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CHAPTER 26
remained the main source of infection. It may be noted that the renal pus showed some
of the bacteria, especially
B. haemolytic
streptococci, as found previously in the suprapubic
catheter specimen. The decision to refrain from nephrectomy in this paraplegic was
guided by the consideration that, in all probability, the left upper urinary tract was also
infected.
Actually, this man's condition improved dramatically after the operation. The right
kidney regained its function, and subsequent I.V.P.s showed practically normal outlines
and good secretion of both kidneys (Fig. iy8b). The suprapubic drainage was discontinued
in October 1945
(2\
years after injury) after he had developed good detrusor action and
the bladder had become automatic, and, in due course, the urine became sterile. He made
an excellent rehabilitation and became a member of the first wheelchair polo and basket
ball teams, and while still an in-patient started work in a factory in Aylesbury with 6
other paraplegics. After his discharge from hospital he was employed full time for many
years in open industry, living as a resident at our Hostel for employable paraplegics, the
Duchess of Gloucester House in Isleworth, London. In 1954, he developed vascular
hypertension, resulting, in due course, in considerable cardiac and aortic changes,
including a temporary left cerebral thrombosis and some sclerotic retinal changes, which
forced him in 1959-60 to give up full-time employment. Until that time, regular check
ups showed sterile urine and blood urea varying between 23 and 38 mg per cent. With
increase of the hypertensive disease, he developed nephrosclerosis and eventually renal
failure and died on 21 August 1961 at the age of 50,18 years after injury.
Of the 32 patients reported by Walsh (1970), one died 5 weeks after operation due to
perforation and haemorrhage of an acute gastric ulcer, probably the result of steroid
treatment. In 3 cases, nephrectomy was carried out at a later date, following the initial
operation (nephrostomy or T-tube in the ureter), when it was proved that the kidney had
not regained function and remained highly infected. One of these, a woman, had appar
ently been obstructed for several months and, when first drained, the pus was sterile. The
second case had a perinephric abscess involving the bowel and he had been obstructed
for 28 days. The third case had a periureteric abscess and had been obstructed for 21
days. In all the remaining 28 cases, the affected kidney resumed excretion of urine within
24 hr and some within 3 hr. The degree of function varied according to the degree of
impaired renal function before the pyonephrosis. In 21 cases, I.V.P.s before and after
the operation were available; of these, 7 cases showed normal findings before and after;
in 7 cases the previous impairment remained unchanged, and in 7 there was deterioration
of renal function—i.e. increased hydronephrosis or impaired dye concentration. The
period between operation and last I.V.P. varied from 2 months to 15 years. Ten of the
21 cases showed satisfactory renal function more than 5 years later.
From all these observations, it can be concluded that immediate nephrectomy in
paraplegics and tetraplegics is very rarely, if ever, justified.
(7) Diagnosis and management of acute and chronic renal failure
Reference has been made earlier in this book to the serum protein changes following the
acute and later stages of spinal cord injuries. The clinical symptoms of renal deficiency
