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Post-Graduate Medical Journal Vol THE Postgrad Med J: first published as 10.1136/pgmj.2.21.129 on 1 June 1927. Downloaded from POST-GRADUATE MEDICAL JOURNAL VOL. II. JUNE, 1927. NO. 21. CONTENTS SUPPRESSION AND RETENTION OF URINE. REVIEWS. By R. H. JOCELYN SWAN, M.S., F.R.C.S. 129 PRACTICAL METHODS IN THE DIAGNOSIS AND TREAT- MENT OF VENEREAL DISEASES. H2EMOPTYSIS. By DAVID LEES, D.S.O., M.A., M.B., F.R.C.S. 144 By L. S. T. BURRELL, M.D., F.R.C.P. 133 CAVERNOUS SINUS THROMBOPHLEBITIS. WELLS P. M.D.. 144 FUNCTIONAL NERVOUS DISORDERS OF THE HEART. By EAGLETON, By R. TRAVERS SMITH, M.D., F.R.C.P. 136 EDITORIAL NOTES.-OFFICIAL INTIMATIONS . 142 FELLOWSHIP OF MEDICINE AND POST-GRADUATE THE CARE AND FEEDING OF THE PREMATURE INFANT. MEDICAL ASSOCIATION.-OFFICERS, 1927 . 5 By DONALD PATERSON, M.B., M.R.C.P. 139 SPECIAL COURSES . 5 care anuria remained complete for 17 days before SUPPRESSION AND death occurred without the onset of headache or vomiting until the twelfth day, and the mental RETENTION OF URINE.* condition remained clear almost until the end. BY Causes of Anuria. R. H. JOCELYN SWAN, M.S. Loxi., F.R.C.S., Anuria may occur from a variety of causes, which SURGEON TO THE CANCER HOSPITAL; CONSULTING SURGEON TO for convenience may be divided into (a) obstructive ST. PAUL'S HOSPITAL FOR GEN-TO-URINARY DISEASES. and (b) non-obstructive. In the former group obstruction may be due to calculous disease, to IT is necessary in the first place to define vesical growths involving both ureteric orifices, exactly what we mean when we speak of suppression to the spread of uterine carcinoma into the broad and of retention of urine-suppression or anuria ligaments causing pressure on the lower ends of are synonymous terms used when there is a failure, the ureters, or to large pelvic or abdominal tumours. temporary or otherwise, of the kidneys to secrete In the -absence of disease causing obstruction, any urine, whereas retention of urine implies the in the urinary passages, anuria may be due to the inability of the patient to void urine which has reflex inhibition of urinary secretion following been normally secreted by the kidneys. Both traumatism to any part of the urinary apparatus, http://pmj.bmj.com/ conditions come under the term of "Surgical even to the passage of a catheter along the urethra ; Emergencies," and it is my intention to spend a it may accompany infection of the kidneys, either short time on the consideration of the various causes from haematogenous causes or from ascending which may give rise to these emergencies and later infection from the bladder. It may be due to to briefly discuss the treatment necessary. increasing renal disease, such as tuberculous disease, polycystic disease or suppurative pyelo- SUPPRESSION OF URINE. nephritis, and in the case of impairment of the Suppression of urine or anuria is a serious renal function by old-standing back pressure on October 2, 2021 by guest. Protected copyright. condition and demands early recognition so that anuria is particularly liable to follow the sudden appropriate treatment can be commenced, for the emptying of an over-distended bladder by catheter- gravity of the case increases as time goes on and isation. Again, suppression of urine may follow until renal function is again established. It most an operation, due either to the low blood pressure frequently occurs in patients in whom the kidneys of shock or to the effect of the anaesthetic on the are already diseased, even though slightly, though renal function. It may be present in any form of it may arise when there has been no clinical severe collapse and occasionally as a manifestation evidence of impairment of function. It may be in hysteria. It is probable that in many cases accompanied by pyrexia, headache, vomiting, more than one cause may coexist, perhaps most dyspncea, or by the muscular twitching seen in the frequently when an operation has been undertaken uroemia of the advanced stages of medical renal on a patient in whom the renal function is already dliseases, but one of the remarkable features of impaired either by infection or by back pressure. anuria, especially in the obstructive form of which Let us study the causes of anuria a little more in I shall speak in a few moments, is that it may go detail. The obstructive form naturally implies a on for several days without any of the above- simultaneous blockage of both ureters, causing mentioned symptoms; in one case under my first increased intrarenal tension quickly followed' failure of secretion. This is not wholly fr- * A lecture delivered before the Fellowship of lMedicine and by true, the Post-Graduate Association. in calculous disease one kidney may be