Utfnmtt Stbrarg Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/pyelographypyeloOObraa PYELOGRAPHY (Pyelo-Ureterography) A STUDY OF THE NORMAL JND I'.ITIIOLOGIC JN.ITOMV Of THE RENAL PELIIS .JND CRETE R BY WILLIAM F. BRAASCH, M.D. MAYO CLINIC, ROCHESTER. MINNESOTA CONTAINING 296 PYELOGRAMS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1915 Copyright, 1915, by W. B. Saunders Company 3-T PRINTED IN AMERICA PREFACE It is now almost ten years since Voelcker and von Lich- tenberg first succeeded in demonstrating by means of pyel- ography the outline of the human renal pelvis and ureter. This method, which was at first disregarded, has been recently more fully developed and appreciated. In all this time no comprehensive collection of the various types of pelvic out- line has been published. The interpretation of the great variety of pelvic deformities outlined in the pyelogram is difficult and is possible only through familiarity with the various types. The publication of a series of plates em- bodying many of the different outlines of the pelvis and ureter seen in routine pyelography would seem to be of some practical value. With this end in view I have selected a number of plates from the several thousand made at the Mayo Clinic during the past five years, trusting that these, together with their description and comments, may increase the value of the method and permit the more general usage which it deserves. I wish to acknowledge my indebtedness to Drs. William J. and Charles H. Mayo for placing at my disposal the clini- cal material for this monograph; to Dr. A. B. Moore and Mr. E. L. Taylor, of the roentgenographic department for making the original radiographic plates ; to Dr. Franz Wild- ner for assistance in the compilation of data; to my asso- ciates, Drs. G. J. Thomas and J. L. Crenshaw, for assistance in the development of the technic; and to Mrs. M. H, Mellish and staff for assistance in compiling the literature, editing, and proof-reading. William F. Braasch. Rochester, Minn. March, 1915 13 CONTENTS CHAPTER I The History of Pyelography 17 Bibliograph}' 32 CHAPTER II Technic 36 CHAPTER III The Normal Pelvis 44 CHAPTER IV Abnormal Position r 79 Movable Kidney . 79 Torsion of the Kidney 94 Dystopic or Pelvic Kidney 95 CHAPTER V Mechanical Dilatation 98 The Pelvis — Hydronephrosis 98 The Ureter — Hydro-ureter 135 CHAPTER VI Inflammatory Dilatation 145 The Pelvis— Pyelitis 145 The Ureter — Ureteritis 166 Renal Tuberculosis 172 CHAPTER VII Renal Stone 183 Shadow Identification 183 Shadow Localization 192 Gall-stones 216 15 16 CONTENTS CHAPTER VIII Ureteral Stone 227 CHAPTER IX Renal Tumor 252 Renal Neoplasm 252 Tumor of the Renal Pelvis 276 Extrarenal Tumor 277 Polycystic Kidney 278 Solitary Cyst 285 CHAPTER X Congenital Anomaly 289 Duplication of the Renal Pelvis 289 Duplication of the Ureter 301 Fused Kidney 306 Congenital Large Pelvis 309 Bibliographic Index 315 Index of Subjects 317 PYELOGRAPHY CHAPTER I THE HISTORY OF PYELOGRAPHY Probably the first attempt to render the urinary tract opaque to the x-ray was made by Tuffier ^ in 1897. He suggested the simultaneous combination of an opaque ureteral catheter and radiography. Schmidt and Ko- lischer," in 1901, independently suggested the same method and published radiograms which showed the course of the ureter and the situation of the renal pelvis by means of a fused wire inserted into the ureteral catheter with simultaneous radiography. They developed the possibili- ties of this method and demonstrated its value in vari- ous conditions. In 1901 Lowenhardt ^ described somewhat similar methods, as did also von Illyes ^ the following year. In 1905 Fen wick ^ suggested for the same purpose the use of a ureteral bougie with its walls impregnated with metal. These methods were the forerunners of the use of Uquid solutions opaque to the :c-ray for the purpose of rendering the outline of the ureter and renal pelvis visible in the radiogram, a method which has been called pyelography or, to be more exact, pyelo-ureterography. The development of the history of pyelography may be considered from the following standpoints: (1) Technic; (2) diagnostic data; and (3) accidents arising from its use. Technic. — Probably inspired by his ability to outline the alimentary tract with bismuth, Klose,*' in 1904, sug- 2 17 18 PYELOGRAPHY gested the injection of an emulsion of bismuth into the pelvis and the ureter with simultaneous radiography. This method failed, however, because the resulting shadow was uncertain, and it was found difficult to remove the particles of bismuth w^hich adhered following the injection. It remained for Voelcker and von Lichtenberg,^ in 1906, first to demonstrate successfully the complete outline of the ureter and renal pelvis in the radiogram. They were the first to suggest the use of colloidal silver (collargol) for this purpose. In attempting to outline the bladder in the radio- gram it was discovered in one of their plates that the solu- tion had entered the ureter and renal pelvis also, causing them to be outlined in the radiogram. Encouraged by this discovery, they injected a 2 per cent, solution, and later a 5 per cent, solution, through the ureteral catheter into the pelvis of the kidney and were able to report the results of a successful series of pyelograms. The value of this method was slow to be recognized, and, consequently, received but little attention until three or four years later. Within the last three or four years, however, the method has received wide-spread recognition, and is at present extensively em- ployed. Various other forms of colloidal silver have been sug- gested by some observers. Ai-gyrol, in solutions of 40 or 50 per cent., was advanced by Keyes ^ in 1909; silver oxid or cargentos, by Uhle and Pf abler ^ in 1910; nargol and electrargol, by others, ^"arious solutions other than colloidal silver have been advocated. In 1913 Doderlein and Kronig ^° suggested the use of xeroform (15 to 20 per cent, in olive oil). Attempts were made to render the out- line of the pelvis and ureter visible by means of injecting gas instead of liquid solutions. Bm'khardt and Polano,^^ THE HISTORY OF PYELOGRAPHY 10 in 1907, first suggested injecting oxygen into the pelvis for this purpose. In 1911 von Lichtenberg and Dietlen '- reported a series of pyelograms made with the use of oxy- gen, and recommended its substitution for colloidal silver. However, the use of the gaseous medium did not receive wide-spread recognition, since the resulting outline was frequently uncertain and hard to differentiate from that of gas in the bowel. The use of an emulsion of silver iodid was suggested first by Uhle and Pfahler.^ Recently Kelly and Lewis ^^ (1913) have also recommended it and demon- strated a series of pyelograms where it was used to ad- vantage. They claim that it cast as good a shadow as colloidal silver, without causing any of the ill results which have been reported to follow the latter. The various solutions had usually been injected into the renal pelvis by means of a hand syringe. Since the degree of pressure by this method was uncertain, and since it was impossible always to determine when the capacity of the pelvis had been reached, effort was made to discover a safer method of injection. For the purpose of overdis- tending the renal pelvis a gravity method apparatus was first suggested by Baker " in 1910. The same year this method was first applied to pyelography by Uhle ^ and his coworkers. They placed the solution in a tube, which was held at a short distance above the level of the patient, and allowed the fluid to distend the pelvis and ureter by grav- ity. Oehlecker,^^ in 1911, also advised injecting the solu- tion by means of the gravity method, rather than by the syringe. In the same year a similar method was suggested by Stanton ^^ and Bruce. ^^ In 1913 Thomas ^^ described a simple apparatus for the bilateral injection by the grav- ity method. Following the recommendation of observers 20 PYELOGRAPHY with wide experience, the gravity method is now almost universally employed. The importance of a careful preparation of the injected solution was emphasized by the writer in 1913.