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. Even with complete anuria lishment of the secretion in a few hours ; this may there is a period in which no further symptoms follow any severe shock and may be seen after an arise, known as the tolerant stage, which is followed operation, especially in those patients in whom there by stage of intoxication in which uraemic symptoms is some degree of nephritis. I have seen anuria develop. The tolerant stage may last from any follow severe abdominal operations in patients in time up to ten days, the patient remaining mentally whom the ordinary clinical tests have shown active and be to all appearances in good health; nothing abnormal in the urine, but it is more when a hydronephrosis is present, the tolerant likely to follow operations on the kidney or upon stage may be still further prolonged. After a the lower urinary passages. Whether this anuria variable period, usually about the seventh day, is due to a reflex inhibition of secretion or to the the patient becomes drowsy, complains of head- effect of the anesthetic I am not prepared to say. ache, and nausea and vomiting frequently occur; These cases are usually of a temporary nature, the ankles may become slightly cedematous, con- but will cause a good deal of anxiety until urine is stipation becomes marked, and muscular twitching again passed. There is no doubt that disease of one may occur, though in many cases these are entirely kidney is often accompanied by a reflex depressing SUPPRESSION AND RETENTION OF URINE. 131 Postgrad Med J: first published as 10.1136/pgmj.2.21.129 on 1 June 1927. Downloaded from effect on the function of the other, but that the due to the obstruction of the ureters by carcinoma removal of the diseased organ is followed by an of the bladder, uterus, or prostate, there will be in increased activity in the remaining one. Should the nearly all cases the ordinary symptoms of the initial second kidney have been inadequate to carry on disease, but if these are absent, a routine vaginal the full function before operation, the removal of or rectal examination will easily reveal the nature the more diseased organ may be followed by anuria. of the trouble. In the obstructive form of anuria Again, in cases in which operation has been per- due to calculus the occurrence of former attacks of formed on the lower passages in whom the renal renal colic followed by the sudden onset of pain in function is impaired anuria may result; in these one side and accompanied by anuria immediately cases there is usually-a period of polyuria accom- suggests that the obstruction is due to calculous panied by loss of appetite, headache, &c., followed disease. In many cases there will be a previous by anuria from which death occurs. history of attacks of renal colic and possibly the In another class of case anuria occurs with history of the passage of a calculus, but it must be symptoms which are much more alarming. There remembered that one kidney may have become may be an initialstage of asuccession of rigors,head- silently disorganised by calculous disease without ache, and giddiness, quickly followed by convulsions causing any symptoms and that the obstruction and coma, resembling the terminal stages of the has occurred to the only functional one. In one ursemia from chronic nephritis. These cases are case under my care, one kidney had already been very acute and are usually accompanied by some removed for calculous disease and my patient was infective process; they are seen in cases of infective fortunate enough to pass her calculus after two pyelitis or pyelonephritis, either from a haemato- days of complete suppression. It can be taken as genous infection or from infection ascending from a general rule that when anuria occurs from the the bladder. The mere passage of a catheter along blockage of the pelvis of one kidney or its ureter, the urethra may be followed by a rigor and by the functional capacity of the other has already been suppression of urine, oven where no disease is impaired by some form of disease and that the present in the urethra and in which no traumatism sudden blockage of the previously functional organ has been caused, and it is probable that there has has caused a reflex inhibition to the decreased been some infection in these cases ; more frequently secretive capacity of the damaged kidney. Thus, the urethra has been the seat of a stricture or in in 28 cases collected by Morris in which calculous which the difficulty in passing the instrument has anuria occurred, there was no trace of a second been followed by hemorrhage. The kidneys are kidney in 6 cases, marked atrophy in 8, almost sometimes the seat of chronic nephritis or of septic entirely disorganised by calculus in 11, destroyed pyelonephritis, though in some cases nothing