CALCULOUS ANURIA*

JOSEPH SCHWARTZ, M.D., F.A.C.S.

Associate in Surgery and SurgicaI PathoIogy, Lebanon Hospital; Assistant Attending Urologist, h4orrisania Hospital

NEW YORK CITY

T HIS paper is a report and brief dis- cussion of I2 cases of caIcuIous anuria. A study of these cases indicates that

anuria, compIicating renaI and ureteral Iithiasis, is a symptom of grave signifi- cance portending a catastrophe unIess urinary secretion is promptIy restored. With this group we studied many other cases with non-obstructive anuria to deter- mine whether or not reflex anuria ever occurred in the absence of renaI or ureteral pathoIogy.

We are concerned here mainIy with the obstructive type of anuria most commonIy caused by caIcuIi. It is the type for which the surgeon is most frequentIy caIIed for assistance and for which the resuIts are most satisfactory.

The foIIowing 12 cases of caIcuIous anuria are reported briefly:

CASE I. S. H., femaIe, aged thirty-nine, had Ieft renaI coIic and anuria of two days’ dura- tion. On cystoscopy no urine was obtained and both ureters were obstructed at the level of the fourth Iumbar vertebra. X-ray examina- tion discIosed a caIcuIus in the right ureter at the IeveI of the fourth Iumbar vertebra. Anuria persisted for four days. Non-protein nitrogen 21 I mg., urea 150, creatinine 3.8. There were no signs of uremia. It was beIieved that she had a right uretera stone causing Ieft renorena1 reflex pain with anuria. A right ureterolithotomy was done and urine drained shortIy after the operation; she was discharged four weeks Iater. Four months Iater there was another attack of Ieft renaI coIic and a small uric-acid caIcuIus was passed, which was most IikeIy present at the previous examination.

CASE II. L. K., femaIe, aged forty-three,

was operated upon twice previousIy for a Iarge infected Ieft hydronephrosis. A nephros- tomy was done each time. On her Iast admis- sion she had chiIls, septic temperature, pain in the right Iumber region and marked ohguria; about IOO C.C. of urine were passed in three days. On cystoscopy 4 C.C. of turbid urine were obtained from the bIadder. A biIatera1 impassable obstruction was found in both ureters at 2 cm. No indigo dye was seen coming from either uretera orifice after one-haIf hour. X-ray examination discIosed a smaI1 shadow in the left ureter. N.P.N. 123 mg., urea 92, &eati- nine 6.5. Her temperature ran a septic course; symptoms of uremia were present; bIood cuIture was positive for coIon baciIIus. This case was aIso considered as a pfobabIe instance of renorena1 reflex. At operation the right kidney was found to have a severe pyeIonephri- tis with muItipIe cortica1 abscesses. A decapsu- Iation and pyeIostomy were done. The patient succumbed after twenty-four hours without having passed or drained any urine. At the post-mortem examination a compIeteIy destroyed Ieft kidney was found with a smaI1 stone in its corresponding ureter. The right kidney had a severe pyelonephritis and a smaII stone in the peIvis and one at the ureterovesica1 junction. Both stones consisted of pure uric acid.

CASE III. A. P., femaIe, aged forty-two, had a right nephrectomy three years before for caIculous disease. She now had Ieft renal coIic and anuria of two days’ duration. The Ieft kidney was Iarge; there was no obstruction in the ureter and no urine was obtained on cystoscopy. X-ray examination showed two stones in the Ieft kidney peIvis. A catheter was Ieft in the ureter for forty-eight hours. No urine drained. N.P.N. 66, urea 32, creatinine 3.2. The stones were removed through a pyeIotomy after four days of anuria. Urine drained im-

* From the SurgicaI Service Lebanon Hospital.

