Management of the Bladder in Traumatic Injuries of the Spinal Cord During the First World War and Its Implications for the Curre
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2011 THE AUTHOR; BJU INTERNATIONAL 2011 BJU INTERNATIONAL Mini Reviews MANAGEMENT OF THE BLADDER IN THE FIRST WORLD WAR SILVER Management of the bladder in traumatic injuries of the spinal cord during the First World War and its implications for the current practice of urology BJUIBJU INTERNATIONAL John R. Silver Stoke Mandeville Hospital, Aylesbury, UK Accepted for publication 19 January 2011 Historical review of the management of the What’s known on the subject? and What does the study add? bladder in patients with spinal injuries. Prior to the First World War, traumatic injuries to the spinal cord rapidly led to death from Spinal injury patients – literature review – severe infections of the bladder. During the Second World War, Ludwig Guttmann personal experience at Stoke Mandeville resurrected the use of intermittent catheterisation at Stoke Mandeville Hospital, by Hospital. Review of the different methods of meticulous attention to detail and was so successful, that this method was introduced catheterisation from the 19th century to into general urological practice. today. Methods learned from the management of the bladder of spinal injuries patients were adopted into mainstream urology. KEYWORDS spinal injuries, bladder management, catheterisation INTRODUCTION Fagge and Hulke have been analysed (Table 1; The bladder was neglected, possibly because [1–5]). The patients in these series were of the lack of specialization; urology had not By the turn of the 19th century, the chief cause described by the physicians and surgeons yet developed as a discipline. Urology was not of death in acute and chronic paraplegia was responsible for their overall care but the considered important enough to be discussed, recognized as renal failure attributable to UTIs patients only visited the hospital on an but with careful analysis of the papers one caused by inappropriate treatment. This occasional basis and their day-to-day care can find descriptions that enable one to problem was addressed in the UK during the there was the responsibility of the house obtain a view of what was being done to the First World War. Although the problem was surgeon who changed every 6 months. There bladder. Some patients had intermittent not solved, the lessons learned served as the was no specialization, no segregation of catheterization, others had an indwelling beginning of successful management of the cases, and few patients were admitted. It took catheter or the bladder was expressed, and bladder which reached its fruition after the Hulke [5] 24 years to accumulate data on 33 some were left to be incontinent into their Second World War. The present review seeks patients, 22 of whom were under his own bed (Figs 6 and 7). Although the management to show how the lessons were learned, care. The descriptions are mainly of the of the bladder was clearly considered to be of adapted and have been so valuable as to be clinical manifestations of the transections of little importance, Bell [6] and Hulke [5] both adopted into the mainstream of general the cord at different levels. All gave detailed recognized its importance in the pathogenesis urology. descriptions of the post-mortem findings. The of renal failure and both commented on the patients had suppurative disease of the dangers of catheterization. Hulke commented kidneys with sloughing bladders full of on how badly the catheter was managed by purulent urine, and the majority had pressure the resident staff and also on how badly the BEFORE THE FIRST WORLD WAR sores. The natural history of the condition of notes were kept because the resident doctors these patients was a retention of urine with only stayed for a few months at a time. Brodie IN THE UK dribbling incontinence with periodic relief [7], when discussing tuberculosis of the spine, when the catheter was passed. There is little stated that when paralysis ensued it was a To gain insight into how the bladder was detailed description of the management of calamity, thus taking a fatalistic approach to managed in the past, five series of patients this but treatment consisted of cupping, the management of paralysis. The small with paraplegia by Curling, Gull, Thorburn, blistering, mercury, leeches and purgatives. number of cases under the care of individual © 2011 THE AUTHOR BJU INTERNATIONAL © 2011 BJU INTERNATIONAL | 108, 493–500 | doi:10.1111/j.1464-410X.2011.10211.x 493 SILVER TABLE 1 Management of the paraplegic bladder in the UK in Victorian times Name Number of cases Cause of death and description Management of the bladder Curling TB (1833) [1] Not given Disease of the bladder He recorded the use of an indwelling catheter in one Surgeon patient and his bladder was drained four times a day Gull W (1858) [2] 40 cases with multiple causes He describes a mixed series of cases with Descriptions are incomplete, urine was dribbling away Physician many dying