has by hydatid disease in one and enlarged in two. been found post mortem. In one case in which an Additional evidence of a calculus causing anuria operation for internal urethrotomy was followed may be obtained by rectal or vaginal examination, by great pyrexia, convulsions, and anuria, the by radiography, or by cystoscopy. By rectal or http://pmj.bmj.com/ kidneys appeared on exposure to be normal and vaginal examination a calculus may occasionally after death no disease was found microscopically. be palpated if it is impacted in the lower terminal Thus it will be seen that suppression of urine ureter, which appears to occur in roughly one-third may occur with marked symptoms of physical of the cases. Radiography may give more valuable disturbance, pyrexia, vomiting, and convulsions, and precise information and may show a small rapidly passing on to coma and death in a short calculus in the renal pelvis or anywhere in the line time or, on the other hand, the anuria of the of the ureter; a collection of shadows in one obstructive form may be unaccompanied by renal area would suggest that this organ is one of on October 2, 2021 by guest. Protected copyright. any other symptom for several days, the so-called old-standing disease and functionally damaged. tolerant stage, before other symptoms appear; Cystoscopy may show a congested or cedematous even then these may be of slight degree compared orifice of a ureter if the calculus is placed in the to the marked disturbance in the non-obstructive lower ureter or more rarely the tip of the calculus form, and death may occur without there being may be seen projecting from an orifice. Catheterisa- any pyrexia or convulsions, the patient becoming tion of the affected ureter may so alter the position gradually more and more comatose. of the calculus that the obstruction to urine may be relieved. Diagnosis. Treatment. When anuria is present, the first point that will The treatment of an anuric patient will depend arise will be the diagnosis of the condition causing it. in a large measure on the condition causing the The anuria that follows the progressive destruction anuria. In cases of old-standing bilateral renal of the kidneys, whether from chronic nephritis, disease and in those of renal obstruction due to chronic pyelonephritis, tuberculosis, polycystic advanced carcinomatous growths in the bladder, disease, &c., will usually cause no trouble by the prostate, or uterus, little can be done, and it is other symptoms which have-been present during doubtful if any such operation as bilateral the illness, whilst that following upon operations nephrostomy is justifiable, as ultimate death or upon catheterisation is recognised by the would follow and in the meantime the misery of a immediate history. In cases of suppression of urine double urinary fistula has to be borne. In cases in 132 SUPPRESSION AND RETENTION OF URINE. Postgrad Med J: first published as 10.1136/pgmj.2.21.129 on 1 June 1927. Downloaded from which the suppression follows operation on the Retention with obstruction or acute inflammation:- lower urinary tract or accompanies acute infections (a) Prostate-simple enlargement. malignant disease. of the kidneys, treatment should be prompt and acute prostatitis. energetic. Hot fomentations should be applied prostatic abscess. to the loins, hot packs given, and diuretics freely (b) Urethra-stricture. administered; diuretin, caffeine, acetate of acute urethritis. Infusion impaction of stone, &c. ammonia, and hot drinks are all useful. pressure from tumours. of saline or of glucose solution into the subcutaneous rupture. tissues or, better, into the vein, should be given Retention without obstruction in the urethra:- and if these measures do not re-establish the (a) From spasm or inhibition- flow of urine, no time should be lost in performing after anal operations, &c. bilateral nephrostomy. Where the anuria is hysteria. due to the blockage of a calculus, the stage of (b) From nerve diseases, tabes, myelitis, &c. tolerance for the first few days allows of some steps The diagnosis of retention of urine is made by to be taken to localise the obstructing calculus, the passage of a large-sized catheter through the but there is no doubt that every day delayed urethra. In cases due to atony of the bladder, to beyond the third distinctly minimises the chance spasms after operations, to hysteria, and to the of a successful result, although cases are recorded presence of a pelvic tumour in the female, the of recovery even when the operation has been catheter will enter the bladder easily, but will be delayed until uraemic symptoms have been present. arrested if obstruction be present. In stricture and In these cases an attempt should be made to remove with the enlarged prostate there is usually a the calculus if this does