^^ He recommended that the colloidal silver crystals be pul- verized, dissolved in lukewarm water, and then carefully filtered; otherwise in the 10 per cent, solution large par- ticles of silver might be deposited in the pelvis and possibly cause irritation. He further recommended that there be no delay in making the radiogram after the kidneys had been catheterized, and that the injection and radiogram should be made simultaneously. Kidd '^^ also, in 1914, urged that the renal pelvis should be subjected to pressure by the solution injected but a short time — preferably less than a minute. The position of the patient while the pyelogram is being made is usually dorsal. In 1912 Fowler ^^ recommended a subsequent pyelogram made in the erect position, in order to observe the degree of renal excursion. Schramm,^- in 1913, recommended the moderate Trendelenburg po- sition, in order more completely to distend and outline the ureter. The size of the plate varies with the purpose for which it is made, and with the size of the field required. In 1911 Oehlecker ^"^ recommended a 40 x 50 cm. plate, so that the entire urinary tract might be outlined. He emphasized the value of comparing the outlines in both renal pelves and ureters. Objections to this method may be raised on the grounds of possible injury to both kidnej^s because of incorrect technic. The opinions of different authors vary as to the degree of pain that should be caused on injection of the solution. THE HISTORY OF PYELOGRAPHY 21 The majority of them say that mild pain should be the signal for stopping the injection. In 1913 Childs and Spitzer -^ stated that severe pain should be the signal for ceasing injection. The writer, ^^ however, has claimed (in 1913) that pain is unnecessary and should be avoided. The greater the concentration of the solution, the clearer will be the outline following its injection, but it is a common experience that the more concentrated solutions are irri- tating. A 10 per cent, solution is now most commonly employed, though it is maintained by some that a 5 per cent, solution will usually suffice to outline with complete- ness and safety. In 1908-09 Albarran and ErtzbischofT ^^ recommended a 7 per cent, solution, as did also Nogier and Reynard -^ in 1911. The possibility of outlining the dilated ureters after filling the bladder with colloidal silver was first suggested by von Lichtenberg ^^ in 1909. In 1911 Clark 2' also de- scribed this method, advising the Trendelenburg position, so that the fluid would more readily enter the ureters. In 1913 the writer ^^ recommended the method in selected cases, but called attention to the fact that its use was necessarily limited. Diagnostic Data. — Attention was first called to the value of pyelography as an aid to diagnosis by Voelcker and von Lichtenberg ^ in 1906. They emphasized its value in the diagnosis of hydronephrosis, and also suggested that it might prove to be of use in the diagnosis of renal tumor and anomaly, although they did not then refer to any actual demonstration of such data. Albarran and Ertzbischoff ^^ were probably the first to follow the suggestions of Voelcker and von Lichtenberg,^ and in 1908 published a summary of their experiences. Although they suggested the various 22 PYELOGRAPHY possibilities of the method, their results were incomplete and unsatisfactory. It remained for later observers to note the full value of the method and to develop its pos- sibilities in the diagnosis of numerous conditions in which its use has been demonstrated. Diagnostic data derived from pyelography may be found in articles by the writer from 1909 to the present time (1914).^^ In papers read in 1909 "^ and 1910 ^° he called attention to its value in the diagnosis of the following conditions: (1) Normal pelvis; (2) hydronephrosis; (3) pyelitis; (4) pyonephrosis; (5) renal tuberculosis; (6) renal tumor; (7) renal and ureteral anomaly; (8) monoc3^stic and polycystic kidney; (9) identification of renal shadows; (10) localization of renal shadows; (11) identification of ureteral obstruction; and (12) as an aid to ascertain renal function. This summary may be said to include practically all possible conditions in which the method has been found to be of value. The early writings of Voelcker and von Lichtenberg demonstrated the possibility of diagnosing the existence of a hydronephrosis by means of pyelography, von Lich- tenberg again described several types of hydronephrotic dilatation in 1909,-^ and referred to the diagnosis of movable kidney and ureteral kinks. In 1909 Keyes ^ described in detail changes taking place in the calyces as the result of mechanical obstruction. He coined the term ''plug-hat pelvis" to describe the appearance of the hydronephrotic pelvis. In a paper read in 1909 -^ the writer also described various types of hydronephrosis, with illustrations, and in 1911 ^^ he called attention to the value of the method in the diagnosis of early hydronephrosis. In 1911 Key ^- reported several cases of hydronephrosis with excellent illustrations. In 1912 Fowler ^^ emphasized its value in the diagnosis of THE HISTORY OF PYELOGRAPHY 23 small dilatation of the pelvis. In 1913 Cabot"*'' further emphasized this point, and stated that it is frequently the only method whereby early hydronephrosis can be diagnosed. He also claimed the relation of the ureter to the pelvis to be of diagnostic importance in early hydro- nephrosis. In 1911 Oehlecker^'^ referred to the value of pyelography in the diagnosis of dilatation in hydroneph- rosis and pyonephrosis. He described several pyelograms showing the dilatation of the renal pelvis and ureter which frequently accompanies pregnancy. In 1911, and again in 1913, Walker,^* in a paper devoted to the diagnosis of hydro- nephrosis, described further details of the method. In 1913 Voelcker ^^ gave a detailed description of the gradual process of pelvic dilatation, and differentiated between the mechanical and inflammatory types of dilatation. Prob- ably the most recent paper on the subject is one by the writer ^^ in which the details and possible variations of the outhnes in the different stages of hydronephrosis are de- scribed. The value of the method in the diagnosis of hydronephrosis has been recognized by numerous other observers, among whom may be mentioned Nogier and Reynard,25 Bruce," Necker,^^ Jaches and Furniss,^^ Keene,^^ and Legueu, Papin, and Maingot.'*'' In 1912 Fowler ^^ called attention to the method of making a pyelogram with the patient first in the dorsal and then in the erect position. In this manner the full degree of excursion of both kidneys, when movable, as well as the consequent course of the ureters, can be more accurately ascertained. The writer was probably the first to describe the various changes in the outhne of the pelvis and ureter as the result of inflammation.29' 30 In a recent article (1914) he de- scribed further details of the various changes found in the 24 PYELOGRAPHY different stages of inflammatory destruction,^^ In 1911 Key ^^ published several excellent plates showing dilatation as the result of infection. In a paper written in 1912 deal- ing with the value of pyelography in the diagnosis of various conditions Paschkis and Necker ^- state that the dilatation seen with inflammation is due to ureteral obstruction. In 1913 Voelcker ^^ described in detail the stages of inflamma- tory change in the pelvic outline. In 1913 Keene ^^ also de- scribed the form of dilatation seen in both the renal pelvis and the ureter as a result of inflammation. In 1911 Clark ^^ described the method of outlining the ureter dilated as the result of inflammation by means of injecting colloidal silver solution into the bladder with the patient in the Trendelenburg position and simultaneous radiography. In 1910 the writer ^^ called attention to the value of pyelography in the diagnosis of renal tuberculosis in cer- tain doubtful cases. In 1911 Oehlecker ^'^ stated that the method is occasionally of value in the diagnosis of renal tuberculosis. Von Lichtenberg and Dietlen ^^ substanti- ated these reports in 1911, and described the various pos- sible deformities seen even in advanced tuberculosis. In the same year Nogier and Reynard ^^ described a case of renal tuberculosis diagnosed by means of pyelography. In 1911 Key ^^ also described the possible value of pye- lography in certain cases of renal tuberculosis. Although the diagnosis of renal tumor by means of the pyelogram was suggested by Voelcker and von Lichten- berg/ as well as by Albarran and Ertzbischoff,-^ they did not illustrate nor describe the many possible deformities. In 1909,-^ and again in 1912/^ the writer detailed the vari- ous deformities which accompany tumor, and illustrated their more important phases. In 1909 von Lichtenberg ^'^ THE HISTORY OF PYELOGRAPHY 25 also called attention to the possibility of peh'ic deformity as the result of renal tumor. In 1911 Nojj;ier and Rey- nard -'-' stated that occasionally renal tumor could be diag- nosed in no other way. In 1911 Oehlecker i'' also called attention to the possibility of diagnosing renal tumor by means of the pyelogram. These findings were corrob- orated subsequently by Jaches and Furniss,'^'* Keene,^'^ and others. The writer -^ has called attention to the value of the method in differentiating tumor in the extrarenal organs from renal neoplasm. In 1914 Kidd -" referred also to the aid given in the differential diagnosis of abdominal tumor. Although Voelcker and von Lichtenberg " were the first to suggest the use of pyelography in the diagnosis of con- genital anomaly in the urinary tract, the first detailed data of the possibilities of the method were furnished by the writer in 1910,^° and again in 1912.'