9 Section ofRadiology 419 often transitory, it can readily be reproduced by In 200 consecutive pyelograms, analysed both instructing the child to hold back urine and we by congenital heart lesion and urinary tract now believe that this is a common variation of the abnormality, the incidence of abnormal pyelo- normal. It is probably due to distension of the grams was 13 %. The range ofabnormality in both thin-walled proximal urethra, the less distensible is very wide. Pyelogram abnormalities in this bladder neck and distal urethra forming two series and subsequently have included failure of relatively narrow segments. maturation of kidney with pelvis lying intra- renally, solitary kidney, chronic pyelonephritic A 'corkscrew urethra' has been seen in 4 boys kidney, large kidneys, renal rotation, hydro- in this series. It may be associated with reflux. nephrosis, absence of renal pelves, duplication of Cystoscopy and urethroscopy has been normal kidney and ureter (one having a pyelonephritic and in one patient recordings of pressure and lower segment and evidence of vesicoureteric flow were also normal. We can only assume that reflux - Williams 1962), hydroureter and spinal this appearance is produced by redundant folds defects with neurogenic bladder. Factors affecting of mucosa; certainly there has been no evidence cardiac development may affect organogenesis in of obstruction in any of our cases. the urinary tract. The rubella virus was the defined factor in a patient, aged 4 months, with patent Summary ductus arteriosus, pulmonary hypertension and Micturating cystograms carried out in 232 pneumonitis and a miniature left kidney (autopsy children presenting with urinary infection, but proof). after control of the infection, demonstrated a number of abnormalities in the lower urinary Coarctation ofthe aorta: Four of 10 patients have tract. Reflux was present in 34 5 % but in none an abnormal pyelogram. The only patient with of these cases was there convincing evidence of abdominal coarctation has a small left kidney bladder neck obstruction. We now believe that whose renal artery arises below the coarctation the 'spinning top' urethra is probably a normal and a large right kidney with a renal artery variant and bladder neck obstruction is a rare arising above. This has a parallel in the experi- condition in childhood. mental study of Selye (1950): he ligated the aorta between the two renal arteries producing the REFERENCES 'endocrine kidney' and malignant hypertension. Cox C E & Hinman F (1961) J. Urol. 86, 739 Edwards D (1964) In: Recent Advances in Radiology. 4th ed. Among the other 3 patients are a proven solitary Ed. T Lodge. London; p 187 kidney, a left hydronephrosis with a small left Keitzer W A & Benhaven C (1963) J. Urol. 89, 384 Lyon R P & Smith D R (1963) J. Urol. 89,414 renal artery and a rotated kidney, one of two Stephens F D (1963) Congenital Malformations of the Rectum, large kidneys. Anus and Genitourinary Tracts. Edinburgh & London; p 244 Williams D I & Eckstein H B (1965) Brit. J. Urol. 37, 13 Williams D I & Sturdy D E (1961) Arch. Dis. Childh. 36, 130 Experimentally, Scott & Bahnson (1951) showed that hypertension in coarctation is likely to be of renal origin. A fall in blood pressure does not invariably follow a successful resection ofcoarctation. Dr A R Chrispin Tetralogy of Fallot, right-to-left shunt, pyelo- and Dr J G Lillie nephritic kidney: Patients with the tetralogy are (The Hospitalfor Sick Children, older than most examined. Of about 80 patients Great Ormond Street, London) with the tetralogy, 4 have chronic pyelonephritic kidneys (criteria Braasch 1938, and Williams The Pyelogram Following Angiocardiography 1958). The lesion is in the right kidney only in 3 in Children with Congenital Heart Disease and in both kidneys in one. This is a preliminary communication based on In the tetralogy there is a right-to-left shunt at 500 pyelograms done after angiocardiography. ventricular level and a reduced pulmonary blood Five to fifteen minutes after injection of contrast flow. Passage of bacteria direct from the systemic medium for angiocardiography an exposure of venous into the systemic arterial circulation has the urinary tract has been made routinely. been held to account for the high incidence of Occasionally, further