Tr U BaBi 409 MARCE 6, 1926] DIAGNOSIS BY PYELOGRAPHY. r MEDICAL JOUNNAr. :r calyces. The calyces are usually grouped into three maii divisions, named upper, middle, and lower (see Fig. 13, left side). Into each main calyx drain the minor calyces, ON which vary in number. Although this is the usuial groutping DIAGNOSIS BY PYELOGRAPHY.* of the calyces, there are many variations of the normanl which require experience for their recognitioni. For varia- (With Special Plate.) tions of the normal see Figs. 6, 10, and 12 (all left side), BY and 13 (right side). R. J. WILLAN, M.V.O., O.B.E., F.R.C.S.E1NG., The solid part of the kidney is made up of the surround- ItONORARY SURGEON AND LECrRER IN SURGERY TO TIE ROYAL VICTORIA inig outer cortical portion, enclosing an inner i-neduillary INFIRMARY, NEWCASTLE-ON-TYNE. part. The cortical portion does not immediately concern us. The medullary part is an aggregation of PYELOGRAPHY (irU{1Aor, the pelvis; ypa4r', a delinieation) is cone-shaped the radiographic outline of the lhollow l)art of tlle kidney, masses, each mass having its base towards the cortex and each apex projecting a (see Fig. 1). after it has been distended by means of a ureter catheter, into calyx The normnal of the kidney mnst be in mind: with a solution opaque to x Its field of usefulness has position kept rays. to the last and three been widened to such a degree that its aid must be often it roughly corresponds dorsal upper invoked if an exact diagnosis is to be arriived at, not only lumbar vertebrae. for nulmerous lesions of the uirinary tract, but also in The size of the kidney can be approximately gauged by obscure abdominal lesions. building an imaginary solid portion around the renal pelvis some on Pyelography dates from 1906, whlen Voelcker and von and calyces, as demonstrated the pyelogram. Lichtenberg first demonstrated the outlinies of the renal Interpretation of Pyelograms. pelvis and calyces. For several years, however, the value The interpretation of the pyelogram depends primarily of this diagnostic aid was unrecognized, and its populariza- on understaniding (1) that the solid medullary apex i)ro- tion has been largely due to the outstanding work of W. F. jects into the outer end of the tube-shaped calyx (seo Braasch of the Mayo Clinic. Perhaps more difficult than Fig. 9), and (2) that if this tube-shaped calyx is (listended the making of a pyelogram is its interpretation, and it is with fluid such fluid surrounds the solid medullary- apex for our knowledge of the interpretation that urologists are which is projecting into that calyx (see Fig. 1). so particularly indebted to, Braasch. His book on the Normal Pyelogram.-Fig. 3 is reproduced from a normal subject is monumental. pyelogram. If the individual calyces are observed therv will It is now possible to diagnose by pyelograpliy conditions be seen to have cup-shaped outer ends; these show that tho such as pyelitis, pyelonephritis, hydr-oniephlrosis, enal sodium iodide has surrounded the normally projecting-apex ptosis, tubercle, and growth, together with congeniital of the solid renal medullary cone. Normal pyelograimis will cystic kidneys and ureteral stricture. It is also valuable be seen also in Figs. 7, 10, and 13 (all left side). as a means of diagnosis in essential haematuria, in renal Pyelonephritis and Hydronephrosis.-Compare the dia- and ureteral calculus, and in cases of obscure extra- grams (Figs. 1 and 2). Fig. 4 is from an abnormal pyelo- urinary tumour, or in which unusual shadows are seen on gram, where there has been absorption of the solid apex of radiography. the renal pyramids. It will be seen that the outer ends of The principles in the interpretation of typical conditions the calyces (instead of being cup-shaped as in the normal) wlich it is possible to recognize by pyelography will first be are " knobbed." This alteration is due to the absence of given; later, brief descriptions of the history of rlepre- a projecting solid apex (see Fig. 2). Such rounding is sentative clinical cases will be given, each case being indicative of inflammation, and indicates pyeloneplhritis illustrated by its pyelogram, and in some instances accom- with destruction of some portion of the solid renal tissuie; panied by a plhotograph of the pathological specimen an advanced stage of this " knobbing " is seen in lhydro- removed at operation. nephrosis (see Fig. 6). A good x-ray plant is indispensable, and the best results Ptosis of Kidneys.