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Use of ultrasonography to examine the urinary bladder, including assessment of its distension in suspected urinary retention.

Poisoning by belladonna characteristically combines delirium with dry secretions and dilated pupils; poisoning by hydrocyanic acid can cause very rapid collapse with failure of breathing. The two patterns are distinctive descriptions, not infallible diagnoses from one symptom.

With belladonna, expect dryness of the mouth and throat, difficulty swallowing, blurred vision and mydriasis. The skin may become hot, dry and flushed; the pulse is often rapid. Restlessness, confusion, visual hallucinations and agitated delirium may be prominent: the person may talk incoherently or pick at imaginary objects. Reduced intestinal activity and urinary retention can accompany the dryness. Severe poisoning can proceed to seizures, depressed consciousness, coma and circulatory failure. This is now understood chiefly as an antimuscarinic poisoning syndrome produced by alkaloids including atropine, which oppose the action of acetylcholine at muscarinic receptors.^[ref]

Hydrocyanic acid is hydrogen cyanide, historically also called prussic acid. Depending on the route and amount, early complaints may include dizziness, headache, anxiety, nausea, weakness and a sense of suffocation. Rapid breathing may give way to slow or failing breathing, followed by seizures, coma, circulatory collapse and death. A sufficiently large exposure may be so rapid that an elaborate sequence of preliminary symptoms is not observed. There is no single obligatory interval from exposure to collapse.^[ref]

In modern terms, cyanide impairs cellular use of oxygen, including inhibition of cytochrome c oxidase in cellular respiration. An apparently oxygenated colour therefore cannot exclude serious poisoning. A bitter-almond odour is an unreliable clue: it may be absent or not perceived, and no examiner should intentionally smell a suspect sample. The historical term “narcotic poison” does not mean that either belladonna or hydrogen cyanide acts like an opioid. The receptor and cellular explanations above are present scientific interpretations, rather than molecular explanations available in 1864.^[ref]

Relieve urinary retention promptly and gently, while distinguishing transient spasm from a fixed urethral stricture or another obstruction. The historical label spasmodic urethral stricture describes a functional component of obstruction; it does not prove that the urethra contains a permanent fibrotic narrowing.

Ask about the onset, previous attacks, instrumentation, injury, discharge, medications and previous difficulty passing urine. Examine for a distended painful urinary bladder, infection and trauma. Current bladder ultrasonography can confirm retention and estimate distension without repeatedly attempting instrumentation. A history of easy passage at other times may support a transient component, but neither that history nor failure to pass a catheter excludes an underlying anatomical lesion.

For the 1864 therapeutic framework, reassurance, warmth, a warm bath and relief of pain were intended to relax muscular spasm. An earlier clinical account documents opium and the warm bath, while warning that the bath was unreliable.^[ref] Period use of opium belongs to that historical account; it must not be assumed to be harmless, since opioids can themselves contribute to urinary retention and sedation. Such measures should not postpone drainage of a persistently overfilled urinary bladder. A lubricated catheter, handled by a skilled operator, should be advanced gently rather than forced through resistance. Producing bleeding or a false passage can convert an initially functional problem into substantial injury.

Current guidance calls for immediate catheterisation in acute urinary retention, with attention to contraindications and the cause. Suspected urethral trauma, major resistance or repeated failure calls for specialist help, not escalating force. Depending on the findings, guided urethral catheterisation or suprapubic catheterisation may be appropriate. The latter requires a suitably localised distended urinary bladder and assessment of contraindications; it is not an instruction for blind puncture.^[ref][ref]

After decompression, address the precipitant: infection, painful local inflammation, medication effects, a fixed urethral stricture or another outlet disorder. Recurrent attacks merit investigation rather than repeated labelling as spasm. An incision or a course of repeated forceful dilatation is not justified merely by the word spasmodic. ^[ref] The principle common to the historical and modern reasoning is to remove the obstruction with the least injury; modern assessment makes the anatomical and infective distinctions more reliable.

Suspect uterine retroversion from examination and the clinical setting, while distinguishing an incidental position from symptomatic disease or an incarcerated pregnant uterus. Pelvic pressure, backache, painful menstruation, pain with intercourse, difficulty voiding or rectal pressure can prompt assessment, but none proves that the uterine position is the cause.

In retroversion the uterus tilts backwards as a whole; uterine retroflexion instead describes bending between its body and cervix. The two can coexist. On an appropriate pelvic examination, the uterine body may be felt posteriorly while the cervix points more anteriorly. Mobility, tenderness, a pelvic mass and the possibility of pregnancy affect interpretation. Symptoms may come from associated endometriosis, adhesions or another pelvic disorder rather than the tilt itself.^[ref]

The especially important historical presentation is early or mid-pregnancy with increasing pelvic pressure and urinary retention. An enlarged backward-lying uterus can remain trapped beneath the pelvic brim, distorting the cervix and bladder outlet. Dribbling urine can represent overflow from retention, not adequate emptying. A distended urinary bladder and a posterior pelvic mass require careful assessment rather than treatment with a diuretic. A pre-1866 account of retroversion after conception emphasized retention as a principal presenting problem.^[ref]

Historical treatment aimed first to empty an overdistended urinary bladder with a catheter, then to restore position where appropriate and prevent recurrence, sometimes with positional measures or a vaginal pessary. A fixed, painful or possibly pregnant mass made blind forceful manipulation particularly hazardous. Describing the aim of a period manoeuvre does not make repeated unassessed attempts at repositioning acceptable.

Modern correction: an asymptomatic retroverted uterus commonly needs no treatment. Symptoms call for investigation of their actual cause; retroversion alone does not establish infertility or explain every miscarriage. For selected symptomatic mobile cases, conservative support or a fitted vaginal pessary may be considered, while associated disease is managed on its merits.^[ref] Suspected incarceration in pregnancy, especially with urinary retention, needs urgent obstetric assessment. Ultrasonography can clarify the anatomy; magnetic resonance imaging may help when the relation of the uterus, urinary bladder and cervix remains uncertain. Drainage of the urinary bladder and any attempt at reduction are specialist decisions guided by gestation, anatomy and complications. Published evidence is largely case reports and series, so a single successful method is not a universal rule.^[ref]

Historical description of transient functional obstruction attributed to muscular spasm. It must be distinguished from a fixed fibrotic urethral stricture and from other causes of urinary retention.