F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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Spinal Injuries Centres
should be organized and they should not be kept in General
Military or Veteran Hospitals where, as a rule, the staff is not acquainted with the
comprehensive management of spinal injured patients. From all my experiences during
and after the Second World War in this and other countries, I am convinced that as a
result of the inadequate management in General Hospitals, these unfortunate victims
of war developed all the complications under the sun, so well described by Jacobson &
Bors on spinal cord casualties of the Vietnam War, before they were admitted to special
ized Spinal Unit for, what is called, 'rehabilitation'.
Tidal drainage
Although tidal drainage was introduced by Lawer (1917) in this country, no great
interest was taken in this method until it was developed by Munro in the U.S.A. (1935)
for both the immediate and long-term treatment of the paralysed bladder, and during the
Second World War it was widely used. He himself has improved his original tidal drainage
apparatus by two later models (1952). We have found Riches' design at Stoke Mandeville
very satisfactory, which, being fitted with a manometer, can also be used for cystemetro-
graphy.
The principle of tidal drainage is based on siphonage with the help of irrigating fluid
which is elicited whenever a predetermined intravesical pressure has been reached, thus
the bladder is alternately filled and emptied automatically. However, in practice, it
works satisfactorily only if its management is fully understood and continuously con
trolled by the medical and nursing staff day
and
night and also by the patient. Munro
(1952) himself has tabulated causes of functional failure, such as air leaks, using a wrong
type of Murphy dropper, formation of a trap in the long catheter connections, kinks in
the connections, leakage of urine around the catheter, if the apparatus is not properly
adjusted, and mistakes in the adjustment of height of the siphon curve. According to
Munro the proper height of the siphon curve should be set at i or 2 cm above the bladder
level during the stage of spinal shock when the bladder is atonic; once the bladder
becomes automatic, at 10 to 13 cm for the reflex bladder and at 15 to 18 cm for the
hypertonic bladder. During and immediately after the Second World War we have used
tidal drainage extensively but later it has only been used in selected cases in later stages
in patients with infected bladders to clear the bladder from debris, mucus and small
stones. It has not been used in the immediate and early stages of spinal injuries as it does
not prevent early infection.
Suprapubic cystostomy
In my Monograph in Volume Surgery of the History of the Second World War (1953),
I reported that 300 out of 351 traumatic paraplegics of the Second World War had supra-
pubic cystostomy carried out for bladder drainage before admission to the Stoke Mande
ville Spinal Centre. In the majority of them (210) this was done within 3 days after
injury. Every case admitted with suprapubic drainage, whether with or without urethral
catheterization prior to the cystostomy, showed signs of infection of the urinary tract,