not entail too serious a history of gradual increasing difficulty and of proceeding in the patient's condition, in which case increased frequency of micturition, whilst the a nephrostomy should be done and the removal palpation of the prostate per rectum will determine of the stone postponed until the suppression has the condition of the gland. been relieved. Treatment. RETENTION OF URINE. I propose to consider briefly the treatment By the term retention of urine is implied the required in those cases of retention of urine most gradual accumulation of urine in the bladder with generally met with in practice. inability to void it per urethram. It is necessary With acute urethritis complicated by retention to distinguish it from anuria on the one hand and there will be a history of purulent discharge from also to distinguish those forms of retention the' meatus, but with the onset of an acute due to some obstruction in the urethra from those prostatitis the urethral discharge may be due to nervous causes in which the urethra is fully temporarily diminished or even absent. Every patent. endeavour should be made to relieve the retention Retention of urine occurring suddenly gives rise before the passage of a catheter. The patient http://pmj.bmj.com/ to severe pain and strangury, but in old-standing should be given a suppository of morphia or cases in which the obstruction has been gradual, belladonna, and after a quarter of an hour placed the bladder may become enormously distended in a hot bath and encouraged to pass his urine before pain is severe. If the condition remains into it. Failing this, an enema of hot water or a unrelieved, urine may continually dribble from the glycerine suppository is occasionally successful. urethra, when a condition resembling incontinence If these measures fail and the pain is becoming to must be The inflamed of urine is produced; it is important distinguish worse, a catheter passed. on October 2, 2021 by guest. Protected copyright. this false incontinence from overflow from the true urethra is intensely sensitive, so that a local incontinence of urine due to injury or paralysis of ansesthetic may be necessary. The urethra should the vesical sphincter. In true incontinence the first be washed out with a hot solution of potassium bladder remains empty and the urine dribbles permanganate (1 in 6000) or of oxycyanide of away as soon as it enters the bladder; there is no mercury (1 in 4000) and the canal then aneesthetised obstruction in the urethra. In the false incontinence by a solution of novocain (2 per cent.) introduced from the overflow of a distended bladder the latter by means of a pipette. A soft rubber catheter is then may be felt as a rounded, smooth swelling above passed very gently and the retention relieved. the pubes, firm on pressure and dull to percussion. Owing to the fear of conveying infection into the In a general sense it may be said that retention posterior urethra or to the bladder in these cases in a young man is most likely to be due to it has been taught that suprapubic puncture should gonorrhea; in adult life, it is more likely to be due be done in preference to catheterisation, but it to stricture; whilst in -elderly men, prostatic must be remembered that retention does not occur enlargement is the most frequent cause. In women in urethral infections unless the posterior urethra it is most frequently due to hysteria or the pressure or the prostate is already infected. and drag on the urethra of a retroverted gravid After operations, especially after those for uterus or some pelvic tumour. haemorrhoids, fistula, hernia, &c., early resort The causes of retention of urine may be classified should be made to the catheter in order to avoid as follows. the acute pain with the overdistended bladder. HAEMOPTYSIS. 133 Postgrad Med J: first published as 10.1136/pgmj.2.21.129 on 1 June 1927. Downloaded from Needless to say, in every catheterisation complete Stricture of the urethra may cause retention and regard to asepsis must be employed. may cause great difficulty in passing an instrument Bloccckage of the urethra by calculus, pedunculated into the bladder. In the majority of cases the vesical growths, calculus, foreign bodies or blood-clot stricture is not very dense and the exciting cause of should be relieved similarly by the passage of a the retention is excess of alcohol or exposure to catheter. A calculus or foreign body may cause a cold. In these cases a fairly large olivary-pointed good deal of spasm in the urethra, but this can be catheter should be first tried and the position of overcome by the use of novocain. In cases in the stricture ascertained. If this fails to pass which the retention is due to the filling of the through the stricture smaller sizes should be bladder by blood-clot, attempts should