^ In 1909 von Lich- tenberg -^ cited a case of dystopic kidney diagnosed by means of pyelography. In 1911 Oehlecker ^^ emphasized the value of the pyelogram in the diagnosis of congenital anomaly, and cited a case with duplication of the ureter and pelvis. In the same year Nemenow^^ made a similar observation, and cited a case of pelvic kidney which was diagnosed by means of pyelography. In 1911 Seelig ^"^ described a case with bilateral duplication of the pelves diagnosed by means of pyelography. In 1914 Joseph ^^ described the value of the method in the diagnosis of a series of congenital anomalies. In 1914 Kidd ^° asserts that congenital anomaly is frequently overlooked, and that its existence can frequently be ascertained by means of pyelography, or pyeloradiography, as he terms the method. That pyelography could be of considerable value in the diagnosis of polycystic kidney was suggested in 1910 by 26 PYELOGRAPHY the writer, ^° who demonstrated with illustrations some of the varieties of deformity accompanying this condition. His later publication suggested that it might also be of value in the diagnosis of solitary cysts. The value of pyelography in the identification as well as the localization of renal shadows was first noted by the writer in 1910,^0 and later fully described ^^ (1913). In 1911 Oehlecker ^^ also described various changes in the pelvic outline as the result of stone, and called attention to their value in the identification of stone. In the same year Holland ^^ described the value of the method in the identi- fication of renal and ureteral shadows, calling attention to its use in the differential diagnosis of gall-stone shadow. In 1911 von Lichtenberg and Dietlen ^^ wrote of the de- sirability of localizing stone shadows by means of pyelog- raphy, and advised the use of oxygen instead of colloidal silver for this purpose. In 1911 Nogier and Reynard,^^ and in 1913 Keene,^^ recommended pyelography in the diagnosis of renal stone. The value of the method in the identification of ureteral obstruction, including that due to lithiasis, was described by the writer in 1909 ^^ and 1910.^° He gave in detail the changes in the outline of the ureter caused by a stone in the lower ureter, and, furthermore, called attention to the value of the method in the diagnosis of certain forms of stricture of the ureter. In 1910 Uhle ^ and his collaborators also described the value of pyelo-ureterography in the diag- nosis of ureteral obstruction and lithiasis. In 1911, Oehl- ecker^^ described the value of pyelography in the identi- fication of certain shadows in the area of the lower ureter. In the same year Dohan ^^ referred to the same method. In 1913 Keene ^^ stated that it had proved to be of greater THE HISTORY OF PYELOGRAPHY 27 value in the diagnosis of stone in the lower ureter than the shadowgraph catheter, and then described the resulting ureteral dilatation. In 1912 Furniss ''^ described in detail the diagnosis of certain forms of stricture of the ureter which could be diagnosed in no other way. Accidents. — The most recent phase of the literature concerning the subject of pyelography deals with the dangers attending its employment. A number of reports were made of lesions found in the kidney after its removal, showing destruction of the renal tissue, evidently by the injected colloidal silver. Thus, in 1911, Zachrisson ^- reported considerable reaction in five days following the injection of colloidal silver, and, on removing the kidney, found that considerable destruction was present and that it was universally studded with black silver deposit. In 1911 Oehlecker,^^ on removing the affected kidney in a case of renal tumor, found the presence of infarcts in the parenchyma stained with colloidal silver. In 1911 Jer- vell ^^ observed a wedge-shaped area of gangrene in the kidney following pyelography. Ekehorn,-^'' in 1911, found renal edema on operating five days after pyelography. Buerger/^ in 1912, reported deposits of silver in surround- ing foci of suppuration in the cortex of the kidney. Blum,^*^ in 1912, reported a series of experiments on the kidney in cadavers, and attacked pyelography on the ground that it is a highly dangerous and, furthermore, useless method in diagnosis. In 1913 the writer ^^ reported three cases operated on for hydronephrosis in which evidence of silver was found in numerous infarcts scattered in the renal parenchyma. He stated that such necrosis of the tissue could follow retention of colloidal silver. If the drainage from the pelvis is blocked, peristalsis may force the re- 28 PYELOGRAPHY tained silver solution into the straight tubules, with re- sulting necrosis of the tissues. Tennant," in 1913, re- ported a case in which the substance of the kidney was damaged by injected colloidal silver. Voelcker,^^ Kelly and Lewis/^ and, later, Vest,^^ reported several cases where evidence of colloidal silver was found at operation in the perirenal tissue. In 1914 Mason ^^ reported two cases where a number of infarcts were found in the kidney fol- lowing pyelography. Troell,'^'^ in 1913, reported a case in which infiltration of the tissue followed the injection of 6 or 7 c.c. of 7 per cent, solution of colloidal silver in a kidney which was otherwise surgical. Legueu and Papin,*^^ in 1913, described in detail the various types of lesions seen in the kidney following infiltration of the parenchyma with colloidal silver. They ascribe such lesions to overdisten- tion of the pelvis with the hand syringe, and have not ob- served them since employing the gravity method. In December, 1913, Schwarzwald ^'^ reviewed to date the acci- dents reported in the literature, of which there were eight. He found that they were all due to error in technic. He also reported a case of a kidney removed for pyelonephritis and multiple abscesses in which a short time before a pyelogram had been made. On examination of the kidney silver was found deposited in the tissues of the diseased portion only. He concludes that the silver particles do not enter via the blood-stream, but probably through the diseased or traumatized tissues. He believes that if the technic is correct, no accidents should follow pyelography. Walker,^'' in July, 1914, gave a detailed resume of the technic involved in pyelography. He claimed that careful injec- tion of the pelvis with hydrostatic pressure will usually obviate any injury to the kidney. He stated that infiltra- THE HISTORY OF PYELOGRAPHY 29 tion of the renal substance resulted from excessive pressure, prolonged pressure, . or previous trauma to the pelvis by the catheter. He advised using a small catheter to insure return flow if the pelvis was overdistended. Fatalities following pyelography have been reported by various observers. In 1911 Roessle" reported a fatahty shortly after pyelography which he believed to be due to colloidal silver poisoning. Evidence of hemorrhagic diathe- sis appeared following the injection. At postmortem the kidney showed silver substance embedded throughout the tissues. In 1914 Smith ^^ reported a death following pyelography which he attributed to be the direct cause. In 1913 Rosenblatt and Morgandies ^« reported a fatahty some hours following pyelography. The patient died in shock following an injection of 40 c.c. of silver solution. Vest ^s reported a death fourteen days after pyelography which he believed caused hemorrhagic diathesis and possi- bly death. In 1914 Hofman^' reported a death four days after pyelography which was found to be due to rupture of a hydronephrotic sac. Such an accident is only illus- trative of technical error in having used enough pressure to cause rupture, and is not an argument against pyelog- raphy. Within the past few months other fatalities have been reported by different American observers. It is of interest to note that in practically every case the solution was injected with the pressure of a hand syringe. The amount injected in most instances was greater than the pelvic capacity. Within the past year a number of papers have been pub- hshed deahng with experimental work on animals in an attempt to discover under what circumstances injuries to the renal substance follow the use of colloidal silver in- jection. 