3oo

NEW SERIES VOL. XXXI, No. 2 Schwartz-Anuria American Journal of Surgery 301

mediateIy after operation; she was discharged ing from the Ieft ureter; this was disIodged and in four weeks. a catheter was then passed up to the Ieft kidney

CASE IV. S. S., maIe, aged twenty-five, had and was Ieft in situ. Urine began to: drain

FIG. I.

severa attacks of renaI colic in the past two years. Forty-eight hours before admission he had an attack of right renaI coIic and anuria. On cystoscopy, the bIadder was empty, and x-ray examination discIosed a caIcuIus in the Ieft ureter at the IeveI of the second Iumbar vertebra and another one at about the same IeveI in the right ureter. About thirty hours after cystoscopy he began to void spontane- ousIy. A right ureteroIithotomy was done a few days Iater. Recovery was uneventful.

CASE v. I. M., male, aged fifty-nine, was first admitted because of right renaI coIic. Cystoscopic and roentgen examination dis- closed a non-functioning right kidney contain- ing one branching and severa smaI1 caIcuIi. A stone was aIso suspected of being present in the Ieft kidney. Operation was refused at this time. He returned in four days with a left renaI coIic and marked oIiguria, having passed onIy few cubic centimeters of cIoudy urine from the bladder; a caIcuIus was seen protrud-

severa hours Iater. Three days Iater the func- tion of the Ieft kidney was norma and the function of the right kidney was considerably aItered. The urine output was exceedingIy smaI1. N.P.N. II0 mg., urea 63, creatinine 3.3. A right nephroIithotomy was done. This was foIIowed by a twenty-four hour suppression, after which urine began to drain freely. He was discharged from the hospita1 after two weeks.

CASE VI. M. S., femaIe, aged nineteen, had right renal coIic three years before and passed a caIcuIus after cystoscopic manipuIa- tion. Because of pyuria, an x-ray examination was advised, which discIosed a branching caIcuIus in the right kidney and a caIcuIus, the size of a grape, in the Ieft kidney pelvis. Opera- tion was advised, but was refused by the pati- ent. She accepted and received cystoscopic treatments eIsewhere. The Ieft caIcuIus descended to the Iower third of the Ieft ureter, when acute suppression occurred. BIood

302 American Journal of Surgery Schwartz-Anuria FEBRUARY, 1~36

chemistry was normaI. There were no symp- Ieft pyonephrosis was drained and urine secre- toms of kidney insuffrciency and after twenty tion promptIy restored. hours a left ureteroIithotomy was performed. CASE VIII. T. C., femaIe, aged fifty-one,

@

e @

4

Case li

FIG. 2.

Urine drained within three hours. Three weeks Iater the caIcuIi were removed from the right kidney.

CASE VII. L. R., maIe, aged forty-nine, had left Iumbar pain with marked costovertebra1 tenderness; temperature 103’~. and anuria of four days’ duration. Cystoscopy and x-ray examination discIosed an empty bIadder and an auto-nephrectomized tuberculous right kid- ney and an obstructing ca!cuIus at the left ureteropeIvic junction. N.P.N. gg mg., urea 67, creatinine 4.1, The catheter was Ieft in situ for twenty-four hours but no urine was ob- tained. Uremic symptoms were pronounced. A Ieft decapsuIation and nephrostomy were done after the stone was removed from the upper ureter. The kidney was the seat of a pyeIonephritis and pyonephrosis. Twenty-four hours Iater urine began to drain. He was dis- charged six weeks after operation. Seven weeks later he returned because of pain on the same side and anuria of thirty-six hours’ duration. A

had left Iumbar pain for forty-eight hours with marked oIiguria. There was marked tenderness in the left kidney region; temperature was 105’F.; about 125 C.C. of turbid urine were obtained in twenty-four hours. Cystoscopic and x-ray examination discIosed no urine from the Ieft kidney and onIy a slight amount from the right. CaIcuIi were present in both ureters and kidneys. The catheter was Ieft in for twenty-four hours; 0nIy a smaI1 amount of urine was passed. During the foIIowing twenty- four hours onIy 4 C.C. of urine were obtained. N.P.N. IOO mg., urea 59, creatinine 4.9. There were pronounced symptoms of renaI insuf- ficiency. A Ieft ureterolithotomy, pyelostomy and decapsuIation were done. The kidney had many cortica1 abscesses. Urine began to drain shortly after the operation. She was discharged four weeks later, refusing further operation.

