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 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 ; 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 , 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 . 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, , 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 .-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. (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 may be required to straighten out the ureter irritation of the of the urinary tract. and ensure a free onward flow of the . 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 ; 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 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 . 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. Examination disclosed tenderness and rigidity over the left kidney, but neither kidney could be pal- gram has the appearance as if the calyx had been pated. On vaginal examination the thickened terminal portion of amputated (see Fig. 10). the left ureter could be felt in the left lateral fornix. Essentiail Haematuria.-From time to time a surgeon is showed ulceration around the left ureteric orifice, which masked the the opening so much that its catheterization was a matter of asked to see a case of painless haematuria. Where considerable difficulty. physical signs, apart from the nion-ipurulent haematuria, Pyelography showed a typical tuberculous left kidney: a definite are negative, the case may be one of considerable anxiety. diagnosis of tubercle linmited to the upper half of the kidney was made, and a nephrectomy was done on February 12th, 1925. Cystoscopy may disclose a n-orm-lal bladder, also evidence patient made an uninterrupted recovery. The pyelogram (see from which kidney the patient is bleeding. Among otlher The Fig. 8) sliows a normal main lower calyx, the upper and middle things, the bleeding inay proceed from a malignant kidney, calyces, however, have lost their definition and have a " fluffy or it may be a case of essential haematuiria. The fact that appearance. This made possible the diagnosis of tuberculosis limited to the upper half of the kidney. On reference to the cut a does not necessarily the patient is bleeding from kidney surface of the removed specimen (see Fig. 9) the tuberculous will demand exploration or nephrectomy, for pyelography ulceration and cavitation is seen in the upper half of the kidney, help in a diagnosis. If the urinary tract x-ray shadows and is particularly in communication with the upper main calyx. can it projects the and pyelogram are normal; if the ureteral catheter end is The lower normal main calyx be seen, and into in the renal pelvis of the affected side and the urine with- normal apex of a medullary cone. drawn contains blood; if the blood pressure is normal; if CASE V.-EAxanple of Malignan t Growth. the urine is free from pus and renal casts; and if the T. G., aged 59, male. Six weeks before admission there was pro- fuse painless haematuria immediately after having lifted a heavy haematuria has been long-standing-then the painless weight; there were no clots. This painless bleeding was the only correct. diagnosis of essential haematuria will probably be symptom; it was intermittent, and occurred on six occasions prior Suclh a diagnosis can only be arrived at bv pyelography. to admission. Except for this the patient was in excellent healtl If the pyelogram is at all suspicious it should be repeated in every way. On admission his urine contained bright red blood; no other abnormal could be but cystoscopy two physical sign elicited, after an interval, when a careful comparison of the showed blood trickling out of the right ureteric orifice. pictures should be made. Pyelography disclosed a normal left-sided pyelogram with an Urinary Calculus.-A uric acid calculus which may not abnormal right-sided one. A definite diagnosis of malignant right kidney was made and a nephrectomy was done. The patient throw an x-ray shadow will sometimes do so after distending made an uninterrupted recovery and has now returned to his opaque solution the renal pelvis and allowing part of the work as a coal miner. The abnormal pyelogram (see Fig. 10) is to drain away; some of the solution may adhere to the hooked at its upper end with a large oval shadow at the calculus and cast a shadow. extremity, the oval shadow corresponding to a calyx. The absence Ureter.-Extraureteral of the otlier calyces (they had been cut off) with the renal dis- Shadows near the Line of the tortion sufficed to convince me that I was dealin with a hyper- shadows can be differentiated by ureterography during nephroma which had destroyed at least half of t e kidney. The pyelography, owing to the presence of some sodium iodide cut surface of the specimen remcved at operation (see Fig. 11) in the lumen of the ureter. shows that the lower two-thirds of the kidney has been replaced by gr owth, and that the dilated renal pelvis was also occupied by malignant growth. The injected sodium iodide had tracked up ILLUSTRATIVE CLINICAL CASES. between the growth and the upper margin of the pelvis, to reach CASE I.-Pyelonephritis. the normal calyx in the upper pole of the kidney. " M. W., aged 30, had right flank pain for ten years and occa- Microscopically, Professor Stuart McDonald reports: This is a sionaj y it was accompanied by vomiting. Nine months earlier typical hypernephroma, portions of which are distinctly adeno- There which the *pendix had been removed without giving relief to symptoms matous. is extensive necrosis of the tumour growth, Physical examination showed a tender spot behind the right kidney is of definite infiltrating type." and the urine contained pDus cells microscopically. Pyelography (see Fig. 4) showed " knobbing " of the calyces of CASE vI.-Example of Abdominal Tumour. the right kidney without dilatation of the pelvis or calyces, Mrs. W., aged 42, was sent to me for pain in her left side enabling a diagnosis of chronic pyelonephritis to be made. A which limited full inspiration; she had had haematuria of sliglit bacteriological examination of the urine gave a pure culture of degree, but without frequency. A large tumour occupied her left staphylococcus, and vaccine treatment was recommended. ileo-costal space, which was justifiably taken to be an enlarged kidney. Her bowels were regular and she was not losing weight. CASE n.-Hydroncphrosis. On examination a large tumour could be felt in the upper part Annie L., aged 15, for some yeals lhad attacks of right-sided of the left ileo-costal space; it was dull on percussion, and this renal colic, associated with increased frequency of micturition. On dullness was continued posteriorly to the middle line. The urine one occasion only had there been haematuria. Her urine con- contained pus and blood; the blood examination 6howed a lympho- tained pus and albumin. There was tenderness behind the right cyte leucocytosis. Cystoscopy revealed an acute cystitis. had kidney, but neither kidney was palpable. Nothing abnormal was Pyelography (see Fig. 12) demonstrated that the left kidney disclosed in the rest of the abdomen or on rectal examination. been displaced downwards so that the hilum of the organ, instead The double pyelogram (see Fig. 6) shows a normal left renal of pointing medially, was pointing towards the iliac f?ssa. The pelvis and calyces, and an enlargement of this (see Fig. 3) is upper part of the ureter forms an acute angle with the lower used as my example of a normal pyelogram. It also shows marked portion. If an imaginary line be drawn above the shadow thrown hydronephrosis on the right side, both pelvis and calyces being by the renal pelvis and upper part of the ureter, the size of the involved. If it is carefully observed the grouping into the three splenic tumour can be gauged. typical main calyces can be seen-namely, upper, middle, and lower; further, there is an advanced degree of " knobbing " of the CASE viI.-Ureter Kink. minor calyces, due to the atrophy of the solid part of the renal Janet R., aged 30, complained of haematuria on a single occa- tissue. This is a further stage of pyelonephritis (see Fig. 4). If sion, followed by acute pain behind the right kidney, but without the photograph of the cut surface of the removed kidney (see increased frequency of micturition. When seen there were no Fig. 7) be compared with the pyelogram the points mentioned can abnormal physical signs. Cystoscopy showed a normal bladder. be confirmed-namely, the dilatation of the pelvis and calvces; Pyelography showed a ptosed kidney with a knot in the upper the arrangement of the three main calyces (each marked by a part of the ureter (see -Fig. 13). The renal pelvis and calyces short piece of wire); and the marked thinning of the solid part were normal, whicll is a definite indication that there was no of the renal tissue, with the disappearance of the apex of all obstruction to the onward flow of urine. The haematuria renal pyramids. The liydronephrosis was due to a stricture at the reniained unaccounted for. A year later the patient was well and outlet of the renial pelvis. The patient made a good recovery had had no return of her symptoms. after nephrectomy. Some of the pyelograms reproduced with this paper were made CASE IIT.-Congcnital Cystic Kidneys. in a private hospital. I am indebted for the otlhers to the H. S., male, aged 28, for soine months had been suffering from physician in charge of the radiography department of the Royal typical attacks of right-sided renal colic. There had been Victoria Infirmary, Newcastle-on-T.yne. r Ts Brm MARCH 6, Igz6 A. J. WILLAN: DIAGNOSIS BY PYELOGRAPHY. I MCDIL JOURWAS.