30 PYELOGEAPHY Tennant," in June, 1913, reported a series of experi- ments in which he subjected the kidneys of pigs to a vary- ing degree of pressure with colloidal silver solution and noted the results. He found that by introducing the so- lution at a pressure of over 40 mm. of mercury, infiltration of the kidney invariably resulted. Strassman,*'^ in January, 1913, reported the effect of overdistention of the renal pelvis in rabbits with colloidal silver under moderate pressure. He found that the silver particles were carried bj^ the lymph-spaces as far as the renal capsule. By the end of twenty-four hours the greater part of the silver had left the renal tissue. He concluded that, with careful technic, taking care not forcibly to dis- tend the pelvis, no injury should follow pyelography. Wossidlo,^^ in December, 1913, concluded, from a large series of experiments on rabbits, that when the physiologic capacity of the normal pelvis was exceeded by a large amount of colloidal silver solution injected under pressure, the colloidal silver entered the interstitial tissue between the tubules. With hydronephrosis, however, if the pelvic capacity is overfilled, the silver solution entered the renal tissue via the dilated tubules. When a hydronephrosis exists, no more should be injected than the amount first drained away. He claimed, however, that no damage would result if the capacity of the pelvis was not exceeded. He believes that if the pelvis is traumatized, as evidenced by hematuria, colloidal silver should be injected with great precaution, since it can then more easily enter the renal tissue. Kidd,"° in January, 1914, reported a series of experi- ments on sheep's kidneys, when he distended the pelvis with silver solution at various pressures. He concluded THE HISTORY OF PYELOGRAPHY 31 that the element of time under which the pressure was made was of equal importance with the degree. He claimed that the solution should be injected at a maximum pressure of 60 mm. of mercury, and that it should be exerted less than a minute; when exerted and with greater pressure longer, the silver solution penetrated the renal substance to a varying degree. He believes that the mode of entrance was via the straight tubules. Rehn,'" in January, 1914, reported similar results fol- lowing even moderate overdistention of the renal pelvis in rabbits, and believes that great care should be used when colloidal silver is injected into the human kidney. In May, 1914, Eisendrath '^ reported the results of several experiments on dogs, with similar results. On injecting a dog's renal pelvis with 20 c.c. of 10 per cent, silver solution under pressure of 100 mm., the animal died within five minutes. Necropsy showed quantities of silver deposited in the various organs as the result of widely dis- tributed silver embolism. He believes that this experi- ment explains the sudden deaths reported in the human. He finds, however, that, as long as only moderate pressure is employed and the capacity is not exceeded, no harm results from injecting the pelvis with silver solution. It is very evident, therefore, that unless a pyelogram is made with strict technical precautions, it may cause con- siderable injury. However, in the hands of those familiar with the necessary technic and the selection of cases it has proved to be a comparatively harmless procedure. Thus the writer reported ^^ a series of over 1000 pyelograms made without serious results to any patient. The method is too valuable in the diagnosis of many conditions in the urinary tract to be discarded. EfTort should be made, however, 32 PYELOGRAPHY to discover a substance which will not injure the kidney under any circumstances, and which may be safely em- ployed in the hands of those with limited experience. BIBLIOGRAPHY 1. Tuffier, Th.: "Sonde ureterale opaque," in Duplay et Reclus, 1897. 2. Schmidt and Kolischer, Gustav: "Radiographic an sonderierten Ureteren und Nieren," Monatsberichte f. Urol., 1901, vi, 427. 3. Lowenhardt, F.: "Bestimmung der Lage des Ureters am Lebenden," Schlesische Gesellsch. f. Vaterl. Kultur, Breslau, 1901, 21, vi. 4. von Illyes: " Ureterenkatheterismus mid Radiographie," Deutsch. Zeitschr. f. Chir., 1902, Ixii, 132. 5. Fenwick, E. H. : "The Value of the Use of a Shadowgraph Ureteric Bougie in the Precise Survey of Renal Calculus," Brit. Med. Jour., 1905, i, 1325-1327, 8 pi. 6. Klose, B.: "Radiographie eines durch das Kystoskop diagnostizierten Falles von kompletter Ureterenverdopplung," Deutsche Zeitschr. f. Chir., 1904, Ixxii, 613-617, 1 pi. 7. Voelcker, F., and von Lichtenberg, A.: " Pyelographie (Rontgenographie des Nierenbeckens nach Kollargolftillung)," Mlinchen. med. Wochen- schr., 1906, Uii, 105-107. 8. Keyes, E. L., Jr. : "Radiographic Studies of the Renal Pelvis and Ureter," Trans. Amer. Urol. Assoc, 1909-10, iii, 351-357, 1 pi. 9. Uhle, A. A., and Pfahler, G. E.: "Combined Cystoscopic and Rontgen- ographie Examination of the Kidneys and Ureter," Ann. Surg., 1910, li, 546-551. 10. Doderlein, A. S. G., and Kronig, B.: "Operative Gynakologie," 3. Aufi., Leipzig, 1913, G. Thieme. 11. Burkhardt, L., and Polano, O.: "Die Fiillung der Blase mit Sauerstoff zum Zwecke der Cystoskopie und Radiographie," Mlinchen. med. Wochenschr., 1907, liv, i 20, 21. 12. von Lichtenberg, A., and Dietlen, H. : "Der Darstellung des Nierenbeck- ens und Ureters im Rontgenbilde nach Sauerstoff -Fiillung," Mlinchen. med. Wochenschr., 1911, Iviii, i, 1341-1342. 13. Kelly, Howard A., and Lewis, Robert M.: "Silver Iodide Emulsion. A New Medium for Skiagraphy of the Urinary Tract," Surg., Gyn. and Obst., 1913, xvi, 707, 708. 14. Baker, H. W.: "An Improved Method of Measuring the Capacity of the Renal Pelvis," Surg., Gyn. and Obstet., 1910, x, 536. 15. Oehlecker, F. : "Ubersichtsaufnahmen vom uropoetischen Systeme (Pyelokystographie)," Fortschr. a. d. Geb. d. Rontgenstrahlen, 1911, xvii, 195-207. 16. Stanton, E. M.: "The Diagnosis of Diseases of the Urinary Tract by the Combined Use of the Cystoscope and the x-Ray," Albany Med. Ann., 1912, xxxiii, 386-393, 6 pi. THE HISTORY OF PYELOGRAPHY 33 17. Bruce, W. Ironside: "Pyelography and the Use of Collargol in the Diag- nosis of Diseases of the Urinary Tract," Brit. Med. Jour., 1911, ii, 908-910. 18. Thomas, G. J. : "An Apparatus for the Injection and Lavage of the Pelves of the Kidneys and Ureters," Jour. Amer. Med. Assoc, 1913, Ix, 184. 19. Braasch, Wm. F.: "Recent Progress in Uretero-pyelography," Jour. Mich. Med. Soc, 1913, xii, 189-191. 20. Kidd, Frank: " Pyelo-radiography. A Clinical Study," Urol, and Cutan. Rev. (Technical Supplement), 1914, ii, 1-27. 21. Fowler, O. S.: "Early Diagnosis of Intermittent Hj^dronephrosis," Surg., Gyn. and Obst., 1912, xiv, 137-143. 22. Schramm, Carl: "Zur Technik der graphischen Darstellung der ab- leitenden Harnwege mittels der Collargol-Rontgenaufnahme," Fortschr. a. d. Geb. d. Rontgenstrahlen, 1913, xx, 36-39. 23. Childs, Samuel B., and Spitzer, Wm. M.: " Roentgenographic Study of the Normal Kidney, its Pelvis and Ureter," Jour. Amer. Med. Assoc, 1913, Ixi, 925-930. 24. Albarran, J., and Ertzbischoff, P.: " Radiographie de bassinets et d'ure- teres normaux et pathologiques," Assoc. Frang. d'urol. Proc-verb., 1908, Paris, 1909, xii, 282-294, 11 pi. 25. Nogier, Th., and Reynard, J.: "Injection de collargol dans le bassinet suivie de radiographie, pour servir au diagnostic de certaines affections renales," Lyon Chir., 1911, vi, 642-651. 26. von Lichtenberg, A.: "L^eber Pyelographie und Biocystographie," Zeitschr. f. Urol., 1909, iii, Beihft., 349-355. Verhandl. d. deutsch. Gesellschaft f. Urol., II. Kongress in Berlin. 27. Clark, J. B.: "Case History of Dilated Ureters with Radiograph," Trans. Amer. Assoc. Genito-Urin. Surg., New York, 1911, vi, 164, 2 pi. 28. Braasch, Wm. F. : "The Results of Early Diagnosis of Urinary Tubercu- losis," Interstate Med. Jour., 1912, xLx, 863-869. 29. Braasch, Wm. F.: "Deformities of the Renal Pelvis," Ann. Surg., Phila- delphia, 1910, Ii, 534-540. 30. Braasch, Wm. F.: "Recent Developments in Pyelography," Ann. Surg., Philadelphia, 1910, Iii, 645-653. 