations in a recent period were performed for the eradication of this condition. The definitive surgical treatment of a series of 319 patients was reviewed. Of these 241 (75 per cent) were primary admissions and seventy-eight (25 per cent) had previously had one or more unsuccessful definitive surgical operations. 2. 2. Pilonidal cysts and sinuses can originate in embryo from the neurogenic medullary canal, from infolding of the dorsal epidermis or from both. Three clinical types result: subcutaneous cyst alone, (neurogenic); sinuses or dimple alone, (epidermal); subcutaneous cyst communicating with sinuses (neurogenic and epidermal). 3. 3. We find no convincing evidence to prove that hair grows from the epithelium of pilonidal cysts. We believe that external hair grows into the sinus, extends into the cyst, breaks off from the external root and in time is moulded into “nests.” 4. 4. Pilonidal inflammatory disease in our clinical cases occurred in four main types: (1) sinuses, (2) acute abscesses, (3) infected subcutaneous cyst and sinuses, and (4) infected subcutaneous cyst alone. Treatment of these types varies for each type as well as for individual variations in type. 5. 5. Recurrent pilonidal disease following previous definitive operation is common; seventy-eight cases in this series. In two-thirds of these, recurrence resulted from unsuccessful primary suture. With characteristic uniformity the lesion in most of these consisted of a deep sinus under a well healed scar. That fundamental surgical principles were disregarded by the original surgeon is indicated by the uniformity of the recurrent lesion. Relationship of surgical repair to the basic anatomy of the sacrococcygeal area is emphasized as a requirement for success in primary closure of these wounds. 6. 6. It was demonstrated that haphazard technics of operation and postoperative management resulted in prolonged hospitalization of many of our patients. In the second half of the series, operation and management of these cases was standardized under the care of three surgeons with resultant reduction in healing time in each type of case. 7. 7. Patients amenable to primary closure were operated upon under procaine-epinephrine local anesthesia. The infected cyst and sinus was carefully excised and the wound was closed with fine alloy steel approximating sutures reinforced by through-and-through tension sutures of heavier wire tied over gauze rolls. Only five of fifty patients so treated required more than three weeks for complete epithelialization. The average healing time for all fifty patients was two and one-half weeks. 8. 8. Cases necessitating wide excisions were partially closed by undermining the skin at the wound margins and suturing these to the post-sacral fascia, thereby minimizing the wound which is then allowed to heal by granulation. 9. 9. Acute abscesses were drained on admission. Revision operation three days later consisted of marsupialization of the wound by saucerizing the margins thereof. Granulations in the base of the wound were curetted and healing allowed to proceed by granulation. 10. 10. Recurrent lesions were explored after exposure, granulations were curetted and wound edges saucerized. As a rule, these healed poorly for two reasons: (1) depth of the lesion especially in the upright position prevented adequate drainage; (2) chronicity of the lesion resulted in marked fibrosis in the wound bed with consequent embarrassment of adequate vascularity. In recent sluggish cases, the wound was excised providing a fresh clean wound. A split thickness skin graft was removed from the lumbar back and sutured onto the fresh wound. A pressure dressing maintained the graft. This procedure has afforded gratifying results in several recalcitrant cases. 11. 11. In postoperative granulating wounds, meticulous and daily wound toilet is necessary to attain healthy granulations and early epithelialization.