of suppurative disease of or passed without the patient knowing it or the the kidneys. bladder was expressed. In several cases a catheter 30 post mortems was passed. Thorburn W (1889) [3] 50 altogether, not all Described suppurative disease of the In five cases, he described how the urine was drained Surgeon traumatic kidney by intermittent catheterization Fagge CH (1891) [4] 36 cases of traumatic Post mortem findings indicated cystitis No description of the bladder management Physician paraplegia out of 244 post and suppurative nephritis mortems. Hulke JW (1892) [5] In 24 years he gathered 33 In a small number of cases he describes Unaware of urine being passed and in case no. 15 he Surgeon cases, 22 under his own death due to suppurative disease of describes how they used intermittent care the kidney catheterization surgeons did not enable experience to be was a 75% death rate for patients with spinal hospital [12]. There was no space for them accumulated in the UK. injuries [10]. there and beds had to be vacated. All the patients in the hospital were then transferred ON THE CONTINENT The First World War was a conflict of onto Bethnal Green hospital. Head, who was unprecedented proportions. A total of looking after the spinal patients at the London Two surgeons, Kocher (1841–1917) and 5 704 000 men served in the British Army. The Hospital, protested and kept his spinal Wagner (1848–1900) paid meticulous British and Commonwealth Empire suffered a patients in the London Hospital. Eventually, attention to the management of the bladder million deaths and two million battlefield the soldiers were transferred to numerous in patients with spinal injuries. Kocher [8], wounded were admitted to British hospitals. hospitals throughout London, the Empire a Nobel Prize winner from Switzerland, In previous conflicts, casualties had been Hospital, The George V Hospital, and the Star described in detail how the bladder should be treated in field hospitals near the battlefields and Garter, which was the only establishment drained by an indwelling catheter and this but the plan at the outbreak of the First World to provide long-term care [13]. catheter should be managed meticulously War was that the casualties should be under a seal. In contrast, Wagner [9] who collected rapidly from the battlefields, taken Two lessons were immediately apparent from congregated a large number of patients with to clearing stations and then transported this experience: firstly, the clearing stations spinal injuries in his unit in Königshutte, speedily back to base hospitals and then had to be expanded to 1000 beds to receive Upper Silesia, described how the bladder to the UK where definitive treatment could the huge number of casualties so that should be managed by intermittent take place (Fig. 5). The unprecedented number definitive treatment could take place and catheterization. This unit closed down at the of casualties from an individual offensive secondly, specialized facilities had to be end of the 19th century but it is fascinating swamped these facilities. Many casualties developed near the front line. Special that Guttmann worked as an orderly at this died on the battlefields of Europe from hospitals were therefore set up in France and hospital at the end of the First World War. exposure. The survivors were extracted with in the UK, for: Both Kocher and Wagner worked full time, difficulty, having survived on the battlefield taking the continental approach to the care of for many days. Thereafter, they were • abdominal surgery in specialized units at patients and accepting that the management transferred slowly, as there was no the front; of the bladder was a medical responsibility, prioritization, back to a series of receiving • plastic surgery in base hospitals in the UK which is in contrast to the approach in the UK hospitals. Cushing [11] describes how he saw (Sidcup, Kent); where analysis of the notes shows that the rows of injured soldiers lying by the side at • orthopaedic surgery in a series of hospitals information was hardly recorded and the the railway station waiting for transport. set up by Robert Jones throughout the UK; bladder was not considered the responsibility When the first casualties arrived in the UK, • amputees (Queen Mary’s Hospital, of the attending doctor. they were not expected and there was no Roehampton); transport for them at Victoria station. When • psychiatric care (Craiglockhart, Edinburgh); Morris, the Chairman of the London Hospital, • the blind; WARFARE: MILITARY TRIUMPHS AND heard of this he contacted Lord Salmon who • nervous diseases where patients were MEDICAL DISASTERS was a member of the house committee of the segregated in different hospitals throughout London Hospital and also the Chairman of the UK, notably the National Hospital for There were no survivors of paraplegia from Lyons & Co. Ltd. Within half an hour, 14 Lyons Nervous Diseases and The Empire Hospital, the Crimean War [5] and in the Boer War there vans were transporting the patients to the which looked after paraplegics in London.