F • CLINICAL ASPECTS OF SPINAL CORD INJURIES
421
increased transudation of fluid from the intravascular into the interstitional space.
Moreover, changes in the intrarenal autoregulatory mechanisms (de Wardener & Miles,
1952; Kinter & Pappenheimer, 1956; Seller, 1965), involved in the maintenance of
glomerular and tubular function and renal blood flow, play an essential part in the
disturbance of salt and water metabolism. A great deal of research on the micro-environ
ments of the nephron has been undertaken in recent years with special reference to the
functional role which the juxta-glomerular apparatus, with its various cell components
and its afferent and efferent arterial and venous blood supply, plays in connection with
the renin-angiotensin-aldosterone system in maintaining a glomerular-tubular balance
(Hartroft
et at.,
1959; Hartroft, 1966; Tobian, 1966; Bull
et al.,
1966; Kirkendahl &
Fitz, 1967; and others). However, there is still much to be learned in this very complex
problem, and no definite conclusions can be reached at present regarding the intricate
function of the hormonal system in relationship to glomerular-tubular balance.
Treatment
The treatment of oedema in the nephrotic phase of renal deficiency has, of course,
to be considered in relation to all the other symptoms of renal deficiency. The improve
ment of anemia and albuminuria by full blood transfusions, special dietetic measures with
reduced salt intake in cases of sodium retention, and the combating of infection
will always take priority. In the case of extensive degrees of oedema with hydrothorax
and ascites, the removal of fluid by mechanical means, such as trocar and Southey tube,
may be followed by rapid improvement. Ascites is removed in semi-reclined position
of the patient to facilitate the flow of the fluid. In order to prevent fainting resulting
from the reduction of intra-abdominal pressure, a broad binder should be placed around
the upper abdomen before the tapping, which should be tightened as the fluid escapes.
Diuretic drugs should be given with great caution and mercurial preparations are, of
course, contraindicated in view of the damaged renal tissues. Peritoneal dialysis in
combination with the conservative therapeutic measures has proved successful, as shown
in the case described earlier.
HYPERTENSION ASSOCIATED WITH PYELONEPHRITIS
AND AMYLOIDOSIS
This problem has been discussed in non-paraplegic subjects since the time of Richard
Bright. Despite the fundamental experimental work of Goldblatt and his co-workers
(1934), who demonstrated the importance of renal ischaemia in the pathogenesis of
hypertension by constricting the renal artery in the dog, the problem of renal hyper
tension is still unsolved. Pickering (1955), in discussing the controversial literature on
the relationship of pyelonephritis to hypertension, came to the following conclusion:
'The part played by chronic pyelonephritis in hypertension is most confusing and most
challenging.' Clinical experiences on unilateral renal disease associated with hypertension
and its disappearance or improvement following nephrectomy of the diseased kidney
and, moreover, the histological findings of renal vascular stenosis in the removed kidney