31. Braasch, Wm. F.: "The Value of Pyelography," Jour. Amer. Med. Assoc, 1911, Ivii, 1986-88. 32. Key, Einar: "Pyelografi," Hygiea, Stockholm, 1911, Ixxiii, d. 1, 129-180. 33. Cabot, Hugh: "Diagnosis and Indications for Operation in Early Hydro- nephrosis," Jour. Amer. Med. Assoc, 1913, Ix, 16-20. 34. Walker, J. W. Thomson: "The Early Diagnosis of Hydronephrosis by Pyelography and the Means," Ann. of Surg., 1913, Iviii, 766-799. 35. Voelcker, F.: "Ueber Dilatation und Infektion des Nierenbeckens," Zeitschr. f. urolog. Chir., 1913, i, 112-125. 36. Braasch, W. F.: "Clinical Notes on Hydronephrosis," Interstate Med. Jour., 1914, xxi, 1180-1188. 37. Necker, F.: "Ueber Pyelographie," Verhandl. d. deutsch. Gesellsch. f. Urol., III. Kongress, in Wien. Zeitschr. f. Urol., 1912, vi, iii, Beihft., 464. 3 34 PYELOGEAPHY 38. Jaches, L., and Furniss, H. D.: "Radiography of the Distended (Col- largol, Argyrol, Oxygen) Renal Pelvis and Ureter," Med. Rec, 1911, Ixxx, 1199, 1200. 39. Keene, F. E. : "Value of Pyelography in the Diagnosis of Surgical Diseases of the Kidney," Penn. Med. Jour., Athens, 1912-13, x^vi, 616-620. 40. Legueu, F., Papin, E., and Maingot, C: "La Cystoradiographie," Jour. d'UroL, 1912, i, 749-768. 41. Braasch, Wm. F.: "Infections of the Renal Pelvis and Ureter," Texas State Jour., 1913-14, ix, 305-308. 42. Paschkis, R., and Necker, F.: "Ueber Pyelographie," Mitt. d. Gesellsch. f. inn. Med. u. Kinderh. in Wien, 1912, xi, 113. 43. Braasch, Wm. F.: "Clinical Data on Malignant Renal Tumors," Jour. Amer. Med. Assoc, 1913, Ix, 274-278. 44. Braasch, Wm. F.: "The Clinical Diagnosis of Congenital Anomaly in the Kidney and Ureter," Ann. Surg., 1912, Ivi, 726-737. 45. Nemenow, M. N. J.: " Zur Kasuistik der angeborenen Missbildungen des Harnapparatus," Fortschr. a. d. Geb. d. Rontgenstrahlen, 1911-12, xviii, 216-220. 46. Seelig, Albert: "Ein Fall von beiderseitigen Verdoppelung der Nieren- becken und Ureteren," Zeitschr. f. Urol., 1911, v, 920-923. 47. Joseph, E.: "Demonstration praktischwichtigerPyelographien," Zeitschr. f. Urol., 1914, viii, 344-347. 48. Braasch, Wm. F.: "Clinical Data on Renal Litbiasis," Journal-Lancet, 1913, xxxiii, 561-564. 49. Holland, C. Thurstan: "Recent Developments in Pyelography," Arch. Roentgen Ray, 1910-11, xv, 371. 50. Dohan, N.: "Zur Differentialdiagnose zwischen Harnleiterstein und verkalkter Lymphdrlise," Fortschr. a. d. Geb. Rontgenstrahlen, 1911, xvii, 165-168. 51. Furniss, H. D.: "Some Types of Ureteral Obstruction in Women," Jour. Amer. Med. Assoc, 1912, lix, 2051-2056. 52. Zachrisson, F.: "Fall von Kollargolinjektion in die Tubuli recti der Niere," Nordiskt. Mediciniskt Arkiv., 1911, 3 f. XI afd. 1, No. 27. 53. Jervell, Kr.: "Partielle Gangran d. Niere nach Pyelographie," IX. Versamml. des nordisch. chirurgischen Vereins, Stockholm, Centralbl. f. Chir., 1911, xxxviii, 1345. 54. Ekehorn: Quoted by Key, Hygiea, 1911, Ixxxii, 129-180. 55. Buerger, L.: "CoUargol in the Renal Parenchyma," New York Acad. Med., Genito-urinary Section, January 17, 1912, Amer. Jour. Urol., 1912, viii, 166-168. 56. Blum, v.: "Ueber den Wert der Pyelographie und anderer Methoden zum Nachweise von Dilatationen des Nierenbeckens," Wien. med. Wochenschr., 1912, Ixii, 1269-1274. 57. Tennant, C. E.: "The Cause of Pain in Pyelography, with Report of Ac- cident and Experimental Findings," Ann. Surg., 1913, Ivii, 893. 58. Vest, Cecil W.: "Observations Following the Use of CoUargol in Pyelog- raphy," Johns Hopkins Hosp. Bull., 1914, xxv, 74-77. THE HISTORY OF PYELOGRAPHY 35 59. Mason, J. M.: "Dangers Attending Injections of the Kidney Pelvis for Pyelography," Jour. Amer. Med. Assoc., 1914, Ixii, 839-844. 60. Trocll, A. : "Full af Pyelografi, dar KoUargol intrangt i njurens Urinkanaler och Malpighiska Kroppar," Hygiea, Stockholm, 1913, Ixxv, 17&-183. 61. Legueu, F., and Papin, E.: "Technique et accidents de la pyelographie," Arch. Urologique, de la chnique de Necker, 1913, i, 12-38. 62. Schwarzwald, R. T.: "Zur Frage der Gefiihrlichkeit der Pyelographie," Beitrage zur klin. Chir., 1913, lxxx'^'iii, 287-300. 63. Walker, J. W. Thomson: "Pyelography: a Critical Review," Brit. .Jour. of Surg., 1914, ii, 128-131. 64. Roessle, R.: "Todliche Kollargolvergiftung," Miinchen. med. Wochen- schr., 1911, Iviii, 280. 65. Smith, E. O.: "Sudden Death Following Pyelography," Amer. Jour. Urol., 1914, X, 121-123. 66. Rosenblatt and Morgandies: "Pyelographie," Verhandl. d. deutsch. Rontgen. Gesellsch., 1913, ix, 81. 67. Hofmann, Eduard Ritter von: "Ueber die Gefahren der Pyelographie," Folia Urol., 1914, viii, 393-404. 68. Strassman, Georg: "Uber die Einwirkung vonCollargoleinspritzungen auf Niere und Nierenbecken," Zeitschr. f. urol. Chir., 1913, 126-138. 69. Wossidlo, E.: "Experimentalstudie zur Kollargolfiillung des Nieren- beckens," Arch. f. klin. Chirurgie, 1913, ciii, 44—72. 70. Rehn, E.: "Experimente zum Kapitel der Pyelographie," Zentralbl. f. Chir., 1914, xh, 142-145. 71. Eisendrath, Daniel N.: "The Effect of Injecting Collargol into the Renal Pelvis," Jour. Amer. Med. Assoc, 1914, Ixii, 1392, 1393. CHAPTER II TECHNIC Instrumental manipulation of the urinary tract should not be made other than such as is necessary to arrive at an accurate diagnosis. If the diagnosis can be made complete without pyelography, its use is contraindicated. It has been common experience, however, that lesions in the urinary tract have been discovered by means of pyelog- raphy which could not be diagnosed with clinical and radi- ographic evidence and the usual cystoscopic technic. On the other hand, the existence of lesions in the urinary tract has been erroneously inferred from evidence obtained through clinical, radiographic, and the usual cystoscopic data which the pyelogram proved was not present. It will be found, in the course of routine examination, that the diagnosis is not infrequently uncertain even after a careful radiographic and cystoscopic examination. Pyelog- raphy should be employed as an aid in determining the actual condition present in doubtful cases only. Selection of Cases. — Pyelography, and frequently ureteral catheterization as well, is contraindicated with hypersensitive and frail individuals, who react violently to any manipulation of the uiinary tract. Not infre- quently the prostration, chills, and fever which follow an ordinary cystoscopic examination in such cases would be attributed to the use of pyelography. Where there is 36 TECHNIC 37 evidence of renal insufficiency, marked emaciation, or acute infection, any manipulation of the urinary tract — and pyelography in particular — is usually contraindicated. Again, with large hydronephroses, when the diagnosis is evident from the data obtained by means of the ureteral catheter, pyelography is unnecessary. The Selection of the Medium to be Injected. — The medium which will cast a well-defined shadow, which is fluid, and yet causes no irritation in case it should not drain, is the best for injection. Unfortunately, this ideal medium has not yet been discovered. It has been the ex- perience of most observers that the original solution of colloidal silver, as advanced by Voelcker and von Lich- tenberg, is the most satisfactory. The objection to the other forms of colloidal silver has been the greater concen- tration necessary in order to cast a shadow of equal density. Other solutions have proved to be less satisfactory than colloidal silver. Silver iodid emulsion, which has been recently advocated, although possibly less capable of causing injury, unfortunately is too viscid to be employed with the gravity method. A 5 per cent, emulsion, care- fully prepared, will cast as good a shadow in the radiogram as a 10 per cent, solution of colloidal silver. Preparation of the Solution. — If colloidal silver is em- ployed, the best results will be obtained from a 10 per cent, solution. Although a 5 per cent, solution, as origi- nally advanced, will usually outline the pelvis and ureter, the pyelogram may appear very dim and many details be lacking. In the preparation of the solution the following precautions should be taken : 1. Colloidal silver (collargol) crystals should be carefully ground in a mortar when put in solution and then filtered, 38 PYELOGRAPHY otherwise the undissolved crystals may be deposited on the walls of the pelvis and ureter and act as an irritant. 2. The solution should be warmed but slightly before the injection, since it may coagulate even at a temperature much below that of boiling. 