CASE IX. S. C., female, aged forty-nine, had right nephrectomy eight years before for caIcuIous disease. She now compIained of pain

NEW SERIES VOL. XxX1, No. z Schwartz-Anuria American Journal of Surgery 303

in the Ieft Iumbar region, chiIIs, fever and marked oIiguria. Cystoscopy and x-ray ex- amination discIosed 3 C.C. of urine in the bIadder and an impassabIe caIcuIous obstruction at 2 cm. No urine was obtained from the kidney and no dye was excreted. N.P.N. 39 mg. creati- nine 2.7, with symptoms of a miId uremia. Forty-eight hours Iater a Ieft pyeIostomy was done. The kidney showed muItipIe abscesses on the surface. No urine was passed after the operation and the patient died forty-eight hours Iater.

CASE x. A. B., maIe, aged sixty-two, had right renaI coIic and anuria of two days’ duration. A Iarge tender kidney was palpable. On cystoscopic and roentgen examination no urine was found in the bIadder; the Ieft kidney and ureter were found absent; there was no obstruction in the right ureter and no urine was obtained from the right kidney. A catheter was Ieft in the ureter for twenty- four hours; no urine drained; cystoscopy was repeated in forty-eight hours and the findings were the same as on previous examination. No caIcuIi were seen on x-ray examination and the pyeIogram showed diIated peIvis and caIyces. Symptoms of uremia were quite marked. N.P.N. 63 mg. The kidney was expIored after six days of suppression and was found to be considerabIy enIarged. Two smaI1 caIcuIi were found in the pelvis; a decapsuIation was aIso done. A Iarge quantity of urine drained two hours after the operation and the patient voided spontaneousIy the foIIowing day. Prog- ress was satisfactory for five days; the temperature rose to 106“~. and death occurred suddenIy. The post-mortem examination re- veaIed a severe infection in the kidney with marked degenerative changes. The Ieft kidney and ureter were absent.

CASE XI. I. K., male, aged thirty-eight, had a stone removed from the right ureter ten years ago. Three months ago he had a right nephro- Iithotomy, folIowed five days Iater by a neph- rectomy for secondary hemorrhage. He aIso had a stone in the left kidney at this time. On his Iast admission, he returned because of a Ieft renal colic and anuria of two days’ duration. N.P.N. rose to 86. FoIlowing cystoscopy and the administration of concentrated gIucose solution intravenousIy he voided I IOO C.C. of urine. SeveraI days later the caIcuIus was removed and the patient made an uneventfu1 recovery.

CASE XII. 0. C., maIe, aged fifty-three, had

a caIcuIus removed from the Ieft kidney ten years before and a nephrectomy a short time after for what, he believes, was a renaI infec- tion. He now compIained of right Iumbar pain and oIiguria. Cystoscopy and x-ray examina- tion discIosed a caIcuIus in the right kidney which secreted smaI1 amounts of infected urine. The peIvis and caIyces were considerabiy diIated. The stone was removed through a pyeIotomy incision. Seven days after the operation his temperature rose to IO$F., and he deveIoped a suppression of urine which was not reIieved by an indweIIing ureteral catheter. N.P.N. IOO mg. He showed symptoms of uremia. After forty-eight hours of suppression a pyeiostomy and decapsuIation were done. The kidney had muItipIe minute abscesses on the surface; he drained a Iarge quantity of urine within one hour and was discharged three weeks later.

The accompanying ihustrations are a schematic representation of the findings in each case. There were 5 cases with biIatera1 stones; 2 of these had caMi in the ureters only; one had a caIcuIus in both kidneys and ureters, and in 2 cases there was an obstructing caIcuIus in one ureter and a branching caIcuIus in the opposite kidney. In 5 cases a singIe kidney was present; in one of these the kidney was congenitaIIy absent whiIe in the others it had been removed for caIcuIous disease. Four of these patients had an obstruction at the ureteropelvic junction and in the other the caIcuIus was situated in the lower end of the ureter. In 2 cases there was a single functioning kidney, its mate having been destroyed in Case VII by tubercuIosis and in Case II by infection. These 12 cases occurred in a series of approximateIy 500 cases of caIcuIous dis- ease in the upper urinary tract admitted to Lebanon HospitaI between 1920-1935,

giving an incidence of anuria in 2.5 per cent of the cases. In Rovsing’s series of 589 cases there were 17 cases or an incidence of over 3 per cent. CauIk had 6 in 280 cases. JoIy had one in 197 cases. This seeming high incidence is probabIy misIeading as it does not incIude the vast number of

