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as shown in Fig. 160 of one of our former, rather obese, female paraplegic patients, who
was treated with an indwelling Foley catheter because of severe incontinence.
Gibbon
et al.
(1969) consider, as the main hazard of continuous catheterization by
indwelling catheter, blockage of the system by mucus or phosphatic debris which, in the
presence of bladder infection, may lead to acute pyelonephritis. The special small
calibre plastic catheter of 1-5 or 2 mm overall diameter devised by Gibbon (1956, 1958)
has been used as indwelling catheter in 100 patients who had been admitted to the South-
port Spinal Centre within 14 days of their injury. Neither routine use of anti-bacterial
or penile dressings were used. In all, the urine became infected 'sooner or later' and in
spite of closed drainage the urine remained sterile only Tor a week or more'. This is in
accordance with our own experience at Stoke Mandeville with this type of catheter.
Kyle (1968), the urologist at the Perth Spinal Unit in Australia, admits that with small
calibre catheters, particularly Gibbon's catheter, one sees fewer strictures; however, he
found these very small catheters only efficient in clear urine. They are easily blocked, as
we also found, and thus render the control of infection more difficult. For this reason he
found that they caused more nursing problems, and, therefore, interference. This does
not prove the views expressed by Cosbie Ross in 1960 that 'it is not necessary to change
the catheter and drainage continues for many weeks with little interference. Cross
infection is eliminated and nursing time saved'. From his experiences Kyle came to
the conclusion that 'the best prophylaxis is not to use indwelling catheters unless essen
tial' and in the Perth Spinal Centre intermittent catheterization is used whenever
possible.
Jacobson & Bors (1970) published a survey of 114 actual combat injuries of the
Vietnam War, 79 complete and 35 incomplete lesions of various levels, the majority
being low thoracic and lumbo-sacral injuries; 77 (67 per cent) of the spinal injuries had
major associated injuries to other parts of the body. Almost all had urinary infection
from catheter, and the genito-urinary complications were numerous such as epididymitis
14 (12-8 per cent), renal stones 14 (13 per cent), bladder stones 56 (49-1 per cent),
hydronephrosis 20 (11-4 per cent), peno-scrotal complications with abscess, diverticulum
or fistula 8-8 per cent. Of special interest is the fact that 5 patients developed pseudo-
papillomata and 2 squamous carcinoma, grade i and grade 2 respectively, of the urethra.
Such most unsatisfactory results could be at least minimized and great misery later
prevented even in war time if the responsible Government Department, in particular,
the military medical authorities, would issue strict instructions that the medical staff
in base hospitals, where the wounded in many instances can be admitted in the shortest
possible time by field ambulance or helicopter, are properly trained in the initial treat
ment of the paralysed bladder. Autoclaved catheterization packs, as described on page 348
(Fig. 1583) can now be manufactured from disposable material and should be part of the
equipment of first aid stations and base hospitals. It should be possible for a medical
officer to carry out proper cleansing of the penis, in particular the meatus with Savion
etc. before inserting the catheter into the bladder even under war-time conditions, as one
expects him to carry out aseptic operations under these conditions. The most important
initial management of these severely wounded soldiers is their evacuation by air to their
home country with highest priority. Moreover, after arrival their
immediate
transfer to