3. The solution should then be filtered carefully through several layers of linen, to prevent any large crystals which may be undissolved from entering the injected solution. A sediment will form in solutions which have been allowed to stand for some time, and only the upper or fluid portion should be used. A solution which is too thick to pass through a fine-pointed needle should not be injected. Method of Injection. — When pyelography was first employed, the solution was injected by means of a hand syringe. However, it was found to be quite impossible thus to estimate accurately the capacity of the pelvis. Consequently it was frequently overdistended, with re- sulting pain and injury to the kidney. It was discovered, moreover, that a better and a more even distention could be obtained by allowing the solution to enter the pelvis of the kidney under the pressure of gravity. For this purpose the simple method was devised of elevating the tube containing the injected medium a short distance above the patient, and allowing the fluid to enter the renal pelvis and the ureter through the ureteral catheter. This has proved to be the most practical method of injection, and has been universally adopted. The tube containing the medium to be injected is graduated into cubic centi- meters, in order to ascertain the amount of fluid used. It may be supported by an adjustable bracket attached to a telescoping stand, which permits the fluid to enter under the pressure of different elevations. The exact elevation TECHNIC 39 above the level of the kidney to which the fluid should be raised varies with the different observers. From one to two feet should suffice, depending upon the rapidity with which the solution enters the pelvis. After the plate and the tube are placed in position, the fluid is allowed to enter and the amount entering the pelvis should be carefully noted. Unless there is some evidence of pelvic dilatation, 4 or 5 c.c. should be allowed to flow in, and the tube lowered to a few inches above the level of the abdomen. The radio- gram should then be made while the fluid is still entering the pelvis under slight gravity pressure. In this way any leakage alongside the catheter will be compensated and the pelvis kept fairly well filled. As a rule, 4 or 5 c.c. will outline the average pelvis; if, however, possible dilatation is present, as high as 10 c.c. may be allowed to enter under gentle pressure. Pain caused by overdistending the pelvis of the kidney should always be a signal to stop further injection. As a rule, little or no pain should be caused by the injection, and it is not necessary to insure an accurate pelvic outline. Occasionally pain will be caused in spite of every precau- tion, and it may follow the injection of even 1 or 2 c.c. of the solution. This may often be explained by the fact that the tip of the catheter has lodged in the end of a calyx, so that the fluid overdistends the calyx. A pyelogram should not be made under anesthesia, since the safeguard of pelvic overdistention would be lost. The advantages of the gravity method of injection are numerous. Danger of overdistention is largely obviated in that the fluid will cause running as soon as the pelvis is filled. The pressure from gravity is so slight that but little damage to the kidney should result. Further, by 40 PYELOGRAPHY keeping the pelvis distended under gentle pressure a com- paratively complete outline is insured. This is accom- plished safely and without making it necessary for the oper- ator to be near the a;-rays. Again, the tube may be lowered following the pyelogram, and may aid in draining the in- jected solution from the pelvis. A moderately opaque catheter should be employed, since occasionally the position and course of the catheter are of value in the interpretation of the pyelo-ureterogram. As a rule, a small ureteral catheter should be used when possible. A No. 5 will usually suffice to drain the injected solution, and at the same time is small enough to allow the superfluous fluid to flow back into the bladder with pelvic overdistention. Drainage of the injected solution through the catheter is not, as a rule, necessary. In case, however, of possible retention in the pelvis, it would be well to drain the pelvis and also flush it with sterile water or boric acid solution through the catheter. The catheter should be introduced into the pelvis in order to obtain as complete an outline of the pelvis as possible. The patient is placed in the usual dorsal position assumed for renal radiography. It may be of some value to elevate the hips above the level of the kidney, in order to assist the distention of the ureter. To outline the ureter by means of gravity from a bladder filled with opaque fluid, the patient must assume an extreme Trendelenburg posi- tion. If a pyelogram in the erect position is desired, it is best obtained on a table so adjusted that motion on the part of the patient is not necessary. Simultaneous bilateral pyelography as a routine pro- cedure is not advisable. Although no harm would result, as a rule, the possibility of retention because of unrecog- TECHNIC 41 nized bilateral pathologic conditions makes a unilateral pyelogram preferable. Occasionally, however, the data which can be ascertained by comparison of the pelves are necessary to accurate diagnosis, and when the possibility of retention is excluded, bilateral pyelography may be employed. Sources of Error. — The possible technical errors which will lessen the excellence of the pyelogram may be due to either the radiographic or the cystoscopic technic. Needless to say that much of the success of the pyelogram depends upon the character of radiographic technic. Unless all the facilities for making a good radiogram are at hand, a pyelogram should not be attempted. Further, it is prefer- able to have the radiographic apparatus in the room where the cystoscopic examination and ureteral catheterization are made. Delay following ureteral catheterization and change in position on the part of the patient are to be avoided. Error as the result of cystoscopic technic is usually due either to insufficient distention or dilution of the injected solution by the retained fluid. Occasionally, the catheter may become plugged or coiled, so that the solution cannot pass through it. Injurious Results. — The accidents which have been re- ported as the result of pyelography have usually occurred because of error in technic or retention of the injected solu- tion. The technical errors have usually been: (1) Forcible overdistention of the pelvis; (2) long-continued pressure; (3) trauma of the pelvic mucosa. Probably the greatest injury to the renal tissue may follow overdistention of the pelvis with the colloidal silver solution. As a result, the metallic silver may either be forced through the straight tubules into the parenchyma, where it lodges and causes 42 PYELOGKAPHY areas of focal necrosis, or it may enter the blood-vessels and be carried as emboli into various parts of the body. Such an accident can be avoided by means of the gravity method of injection. Long-continued pressure, even with the gravity method, is to be avoided, since the pelvic tissues may give way if thus subjected to pressure. Al- though it is questionable if trauma to the pelvic tissues would facilitate the entrance of colloidal silver into the renal tissue, nevertheless every precaution should be taken to guard against it. It has been found that colloidal silver injected into the renal pelvis, when unable to drain out, will occasionally cause considerable irritation and even necrosis in the renal tissue. Pyelography is, therefore, usually contraindicated where it is evident that the injected fluid cannot ultimately drain. Since the existence of such marked obstruction or the retained fluid above it can frequently be ascertained by means of the ureteral catheter alone, a pyelogram will often be superfluous. The number of accidents in the hands of observers with wide experience has been small and of minor consequence. Where invasion of the cortex occurs in spite of every pre- caution, the kidney is otherwise surgical and would usually be removed. Pyelography has proved of too great value to allow it to be discarded because of occasional reaction. It should, however, be employed only with the strictest precautions, where every technical facility is at hand, and by those who are thoroughly familiar with cystoscopic technic and its interpretation. Every effort, however, should be made to discover some substance which will not harm the kidney when injected into the pelvis under any TECHNIC 43 circumstances, and which will permit unrestricted employ- ment. Gas