304 Americnn Journal of Surgery Schwartz-Anuria FEBRUARY, 1936

ambuIant cases which never gain admission to the hospital. In biIatera1 caIcuIi the occurrence of anuria is much higher, probabIy IO per cent, and is stiI1 greater when the caIcuIus is in a congenital or acquired single kidney.

In a11 of the foregoing 12 cases it shouId be noted that the kidneys or ureters, whether one or both were present, were aIways invoIved in some pathoIogic change. When a kidney becomes obstructed aIong its conduction system, suppression very frequently resuIts. This seems to be a natural defensive mechanism to safeguard the kidney against overdistention and prob- abIe injury. The finding of a temporariIy suppressed kidney must not be construed to mean that the kidney is dead and not capable of recovery which generaIly occurs after the obstruction is reIeased. If the other kidney is present and is normaI, it assumes the burden of this temporariIy functionIess and hibernating kidney with- out any disturbance in the weII-being of the patient. In routine cystoscopic ex- amination for uniIatera1 obstructing cal- cuIus, it was rather common to find a temporariIy suppressed kidney. If suppres- sion did not occur, urine secretion wouId continue with a resuItant hydronephrotic kidney. When the remaining kidney be- comes obstructed, as may happen in biIatera1 caIculous disease, then acute cIinica1 suppression ‘supervenes. In those cases with acute suppression incident to biIatera1 caIcuIous obstruction, it is highIy probabIe that in most, of suppression of one kidney preceded that of the other.

Considerable controversy exists regard- ing the reflex inhibition of a normal kidney which may be the result of a caIcuIus obstructing the opposite kidney or ureter. Neuwirt, JoIy and Eisendrath each re- ported a case of refIex suppression of urine caused by a uniIatera1 obstructing caIcuIus, the opposite kidney and ureter being apparentIy normaI. In severa hundred hospital and private patients known to have a caIcuIus in one kidney or ureter, the opposite side being uninvolved, we

have never observed compIete anuria. There are cases reported showing reflex anuria not based on any obstructing Iesion. Harder and Eisendrath each reported a case foIIowing submersion aIthough in the Iatter’s case one kidney was shown to have some anatomic deformity. Rovsing re- ported 3 cases in which anuria occurred after nephrectomy; urine secretion was reestabIished after reIeasing the cIamp Ieft on the renaI pedicIe. We have seen severa patients who deveIoped anuria after being operated upon for such surgica1 lesions as peritonitis, intestinal obstruction, biliary- tract infection and pancreatitis. Because the preoperative examination gave no indication that renaI pathoIogy existed, we naturaIIy regarded this symptom as a reflex phenomenon unti1 the subsequent clinica course or post-mortem examination revealed definite renaI pathoiogy as a basis for this renaI suppression. In those cases reported as reflex anuria no concIusive evidence has been produced to indicate absence of some pathologic process in the upper urinary system. The fact that renal function, determined after urine secretion is restored, seems normal according to routine functiona tests, stiI1 does not precIude the possible existence of some pathoIogic change which may defy detec- tion by known cIinica1 methods. Kidneys showing any pathoIogic change may be susceptibIe to reflex inhibition. Even the faiIure of the x-ray to discIose an opaque shadow suggesting a caIculus is certainIy not suflicient proof that a caIcuIus may not be present. Non-opaque caIcuIi occur too frequently and one must not beIieve that a caIcuIus is not present because the Mm is negative. One must be particuIarIy guarded in the opinion that a refIex anuria is the result of an obstructing caIcuIus on one side, when the opposite kidney and ureter are normal.