-Patients suffering from renal ptosis are obtained when the combined measures of ureter commonly complain of vague, long-standing abdominal catheterization, followed by radiography, can be carried pains. In these chronic cases a combination of the separate out on the same couch without movinig tlhe patient. results of pyelography and a barium enema will make tlhe Voelcker used a solution of collargol which gave a diagnosis of general visceroptosis.' Kinks and twists in the good shadow, but occasionally it damaged the kidneys; ureter are common in renal ptosis (see Fig. 13). Their therefore thorium nitrate was substituted, but this discovery by pyelography may or may not be of moment; sometimes had the same deleterious effect, though to it entirely depends on the presence of " cupping " or a lesser degree. Sodium bromide, 25 per cent. solution,, " knobbing " in the minor calyces. " Cuppilng " indicates was found by Weld to give an excellent shadow; it medical treatment, for there is no back pressure; " kinob- was cheap, and did not cause any real damage. bing " means back pressure due to obstruction, and It, however, in some cases cau.sed an acute temporary nephropexy may be required to straighten out the ureter irritation of the mucous membrane of the urinary tract. and ensure a free onward flow of the urine. I now use a 131 per cent. solution of sodium iodide, as Congenital Cystic Kidneys.-In a congenital cystic kidney recommended by Cameron; I have never known it cause there is a general enlargement of the organ, which is shared inconvenience, either local or general, to the patient, and by the hollow part-that is, the pelvis and calyces (see it is easily sterilized. Fig. 5). The knowledge is used inl diagnosing th;is condi- The sterilized wlution can be run into the renal pelvis tion by pyelography. The disease is always bilateral, but either by gravity or by means of a syringe. It must be one kidney is in a more advanced stage of disease than tlho done carefully, so as to avoid overdistension with the other-that is, one is usually the larger. When only one resultant renal colic; at the saiime time sufficient disten- enlarged kidneyt is felt, it might be mistaken for growth sion must be achieved, otherwise ani incompletely filled or hydronephrosis; and the surgical removal of a con- pelvis or calyces may give a misleading picture. Where- genital eystic kidney is usually fatal from uraemlia. ever possible ureters should be catheterized without a Recently a patient was sent to me with two enormous general anaesthetic; a pyelogramn slhould niever be made tumours occupying the whole abdomen. It was thought to when the patient is unconscious, for to do so invites disaster be possibly a case of miialignant ovarian cysts, and operationi by rupturing the renal pelvis from overdistensions. was desired. Fortunately pyelography provided a definito Anatomical Points. diagnosis of congenital cystic kidneys, and a useless risky To appreciate a pyelogram the gross elementary aniatomy laparotomy was avoided. of the kidney must be borne in mind-namely, that the Tubercilosis.-The characteristic tendenev of tubercle kidney comprises solid and hollow portions. anywhere in the body is for it to undergo caseation and part of the kidney consists of the funinel- disintegration, when the contents are discharged, thus The hollow leaving a cavity. In the case of a disintegrating kidney shaped pelvis, into which drain tho cylindrical-shaped focus the tuberculous debris escapes into the nearest calyx * Given to the students at the Royal -Victoria Infirmary and is voided down the ureter with the urine. Thereform3 on-Tyne, on December 9th, 192a.r e s [34011 DIAGNOSIS BY [ TR BRTiss 410 MARCH 6, 19261 PYELOGRAPHY. I MEDICAL JOUsMti when making a pyelogram, the sodium iodide injected with slight haematuria. Recently he had had rigors, intense thirst, frontal headaches on awakening in the and had through t-he ureteral catheter escapes fromi the calyx into morning, lost weight. On examination both kidneys were enlarged, cavity situated in the solid movable, the disintegrated tuberculous and tuberose, especially the left-sided one. The urine of low part of the kidney; the sodium iodide has escaped the specific gravity and contained pus. normal confines of the hollow and has " run amok" Pyelography (see Fig. 5) showed general uniform enlargement calyx of the pelvis and calyces of both kidneys, particularly the right. in the solid part of the kidney. A tuberculous pyelogram The clear definition of the pelvis and calyces outlines excluded in connexion with one or a shows, ther efore, a blurring tuberculosis, growth, and . hydronephrosis, and confirmed more calyces, according to the extent of the tuberculous diagnosis of congenital cystic kidneys. disintegration (see Fig. 8). Hypernephroma.-A hyperllephroma usually invades one CASE iv.-Exainple of Tuberculous Kidney. Mary K., aged 20, for some years had occasional pain behind or kidney when it involves at least one other pole of the the left kidney. Six months prior to admission she began to lhave main calyx. Depending on the extent of the lesion, the mild attacks of renal colic associated with strangury, but with resultant pyelogram may show one or two normal calyces haematuria on one occasion only.N She had lost weight and was only, while the third main calyx is absent; and the pyelo- tr-oubled with night sweats.