F - CLINICAL ASPECTS OF SPINAL CORD INJURIES
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outs of pelvis and calyces through the ureteral catheter, which could then be left
in situ
for 24 hr for drainage and for further irrigation. This procedure has proved most effective
in bringing down the raised temperature (as a rule of swinging type), which the patient
may have had for several days before admission. If a pyelitic attack does not respond to
an appropriate course of antibiotic treatment with temperature returning to normal within
three or four days, or a rise of temperature recurs after a few days, blockage in the upper
urinary tract by a stone or other cause may be suspected and the patient should be
re-admitted to a spinal unit without delay, which might be a life saving measure. Blockage
of a ureter or pelvis by a stone will produce not only a pyonephrosis but generalized
septicaemia if immediate surgical relief is not carried out. Recently Silver & Martindale
(1970) described a case of septicaemia as a result of a calculus in the left proximal ureter
producing blockage and hydronephrosis of the left kidney. Blood cultures grew the same
organisms, proteus and B aerogenes, as found in the urine.
The management of renal stones is in the great majority of patients surgical. While
small quiescent stones in the upper or lower calyces may be left alone and watched for
some time, pelvic stones should be removed at an early date by pyelostomy. There is
now general agreement amongst urologists and spinal specialists that nephrectomy for
calculosis should be avoided in paraplegics and tetraplegics as long as possible, and that
renal stones of large size including stag-horn type can be removed by nephrostomy.
It may not always be possible, for one reason or another, to remove completely
multiple or stag-horn type renal stones, and the instillation of dissolving solution
through nephrostomy, pyelostomy or ureterostomy tubes may be necessary, unless, as
in the case of a residual stone or stones in the lower calyces, an amputation of the lower
renal pole is preferred at a later date. However, great care has to be taken regarding the
time of onset, the number of drops employed and the duration of these dissolving solu
tions. At Stoke Mandeville, we have given preference to Suby's solution G and M but
have also used Renacidin, first used by Mulvaney (1959-64). It may be noted that several
fatalities were reported in the literature following the use of Renacidin (Auerbach
et
a/.,
1963; Fostvedt & Barnes, 1963), and as a result the manufacturers of Renacidin withdrew
the drug from the market. In one of our patients—a complete paraplegia below T5 who
was suffering from hydronephrosis and calculosis in the left kidney—a nephrostomy was
carried out and 12 days after the operation a Renacidin instillation through the nephros
tomy tube was started. However, one day after this treatment the patient developed
haemorrhagic urine and an acute renal failure. He was immediately transferred to the
renal unit of Princess Mary's R.A.F. Hospital, Halton, for haemodialysis, where he
gradually recovered after some stormy weeks. Two months after the onset of the acute
renal failure, he was discharged from the Spinal Injuries Centre and returned to his job
three months later. However, in due course he died on account of progressive renal
deficiency from which he was already suffering before the operation. Scibutis
et al.
(1962) also reported bleeding and raised temperature during irrigation by Renacidin and
also found it disappointing in its use for bladder stones. It does not replace clean surgery
but may be indicated for patients who previously had operations and for whom additional
surgery of the kidneys would be hazardous. Bors & Comarr (1971), who considered the 5
fatalities reported following Renacidin treatment to be a result of faulty technique rather
