F - CLINICAL ASPECTS OF SPINAL CORD INJURIES
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only complain of paraesthesia in fingers and a sensation of tightness in the face, especially
around the mouth, lasting one or two days. In a few cases, slight dizziness for a day or
two was observed, especially when the patient changed his position. Some patients with
raised blood urea felt very sleepy during the first day which induced us to reduce the
amount of the first high doses. Two tetraplegics who had previously had a course of
streptomycin without any adverse reactions developed allergic attacks to local strepto
mycin application to their pressure sores. One patient developed some deafness.
With this regime applied to the first 100 patients with closed bladders, immediate
sterility of urine was achieved in over 50 per cent. However, only 16 per cent remained
sterile after four up to seventeen months. In certain cases with pluri-bacterial infections
or those who became re-infected, a second or third course carried out at various periods
succeeded in eliminating these organisms. In one case, the urine was infected with
proteus Morgagni and staphylococcus pyogenes. The first course of streptomycin
(7-9 g) eliminated the proteus but not the staphylococcus, although the latter was found
to be sensitive to streptomycin but resistant to penicillin. Nevertheless, it was eliminated
by a course of 10 million units of penicillin. The urine became re-infected with B. coli
but became sterile after a second course of streptomycin (10 g) and it was found to be
still sterile after 6 months.
Although dissociations were repeatedly found between the therapeutic effect and the
sensitivity of organisms to streptomycin, the therapeutic effect of this antibiotic on the
patient's clinical condition is unquestionable. A frequent voluntary statement of patients
as a result of the streptomycin treatment was 'I feel much better in myself, less tired, not
so hazy, more energetic'—in other words they were less toxic. The antibacterial effect
of streptomycin increases as the alkaline reaction of the urine becomes stronger
(Abraham & Duthie, 1946), and, therefore, we have used Potass, citr. in doses of 30 to
60 g three times daily during the treatment to ensure a pH of 7 or more in cases without
raised blood urea.
Unfavourable conditions for the elimination of infection by any antibiotic treatment
are marked trabeculation and diverticula formation of the bladder, continuous urethral
or suprapubic drainage, obstruction of the upper urinary tract by calculosis and undrained
abscesses. The two latter complications, naturally, have to be dealt with first surgically,
but a course with antibiotics may at least prevent general septicaemia.
In spite of the ever increasing number of new antibiotics we still use streptomycin
as a most valuable agent against urinary tract infections, the more so as its price has
considerably decreased in view of the many rival products.
COMPLICATIONS OF THE URINARY TRACT AND
THEIR MANAGEMENT
A. FISTULAE AND DIVERTICULA
(i)
Suprapubic fistulae
Breakdown of a suprapubic scar resulting in a urinary fistula was found to be not an
infrequent occurrence in our war-time patients (Guttmann, 1953). This complication