In 4 of our cases the caIcuIus did not cast any shadow. In 16 cases reported by Cabot and Iber, 4 failed to show positive x-ray evidence. Because of the Iack of positive roentgen findings of a caIcuIus on

NEW SERIES VOL. XxX1. No. 2 Schwartz-Anuria

both sides, we favored the opinion in Case I that we were dealing with the phenomenon commonIy referred to as renorena1 reflex and reflex anuria unti1 this patient passed a uric-acid stone from the non-operative side. Case 11 was aIs of this type.

Can a caIcuIus on one side cause con- traIatera1 reflex renaI colic? Proof of this is compIeteIy Iacking. With our improved diagnostic methods and carefu1 foIIow-up study more of these cases designated as renorenal reflex pain or reflex anuria beIieved to arise as the resuIt of a uniIatera1 obstructing stone wiI1 uItimateIy discIose some pathoIogic background on the op- posite side.

It was formerly feared that catheteriza- tion of both ureters foIIowed by pyeIo- graphic study might induce reffex renaI suppression. Such instances were reported by Morton, Shapiro, LowsIey and Harbach. We have fortunately never encountered this compIication incident to the trauma produced by the simpIe passage of a catheter, or even after pyelographic study. The cases of traumatic anuria reported by these authors are not instances of traumatic reflex anuria but rather of a renaI suppression caused by a complicating infection as the Iater cIinica1 course or post-mortem study indicated. Legueu studied 31 cases of anuria and found biIatera1 renal pathoIogy in a11 but one patient, whose kidneys he believes might aIso have discIosed some change were they subjected to carefu1 microscopic study. CauIk Iigated a ureter in IOO dogs and faiIed to produce anuria. Gmelin exposed the bIadder, ureter and kidney in dogs and appIied chemica1, eIectrica1 and therma stimuIation without producing any sup- pression of urine. We are incIined to beIieve from our own cIinica1 study of patients with obstructive and non-obstructive anuria and the experimenta work of others that reflex anuria in the presence of norma and un- obstructed kidneys does not exist or is extremeIy rare. Such eminent uroIogists as KiimmeI, Gyuon and Rubritius doubt the

existence of reflex anuria without involve- ment of both kidneys, or a singIe function- ing kidney.

AIthough anuria in itseIf is a symptom of a grave renaI disturbance, its persistence may be accompanied by a train of symp- toms depending upon its duration. The cIinica1 features of these cases may be divided into two stages. In the first, aside from the fact that no urine had been passed for a variabIe period, the patient may be in perfect comfort except for some sIight Iumbar pain or renaI coIic which may have initiated the onset. In IO of our cases renaI coIic preceded the onset of anuria, whiIe 2 patients noted that their voIuntary efforts to void yieIded no urine at first and none was found on catheteriza- tion. In these 2 cases it was the first evi- dence of some lesion in the uroIogic tract. The Iumbar pain or coIic was usuaIIy not of great severity. Marked tenderness, if present, was usuaIIy suggestive of a kidney infection rather than acute hydronephrosis whose absence was generaIIy confirmed at the operating table. The second phase or period of intoIerance is synonymous with uremia, the severity of which depends upon the duration of the anuria. In the 12 cases reported here anuria Iasted from twenty hours to six days, a comparatively short period when compared to twenty to thirty days’ duration in the 19 cases coIIected by Meyers. Cases showing periods of Ionger duration have been reported. AI- though Iong-standing anuria mav be an interesting and amazing spectacIe,‘;t might quite properIy be considered that one has faiIed to appreciate the significance of this symptom and institute proper and timeIy surgica1 measures. Infection has a very deleterious effect and shortens the period of toIerance so that uremic manifestations occur shortIy after the onset of suppression.