films have been needed cerebral abscess. Normally, the largest single after several hours. This study cannot give a fraction of left ventricular output (rather more comprehensive survey of the urinary tract in than a quarter) passes to the kidneys. Hamo- patients with congenital heart disease. Autopsy dynamically the tetralogy predisposes to a renal results differ (Mehrizi 1962). infection. One of the 4 patients had a cerebral 420 Proceedings ofthe Royal Society ofMedicine 10 abscess when aged 11 months. Three have had Dr I Kelsey Fry, Mr J A McKinna, no urinary symptoms. One with a pyelographic Dr G Simon and Mr P J G Smart sign of vesicoureteric reflux (striation of the renal (St Bartholomew's Hospital, London) pelvis) has had a number of urinary infections. It would appear that renal infection has passed Some Observations on the Lower Urinary Tract undetected in 3 patients and in the fourth has in Infants with Spina Bifida Cystica resulted in a kidney susceptible to recurrent infections and vesicoureteric reflux. The parallel There are numerous descriptions of the clinical with the experimental work of De Nevasquez features and radiological appearances in infants (1954) is close: in rabbits, he injected intra- with spina bifida cystica (Williams 1956, Nash venously first staphylococci then Esch. coli 1957, Roberts 1962, Smith 1965). Most accounts producing a typical pyelonephritic kidney. refer mainly not to infants but to older children Hodson & Wilson (1965) liken the pyelonephritic in whom the underlying pathology has often been lesion to renal tuberculosis. Colby (1959) notes modified by the effects of obstruction and renal tuberculosis as a blood-stream infection. infection. Because of this we have studied a group of 16 infants between the ages of 3 weeks and 1 Kincaid-Smith (1955) showed an association year. They form part of a larger series of more between pyelonephritis and vascular occlusion. than 70 children with spinal palsy. These 4 patients had polycythaemia. It may be We have visualized the lower urinary tract by that the tendency to vascular occlusion is thereby cystourethrography with simultaneous cysto- accentuated resulting in the heavy scarring seen. metry using an aneroid manometer to assess Smith (1962) has shown that renal infarction and bladder contractility. scarring does not ordinarily lead to the caliectasis Two types of cystometrographic pattern were shown in these 4 patients. His study was ap- seen. Ten children had an 'automatic' type of parently concerned with adult patients (one of response (Fig 1), similar to that in normal infants, the two described being 83 years old) in whom but differing from normal in that bladder natural renal growth has ceased and a reduced renal blood flow is likely. In childhood the 120 abnormal pyelogram resulting from developing pyelonephritis is due partly to the pyelonephritic E100oo Automatic lesion and partly to growth and hypertrophy in competent renal tissue. Therefore, Smith's study f 80 is of uncertain relevance to the situation in child- hood. = 60 Y 40 The notion that pyelonephritis is a blood- stream infection is not new (Rosenheim 1954). 20 In infancy a potential right-to-left shunt via the foramen ovale is present for many months. The - 0- . .U incidence of urinary infection at this age does not 0 20 40 60 80 100 120 show the marked female predominance of later VOLUME ml childhood (Stansfeld 1954) and lower urinary tract factors may be less important in infancy. Acknowledgments: We are indebted to our clinical colleagues for their considerable help in the analysis. REFERENCES Braasch W F (1938) J. Urol. 39, 1 Colby F H (1959) Pyelonephritis. Baltimore; p 33 De Nevasquez S (1954) Proc. R. Soc. Med. 47,629 Hodson C J & Wilson S (1965) Brit. med. J. ii, 191 Kincaid-Smith P (1955) Lancet ii, 1263 Mehrizi A (1962) J. Pediat. 61, 582 Rosenheim M L (1954) Proc. R. Soc. Med. 47,628 Scott H W jr & Bahaon H T (1951) Surgery 30, 206 Selye H (1950) The Physiology and Pathology of Exposure to Stress. Montreal; p 540 Smith J F (1962) J. clin. Path. 15, 522 Stansfeld J M (1954) Proc. R. Soc. Med. 47,631 Williams D I (1958) Urology in Childhood. Berlin; p 148 Fig l Cystometrogram and radiograph from a boy aged (1962) Postgrad. med. J. 38, 520 10 months. The bladder is contracting.