partially 130 SUPPRESSION AND RETENTION OF URINE. Postgrad Med J: first published as 10.1136/pgmj.2.21.129 on 1 June 1927. Downloaded from destroyed or calculi may have been present in the absent. The respirations become embarrassed, ureter for a considerable time, when the other often of Cheyne-Stokes sequence, and the patient ureter becomes suddenly blocked by a balculus dies in coma of respiratory or of cardiac failure. passing into the upper ureter from the renal I have described the sequence of events in pelvis. Again the sudden blockage of both sides at calculous suppression somewhat fully, because it is the same time must be very rare, but the impaction in the tolerant stage that too little significance may on one side in cases in which the other kidney is be given to the story of failure of renal secretion, diseased or in which previous disease has already whereas if any good is to be done for the patient, rendered it functionless, is not so uncommon. the sooner operation is undertaken the better Cases have been recorded in which the sudden chance there is that the renal function may be impaction of a calculus in one ureter has led to re-established. The occurrence of suppression in anuria when the kidney of the other side has been these cases is a serious event, but is by no means normal and has been assumed to be of a reflex necessarily fatal. In a few cases recovery takes nature. Such an anuria is most probably of short place by the passage of the calculus into the bladder, duration, the secretion becoming re-established but when the diagnosis is confirmed byradiography, when the first effect of the impaction has gone &c., no time should be lost in operating either to off; most authorities deny that suppression does remove the calculus or to provide drainage to the occur with one healthy kidney, but that if such recently blocked kidney. Ikidneys as were supposed to be normal were The other common causes of obstructive examined microscopically some form of nephritis suppression are from the implication of the ureters would have been found. Thus in calculous anuria in progressive carcinomatous growths in the base the following conditions may be present. of the bladder or in the broad ligaments from 1. The ureters of both kidneys are simultaneously carcinoma of the uterine cervix or more rarely blocked by calculi. from carcinoma of the prostate. In these cases 2. The ureter of one kidney is blocked by a anuria occurs as a terminal event in the illness, calculus,the other being absent, previouslyremoved of which the characteristic symptoms will have or destroyed by disease. been for some time in evidence. In these cases 3. The ureter of one side is blocked by calculus, infection of the kidneys may have already occurred, the function of the second kidney been suppressed but the onset of nausea, refusal of food, headache, reflexly by it. The second kidney is practically and subnormal temperature with coldness of the always already of diseased form. extremities may proceed anuria, and after a variable period death takes place without any true Obstructive and Non-obstructive Suppression. uraemic symptoms. In both cancer of the uterus In calculous anuria there is usually a history and of the bladder hydronephrosis is very liable of an acute attack of renal colic accompanied by a to occur from the gradual pressure on the ureters, both these frequent desire to micturate, but that the quantity but in the numerous cases of cancer in http://pmj.bmj.com/ of urine becomes lessened until none is passed. organs that I have seen in the Cancer Hospital I In these cases the kidney of the affected side may cannot remember one dying of suppression of urine be tender on pressure, may be palpable, and the before the usual symptoms of the disease have abdominal muscles- of that side may be resistant. been evident, although cases have been recorded of When the suppression is established there follows this nature. a period in which no symptoms may be present, Suppression of urine in the non-obstriuctive and this forms one of the striking features of variety presents a very different clinical picture. cases of obstructive suppression, as opposed to It mayoccur from a variety of causes,the antecedent on October 2, 2021 by guest. Protected copyright. the non-obstructive form. The anulia may be symptoms of which will usually have been so complete or may be interrupted by periods in apparent that little difficulty will be found in the which large quantities of very pale urine of low diagnosis of the condition. The anuria may be a specific gravity may be passed, only to be followed purely transient trouble, passing off with re-estab- again by suppression.
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