Pyelogram. — Theoretically, air or oxygen would be admirable substitutes for any opaque fluid and would obviate the disagreeable features of the latter. Simplicity in the technic of making the injection, absence of subse- quent pain or irritation, and rapid drainage are all argu- ments in favor of gas. However, the use of gas with the present technic has not always proved to be practical. The first obstacle encountered in spite of careful preparation is the difficulty of eliminating gas in the bowel. Confusion of the shadow in the renal pelvis with the shadow caused by gas in the adjacent bowel renders interpretation un- certain. Further, it is difficult to keep the pelvis fully distended with gas while the pyelogram is being made, so that the pelvic outline will fail to show minor changes and details which are frequently necessary to make a diagnosis. It is also difficult to distend the ureter completely with gas; thus the many data to be gained through evidence of pathologic change in the outline of the ureter are also lost. Its use, therefore, will probably remain limited to but a few conditions. It might be applicable to demonstrating large hydronephroses where the exact condition cannot be ascertained by means of the ureteral catheter alone. Theo- retically, at least, it offers an excellent opportunity for the localization of renal stone. The contrasting shadows of pelvis and stone will occasionally outline the exact position of the latter, particularly if the stone is situated in the pelvis or at the end of a calyx. Unfortunately, however, the method cannot be relied upon, and after the gas has been injected, it is advisable to make a subsequent pyelo- gram with an opaque fluid in order to insure definite results. CHAPTER III THE NORMAL PELVIS The outline of the normal renal pelvis varies consider- ably in contour and size. In order correctly to interpret abnormality in the pelvic outline, it is necessary to become familiar with the wide range of normal pelvic contour. The normal pelvis is said to be made up of the true pelvis, the major calyces, and the minor calyces. The true pelvis is irregularly pyramidal in shape, tapering toward the uretero- pelvic juncture. That portion of its outline which is nearest to the vertebrae may be regarded as the median border, and the opposite side as its lateral border. The major calyces are commonly three in number — the upper, the middle, and the lower. The direction of the upper calyx is perpendicular and slightly lateral; that of the middle calyx, horizontal; while that of the lower calyx is downward and lateral. The major calyces are usually connected by a comparatively narrow isthmus where they leave the true pelvis. They then become broader and finally subdivide into a variable number of minor calyces. The minor calyces are seen as irregular, finger-like pro- jections extending a short distance beyond the ends of the major calyces. They may be called the terminal irregu- larities of the pelvic outline. A typical normal pelvis is exemplified in Fig. 1, in which the arrangement of the true pelvis and the major and minor calyces are clearly illus- trated. However, the variation in the normal pelvic outline is so great that such a pelvis would constitute but 44 THE NORMAL PELVIS 45 Fig. 1. — Normal pelvis. Fig. 2. — Normal pelvis. 46 PYELOGRAPHY a small percentage of the pelves that are observed in routine pyelography. The True Pelvis. — The outline of the true pelvis may Fig. 3. — Normal pelvis. 17921 / __ -...j*/ 1j Fig. 4. — Normal pelvis. Fig. 5. — Normal pelvis. THE NORMAL PEI>VIS 47 assume a great variety of forms. The outline may be well rounded, as in Fig. 2, squared as in Fig. 3, or elongated as in Fig. 4. Instead of being symmetric and tapering, as in Figs. 5 and 6, it is frequently broad and squared at the ureteropelvic juncture (Fig. 7). The true pelvis may be formed so that the major calyces become practically a Fig. 6. — Normal pelvis. part of it, the pelvis leading directly into the minor calyces. In Fig. 7 no distinct major calyces are present. Numerous small calyces lead directly from the true pelvis. In Fig. 8 an unusual nodular broadening of the true pelvis is visible which is probably due to coiling of the end of the catheter. The capacity of the true pelvis is usually greater than 48 PYELOGKAPHY Fig. 7. — Normal pelvis. Fig. 8. — Normal pelvis. THE NORMAL PELVIS 49 that of the combined calyces. It may, however, be much smaller, and occasionally is seen as a slight rudimentary space. The pelvis may divide at but a short distance be- yond the ureteropelvic juncture into major calyces, having a capacity much larger than the free pelvis itself. Such a type of pelvic division may be regarded as a distinct at- tempt at reduplication of the pelvis. In Fig. 9 a true pelvis is absent. In its place are two divisions of the pelvis Fig. 9. — Normal pelvis. which may be regarded as elongated major calyces, and which unite at the ureteropelvic juncture. The lower di- vision branches immediately into three well-formed sec- ondary major calyces, while the upper division branches into several rudimentary major calyces. In Fig. 10 the combined capacity of the major calyces and branches is greater than that of the true pelvis. 50 PYELOGRAPHY When the normal pelvis is found to be unusually large, the increase in size is confined more to the true pelvis than ^^ \ CO. 17952 Fig. 10. — Normal pelvis. Fig. 11. — Normal pelvis. to the calyces. In Fig. 11 the true pelvis of both kidneys is unusually broad, while the calyces are about the usual THE NORMAL PE1.\'IS 51 size and are normal in outline. In Fig. 12 the true pelves are exceptionally large in both kidneys, while the calyces are unusually small, although rather dimly outlined. In Fig. 13 the size and shape of the true pelvis in the right kidney are such as to suggest early hydronephrosis, though this would be precluded b}- the normal outline of the minor calyces. Fig. 12. — ^Normal pelvis. When the entire pelvic outline is unusually small, the diminution in size of the true pelvis is shared by the calyces. In Figs. 14 and 15 the true pelvis and the calyces of both kidneys are unusually small. Although the capacity of the true pelvis is, as a rule, relatively symmetric in the two kidneys, it is not neces- sarily so. In exceptional instances one pelvis may be con- 52 PYELOGRAPHY Fig. 13. — Normal pelvis. Fig. 14. — Normal pelvis. THE NORMAL PELVIS 53 Fig. L5. — Normal pelvi «^ Fig. 16. — Normal pelvis. 54 PYELOGRAPHY siderably larger than the other. It must be remembered, however, that unless both pelves are equally distended, there may be evident disparity in the size. Thus in Fig. 16 the pelvis of the left kidney is incompletely distended and appears much smaller than that on the right side. The contour of the pelvis depends to some extent on the degree of distention by the injected medium. Unless the pelvis is fully distended, its exact outline cannot be ascer- Fig. 17. — Normal pelvis. tained. Incomplete distention may give an erroneous impression of the outline and may be the source of error in interpretation. In Fig. 17 both pelves are incompletely distended. The pelvis of the right kidney is but partially filled, and the calyces appear as irregular, narrow streaks which are suggestive of tumor deformity. The axis of the pelvis is usually perpendicular and lateral THE NORMAL PELVIS 55 to a varying degree. When the pelvis is so situated that the calyces all extend caudad or median, the kidney is abnormally rotated. In Fig. 18 a rather unusual arrange- ment of the calyces is visible, in that a considerable dis- tance separates the upper calyx from the other calyces, and also in that the direction of the pelvic axis and of the other calyces is transverse and caudad. In Fig. 19 the calyces all extend caudad, showing the rotated position of the kidney. Fig. 18. — Normal pelvis. Major Calyx. — The outline of the major calyx may be divided into three parts: (1) The base, or the portion where it leaves the true pelvis; (2) the isthmus, or the cylindric portion which leads to a variable distance from the true pelvis; and (3) the apex or terminal portion of the calyx, from which the several minor calyces extend. The varia- tions from this common type are, however, considerable, and it may be difficult to identify the various divisions. Unusual length of the isthmus of one or more calyces is 56 PYELOGRAPHY Fig. 19. — Movable kidney, Fig. 20. — Normal pelvis. THE NORMAL PELVIS 57 not infrequently seen. It is more apt to occur with the upper calyx, and may be regarded