1 2 FIG. 1.-Diagram of section of normal kidney. Note the conical apex projecting into the calyx, producing the normal " cupping " of the calyx in a pyelogram. FIG. 2.-Diagram representing pyelonephritis. Note the disappearance of the conical apex, thereby producing " knobbing " of the calyx in a pyelogram. FIG. 3.-Normal Pyelogram. To illustrate the "cupping" on the minor calyces. !

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FIG. 4.-Pyelonephritis Pyelogram. Shows the " knobbing " of the minor calyces due to absorption of the renal pyramid apices.

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....r. 93_... FIG. 6.-Hydronephrosis Pyelogram. See dilatation of the FiG. 7.-Hydronephrotic Kidney. Shows dilatation of renal pelvis right renal pelvis and grouping of the three main calyces, and calyces; thinning of the solid part, with disappearance of the with marked " knobbing " of the minor calyces. Fig. 7 is the pyramid apices; stricture of the pelvic outlet. The three main specimen relating to this pyelogram. calyces are each indicated by pieces of wire. (Cf. Fig. 6.) r THz BRITIsN MARCH 6, x926] R. F. WILI,AN: DIAGNOSIS BY PYEI.OGRAPHY, I MZDIcAL JOURNAL _i_ i:iEWexmmssSSs,. e...''.| :::. i ::: ss...... _ ,S'0:.'0 _S 1 | I |L. ,,,.sgs, !! X | | S-I|-iiisa111 ita§F-- jlS>-Sm0W"d W1 R 111 l IW _|1 - 11 | 1111 _L: l62L ' E r:

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FIG. 9.-Tuberculous Kidney. Note tuberculous ulcera- tion and cavitation in upper half of the kidney, also lack of outline of the upper and middle calyces. Note also normal lower main calyx, with a pyramid apex projecting into a calyx. (Cf. Fig. 8.) rIG. B.-Tubercuious idaney ryelogram. Note lack of ail denni- tion of the upper and middle main calyces; the lower main calyx is normal. Fig. 9 is the specimen relating to the pyelogram.

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FIG. 10.-Malignant Kidney Pyelogram. Note normal left FIG. l1.-Malignant Kidney Section. The upper main calyx is pyelogram with filling defect right side, where only one main the only one to be seen; the others have been " amputated " by calyx can be recognized, and that indistinctly. Fig. 11 relates growtth. Note growth in renal pelvis, also in lower two-thirds of the to the removed specimen.';:.:'let'',,::,w~~~~~~~~~~~~~~~~~~~~~~~...... ,.:; kidney. (Cf. Fig. 10.)

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FIG. 12.-Kidney displaced by Splenic Tumour. There is an angulation of the ureter, the horizontal part of which, together FIG.; 13.-Ureter Knot. Shows a knot in the upper end of the with the kidney, is displaced downwards by a splenic tumour. The ureter in a ptosed kidney. There-is no " knobbing " of the calyces convexity of the kidney is displaced towards the left iliac fossa. -that is, there is no obstruction to the urine flow.-