When these cases with caIcuIous anuria are first seen, one must immediateIS estabIish the existence of a true suppression and its pathoIogic bases. Any deIay in estabIishing the nature and cause of this symptom wiI1 mean delay in the necessary

306 American Journal of Surgery Schwartz-Anuria FEBRUARY, 1936

surgica1 therapy for the restoration of renaI function. WhiIe the preIiminary investigations are made, Iarge quantities of ffuids shouId be administered through every conceivabIe channe1. A preferred method, which has inffuenced the restora- tion of urine secretion, is the intravenous drip of a concentrated solution of gIucose. The primary object then is to overcome the obstructing lesion. This may at first be accompIished by the passage of a uretera catheter, which may either dis- Iodge a caIcuIus or simpIy pass by it. Under these circumstances a great dea1 might be gained by Ieaving the catheter in for twenty-four to seventy-two hours. This proved of some vaIue in 3 of the cases. If the urine secretion is not restored by these conservative measures within a reasonabIe period, surgica1 intervention becomes imperative. Symptoms of renaI toxemia or a renaI infection precIude any temporizing by fruitIess cystoscopic pro- cedures which usuaIIy cause deIay in the necessary surgery, with the eventua1 fata outcome, as occurred in 3 of our cases. Even though secretion of urine may be reestabIished the remova of a caIcuIus, especiaIIy one too Iarge to pass, is stiI1 indicated in order to prevent recurrence of suppression. Any operative procedure is best toIerated in the interva1 free from azotemia.

At this point it might be worth whiIe to caution against the use of spina anesthesia in uremic patients. One may be confused in deciding which side to operate on when a biIatera1 obstruction exists. Inasmuch as pain is generaIIy present on the Iast side to be obstructed this wiI1 undoubtedIy heIp one in this decision. JoIy stresses this point and beIieves it of considerabIe heIp. If pain cannot be depended upon as a guide, the remova of the obstruction on either side wouId heIp to restore urinary excre- tion. Case I iIIustrates this point.

In addition to the remova of the obstructing caIcuIus, when its Iocation is known, other surgica1 procedures, such as pyeIostomy, nephrostomy and decap-

suIation may be indicated because they may contribute materiaIIy to a successful outcome. In 5 cases pyeIostomy was instituted. This additiona procedure is of particuIar advantage, when infection com- pIicates a caIcuIus in the upper portion of the ureter, or as preIiminary drainage of a badIy infected kidney when the caIcuIus is situated at the ureterovesica1 junction. We cannot too strongIy emphasize the necessity of opening the peIvis as an emergency measure to estabIish drainage, when a suspected caIcuIus cannot be definiteIy Iocated. This procedure is equiva- Ient to enterostomy in acute intestina1 obstruction when the seat of obstruction cannot be Iocated. One might be incIined towards a conservative attitude of watch- fu1 waiting for the natura1 response of the kidney to the appIied therapeutic measures in order to avoid the embarrassment which may resuIt from the faiIure to find the suspected caIcuIus in the event of operation. In Cases II, IX, and x there was, unfortu- nately, unnecessary deIay which undoubt- edIy was the responsibIe factor in the fata outcome. Nephrostomy was more advisable in Case VII on account of a pyonephrosis which, we beIieved, wouId drain more adequateIy through an incision in the kidney.

DecapsuIation suppIemented the re- mova1 of the caIcuIus in 6 cases. Consider- abIe controversy exists as to its vaIue. The appIication of this procedure usuaIIy de- pends upon the pathoIogic state of the kidney as judged from its gross appearance at the time of operation. In obstructive cases decapsuIation aIone cannot be of any materia1 benefit unIess the obstruction is first reIieved. When severe pyeIonephritis is present, as evidenced by muItipIe minute abscesses on the surface of the kidney, or when a subcapsuIar exudate, the resuIt of an advanced pyeIonephritis, is aIready present, decapsuIation may contribute a Iarge measure to the successfu1 outcome. This resuIt, we beIieve, was accompIished by decapsuIation in at Ieast 3 of our cases. Even though infection is not present, the

NEW SERIES VOL. XXXI. No. 2 Schwartz-Anuria American Journal of Surgery 307

marked congestion of the kidney is reIieved, thereby removing the pressure on the secretory renaI substance.