be made to successively tried until one is passed through into break up the clot and extract it by means of a the bladder. This should then be tied in and the lithrotity evacuator, but in these cases it is often urine allowed to trickle away slowly. Subsequently, better to proceed immediately to a suprapubic larger sizes should be passed and the stricture cystostomy, turn out the clot, and drain the gradually dilated. In other cases great difficulty bladder; the cause of the excessive haemorrhage may be experienced in passing any catheter and can then be treated at a future date. resource may have to be made to filiform bougies. With enlarged prostate retention of urine may A straight one should first be tried, failing which occur from the increasing obstruction of the gland the point should be slightly bent and a further or from the increased congestion of the enlarging attempt made. It is often useful to inject warm oil gland from excess of alcohol, exposure to cold, etc. into the urethra and to pass several filiform bougies In every case of retention in which there has been into the canal down to the face of the stricture gradually increasing obstruction in the lower when one may be manipulated through. This urinary passages, it must be ever borne in mind should be then tied in and after a little time the that there is very frequently interference with the urine will trickle alongside it. After a day or so the full renal function from the gradually increasing stricture will allow of dilatation by one of the intrarenal pressure, and it cannot be too strongly usual methods. When complete failure has been enphasised that in every such case the bladder the result of attempted passage of a bougie, an must be emptied very slowly, as otherwise the anmesthetic should be given, when a filiform may sudden relief to the intrarenal pressure may cause frequently be passed; in other cases a suprapubic such congestion of the renal tubules that complete puncture may be done or a Wheelhouse's external and fatal anuria follows. Believe me, it is not by urethrotomy performed. any means unusual to see a case in which a doctor has been called to see a case of retention and in which he tells us with some pride that he drew HfEMOPTYSIS. off 40, 50, or 80 ounces of urine, but that since then no more urine has been passed and there is none BY http://pmj.bmj.com/ in the bladder. L. T. M.D. F.R.C.P. LOND., made to obtain S. BURRELL, CAMB., Attempts should first be voluntary PHYSICIAN TO THE BROMIPTON HOSPITAL FOR CONSU31PTION mlicturition by means of a hot bath, belladonna AND DISEASES OF THE CHEST; PHYSICIAN TO THE suppositories, or hot enemata. Should these fail, ROYAL FREE HOSPITAL. a catheter must be passed with rigid asepsis and with great gentleness. It is best to try with a large WHEN a patient coughs up blood it is often Coude catheter, size 18 or 20 French scale, first; taken for granted that he is consumptive. This is smaller or pointed catheters are prone to be caught not wise, for heemoptysis may result from a variety on October 2, 2021 by guest. Protected copyright. in folds in the prostatic urethra. If difficulty is of causes. Pulmonary tuberculosis is, however, found with the Coude catheter a long, fully-curved such an important cause that in this paper I prostatic metal catheter should be tried, or an propose to discuss the subject under two headings: English gum-elastic instrument used, the curve (1) hsemoptysis of non-tuberculous origin; (2) of being increased whilst the catheter is in the urethra tuberculous origin. by withdrawing the stilette for two inches. Should catheterisation be found impossible, suprapubic HEMOPTYSIS OF NON-TUBERCULOUS ORIGIN. puncture by means of a small trocar and cannula 1. Heart affections and especially mitral stenosis mnay be necessary. Where the catheter has been may give rise to hsemoptysis which is often large passed into the bladder, only a small quantity of and of frequent recurrence. In any case of urine should be withdrawn, say 10 or 15 ounces, heemoptysis it is very important to examine the when the catheter should be tied in and directions heart. Indeed, in all routine examinations of the given that 4 to 5 ounces be drawn off every hour chest it is a good rule first of all to find the position until the bladder is empty. The catheter should be of the apex beat, and then to examine the heart kept in for several days and then withdrawn, before coming to the lungs. This practice will save and the patient encouraged to pass his urine many a mistake. It is surprising how often there is naturally, but it may be necessary to replace the found in a tuberculous institution a case with so catheter and decision made as to the necessity for obvious 'a murmur that it could not have been operation. overlooked had the heart been examined. In