F • CLINICAL ASPECTS OF SPINAL CORD INJURIES
423
should be the indication for detailed clinical and biochemical investigations, including
blood urea, serum creatine estimation, creatinine clearance, electrolytes, renogram and
rectal biopsy. Ophthalmological examination may also be helpful in the diagnosis of
hypertension by revealing early retinopathy (see case P.R. in Table 22).
Tetraplegics with complete lesions are known generally to have a low blood pressure
in sitting position, the underlying cause of which has been discussed earlier in this book
(see page 271). Although we found on occasions increase of the pressure readings in
lying supine position, these observations do not allow definite conclusions, and systematic
studies comparing blood pressure readings in sitting and lying position in tetraplegics
suffering from chronic ascending infection of the urinary tract, may be helpful in ascer
taining persistent blood pressure changes due to renal pathology and/or amyloidosis in
these high cord lesions.
Drug therapy
The early diagnosis of renal hypertension resulting from ascending infection of the upper
urinary tract by various methods necessitating active and specialized management is
now possible, and various therapeutic measures have been discussed. I have always
been opposed to sedatives such as phenobarbitone, in particular for long-term therapy,
because of their undesirable side-effects, especially fatigue and mental depression as they
adversely affect the paraplegic's active life. There are now more potent anti-hypertensive
drugs available which can be used advantageously, such as Rauwiloid (Cooper & Crans
ton, 1957), Inversine—mecamylamine hydrochloride—a ganglion blocking agent given in
combination with Saluric, furthermore Esbatal-Bethanidine Sulphate, an adrenergic
neurone blocking agent (Johnston, Prichard & Rosenheim, 1962; Boura & Green, 1963)
and Aldomet, methyldopa (Cannon & Laragh, 1963; Hamilton & Kopelman, 1963;
Johnson
el al.,
1966). Side-effects of these drugs can be minimized or altogether avoided
by careful, individual selection of the cases suffering according to the degree of their renal
hypertension. Aldomet is contra-indicated in cases with oedema.
CAUSES OF DEATH IN THE ACUTE AND CHRONIC STAGES
RENAL PATHOLOGY
In discussing the pathology
of postmortem
findings in 26 out of 458 traumatic lesions—
388 soldiers and 70 civilians (Guttmann, 1953), it was found that in 20 patients of our
series, whose deaths were related to spinal cord injuries during the Second World War
and the following years until 1950, the only or main cause was ascending urinary infec
tion resulting in pyelonephritis and renal deficiency. Nineteen out of the 26 patients had
suprapubic drainage at the time of death which was instituted elsewhere on the day or
within the first few days following injury. In 5 cases the suprapubic drainage had been
closed at varying periods before death, while only 2 cases never had suprapubic drainage.
The necropsy findings in all the 19 cases were uniform. The bladder, showing all
signs of chronic infection, was contracted and adherent to the pelvis, being surrounded
by a thick wall of fibrous tissue. The ureters were dilated, tortuous and adherent to the