A word might be said in regard to the prevention of renaI suppression. It is not within the scope of this paper to discourse on the prevention of caIcuIus formation but rather to suggest its timeIy remova when it is known to be present and is apt to initiate this serious renaI disturbance. Even when a uniIatera1 caIcuIus is present which, in itseIf, may not threaten the patient with this comphc’ation, it may be a constant source of progressive renaI de- struction and eventua1 Ioss of the kidney at the time when the opposite kidney may aIready be infected or contain a nucIeus for subsequent stone formation. The 4 cases in this group with acquired singIe kidneys were probabIy negIected cases which might have been spared the Ioss of a kidney had they been treated at the opportune time. Patients with a singIe kidney, which is infected or contains a caIcuIus, are notori- ousIy prone to develop renaI suppression. It therefore behooves the surgeon to avoid the unnecessary remova of a kidney when there is even the remotest chance of saving it. Of course, a conservative attitude of Ieaving behind a pus kidney which con- stantIy threatens the opposite good kidney with infection is not a wise procedure. In Case VI, operation was advised because renal suppression was anticipated. The patient, however, preferred cystoscopic treatments given by an enthusiastic cysto- scopist, who skiIfuIIy aided the descent of the peIvic stone which, shortIy after, obstructed the ureter and caused acute urinary suppression.

COMMENT AND SUMMARY

A study of the foregoing cases with caIcuIous anuria wouId indicate that an obstructing Iesion in both ureters or kidneys or a uniIatera1 obstruction with the opposite kidney diseased, or an obstruc- tion in singIe functioning kidney, is essentia1 to the deveIopment of anuria.

When suppression of urine foIIows a uniIatera1 obstructing caIcuIus and no Iesion is found on the opposite side, one must not concIude that a reff ex suppression exists because of the faiIure to find a Iesion on the opposite side which is probabIy present and not detected in spite of our advanced diagnostic aids. Continued care- fu1 observation wiI1 uItimateIy discIose a Iesion. It seems to us that a kidney may be refIexIy inhibited in function when it is the seat of some pathoIogic change or when there is some interference with the proper drainage of urine. We regard caIcuIous anuria as a serious symptom which may often be anticipated; the outcome is favorabIy inff uenced by earIy recognition of the responsibIe Iesion and prompt reIief of the obstruction. Infection is a serious deterrent in the recovery of these patients. When infection in the kidney is present proper drainage and decapsuIation are suppIementary procedures which may be of great benefit after the obstruction has been removed.

REFERENCES

CABOT, H., and IBER, F. C. Anuria. Proc. St& ll/ieet. Mayo Clin., 8: 354, 1933.

CAULK. J. R. Post-renaI anuria. J. Ural., IX: 265. 1026. EISI&RATH, D. Anuria. J. Ural., 25 : qir,;gs 1:. ’ _ GMELIN, E. TierexperimenteIIer Beitrag zur Frage der

RefIektorischen Anurie. Ztscbr. j. urol. Cbir., 21: 182, 1926.

GUYON. Quoted by GmeIin. HOARDER. Quoted by Rubritius. JOLY, J. S. Stone and Calculous Disease of the Urinary

Organs. St. Louis, Mosby, 1929. K~~MMEL. Quoted by GmeIin. LEGUEU. Quoted by JoIy. LOWSLEY. 0. S.. and HARBACH. F. H. Traumatic

anuria. Internat. J. Med. @ Surg., ~5: 305, 1932. MEYERS, W. A. Obstructive anuria. J. A. M. A., 85:

10, 1925. MORTON, H. Temporary suppression of urine foIIowing

doubIe pyeIography. J. Ural., IO: 261, 1923. NEUWIRT. Ein Beitrag zur Therapie der ReRex Anurie.

Ztscbr. j. urol. Cbir., I I : 75, 1922.

RANDALL, A. Pre-renaI anuria. J. urol., 13: 257, 1925. Rovsrxc, T. iiber die Diagnose und Behandlung der

Nierensteine auf Grund Neunundzwanzig Jahriger Erfahrung. Ztscbr. j. urol. Cbir., 12: 358, 1923.

RUBRITIUS, H. Die reffektorische Anurie. Wien. klin. Wcbnscbr., 38: 749, 1925.

SHAPIRO, S. J., and VESSEEN, L. L. Untoward resuIts in biIatera1 pyeIography. J. Ural.. 24: 621, rg3o.