as the result of partial reduplication of the pelvis. In Fig. 20 the upper calyx is connected with the true pelvis by a long, narrow isthmus which extends upward an unusual distance. In Fig. 21 a similar extension of the isthmus exists in the upper ma- jor calyx of the left kidney. In Fig. 22 the upper major Fig. 21. — Normal pelvis. calyx is markedly elongated, and the irregularity of the pelvis is such that it might easily be confused with de- formity caused by tumor retraction. Fig. 23 illustrates, in the left pelvis, an extension of the upper major calyx and an unusual branching of the lower major, the middle calyx being rudimentary and but a branch of the lower major. In the right renal pelvis both the lower and upper calyces 58 PYELOGRAPHY Fig. 22. — Normal pelvis. Fig. 23. — Normal pelvis. THE NORMAL PELVIS 59 are retracted. The apex of the major calyx is usually broader than the lower portion. It may be of considerable size, and assume the characteristics of a secondary pelvis. The size and arrangement of the calyces of the two pelves are commonly more or less symmetric. The outline of the individual calyces may, however, vary considerably. Fig. 24. — Normal pelvis. Marked asymmetry in outline is occasionally present with- out apparent cause. In Fig. 23 the pecuhar elongation of the upper calyces is present in both pelves. In Fig. 21 the outline of the left renal pelvis is quite different from the right in that the isthmus of its upper calyx is elongated to an unusual extent. Ordinarily, there are three major calyces; there may, 60 PYELOGRAPHY however, be an increase or decrease from the usual number. While frequently but two major calyces are visible, one major calyx rarely, if ever, occurs without the presence of some pathologic condition in the kidney. In Fig. 24 four distinct and separate major calyces are visible in the pelves of both kidneys. Although the distention of the right pelvis is incomplete, it suffices to show the outline of the calyces. Fig. 25. — Normal pelvis. An increase in the number of calyces is frequently seen to be due to the branching of the major calyx into two or more secondary calyces. Such branching occurs more frequently with the lower major calyx. In Fig. 25 but two major calyces are visible. The lower calyx divides into three distinct branches, which may be regarded as secondary major calyces or as large minor calyces. In Fig. 18 four major calyces are visible in both pelves, but the increase THE NORMAL PELVIS 61 in number is seen to be the result of division of the lowest major calyx into two branches. Actual increase of the major calyces may be simulated by divisions of the major calyces at the various planes in the parenchyma. In Fig. 26 a bilateral symmetric arrangement of the major calyces is visible. They are evidently four in number, but on closer inspection the lower two calyces aie seen to be divisions of Fig. 26. — Normal pelvis. the lower major calyx. An unusual number of major calyces extend from a diminutive true pelvis in Fig. 27. The upper and lower major calyces subdivide into two secondary calyces. The pelvis is situated at an abnormally low level. The middle calyx is apt to be smaller than the other two, and may even be very rudimentary or absent entirely. It 62 PYELOGRAPHY Fig. 27. — Normal pelvis, Fig. 28. — Normal pelvis. THE NORMAL PELVIS 03 is fre(iuently seen as a secondary major calyx branching from the lower major calyx. No evidence of the middle calyx is visible in Fig. 28, its place being taken by an in- crease in the size, an unusual degree of branching of the upper calyx, and a slight branching in the lower calyx. At times the middle major calyx may be obscured because it is situated on a different plane from that of the other Fig. 29. — Normal pelvis. calyces. In Fig. 29 the borders of the middle calyx are dimly seen at a plane beyond that of the lower major calyx. Apparent Anastomosis. — Apparent bridging or continua- tion of the lumen of different calyces may be observed in the pyelogram. Anastomosis of the calyces does not, how- ever, actually occur, the evident bridging being caused bj^ the fact that the outlines of the calyces override at different levels. In Figs. 16 and 30 various major calyces are situ- 64 PYELOGRAPHY Fig. 30. — Normal pelvis. Fig. 31. — Normal pelvis. THE NORMAL PELVIS 65 ated at different levels, so that they appear to anastomose. It will be seen, however, that their outlines are distinct. Multiple branching of the major calyces at irregular angles is clearly demonstrated in Fig. 10. A rather un- usual distribution of the major cal3'Ces, which is to be ex- plained partially by incomplete distention, is seen in Fig. 31. A rather unusual and tortuous contour to the upper calyx is seen in Fig. 32. • Fig. 32. — Xonnal pelvis. Minor Calyx. — The outline of the normal minor calyces is usually characterized by an irregularly pyramidal shape, extending from the apex of the major calyx to a variable distance into the parenchyma. Upon closer inspection these terminal irregularities are seen to be caused by in- dentations of the minor papillae into the ends of the calyces. The radiogram shows but one border of these indentations, 5 66 PYELOGRAPHY Fig. 33. — Normal pelvis. Fig. 34. — Normal pelvis. THE NO KM A L PEI.VIS 67 and so gives the minor calyx a pyramidal appearance. The typical arrangement and appearance of the terminal irregularity caused by the minor calyces is well illustrated in Fig. 33. Whenever such uniform irregularity is present in all the calyces, the pelvis may definitely be called nor- Fig. 35.— Normal pelvis. mal, and the absence of a chronic pathologic process in the kidney, particularly inflammatory, may usually be in- ferred. Several minor calyces, more or less rounded and indefi- nitely outlined, may occasionally appear in the normal pelvis. Even though a few of the minor calyces are not 68 PYELOGRAPHY well defined, as long as the outlines of the other calyces are normal, one may usually infer that the entire pelvis is normal. In Fig. 34 the minor calyces are not well defined in the upper major calyces, which appear rounded. The minor calyces in the lower major, however, appear normal, and the absence of other evidences of inflammatory change would exclude any pathologic lesion. In Fig. 35 the ab- Fig. 36. — Normal pelvis. sence of the terminal irregularities in the upper calyx and the general broadening of the ends of the calyces are sug- gestive of inflammatory changes there; however, the presence of a normal contour in the remaining calyces ex- cludes the probability of infection. As a rule, the normal minor calyces are narrow and short, but not infrequently they are seen to be of considerable size. In Figs. 25 and 36 the minor calyces are of such size that THE NORMAL PELVIS 69 they might be regarded as secondary major calyces. Unless the pelvis is well distended, the minor calyces may be more or less obscured and give the impression of slight inflamma- tory changes. Should the patient breathe or move while the pyelogram is being made, the outline of the minor calyces may become blurred, and suggest the presence of a pathologic process. In Fig. 37 the minor calyces in the Fig. 37. — Normal pelvis. right pelvis are but faintly visible because of insufficient distention. Position of the Normal Renal Pelvis. — The position of the normal renal pelvis as seen in the pyelogram taken in the dorsal position varies considerably. It is usually found at a level of the last rib or a short distance below it. With a high-lying kidney the upper calyx may often extend as high as the tenth intercostal space, and, in exceptional 70 PYELOGRAPHY instances, even as high as the tenth rib. Although it would be difficult to place any arbitrary limit to the lowest normal level at which the pelvis may be situated, nevertheless, when it is found below the level of the third lumbar vertebra, its position may be regarded as abnormal. When the pyelogram is made subsequently with the patient in the erect position, both pelves usually drop to a varying degree. When the kidneys are freely movable, this excursion is often quite marked. The pelvis of the right kidney is found to lie at a lower level than that of the left kidney in the majority of cases. The difference in levels may be slight, but more frequently the right pelvis lies at least three or four centimeters below the left. Whenever the left pelvis lies lower than the right, there is frequently some pathologic reason for it. In Fig. 26 both pelves are situated unusually high and at the same level. The calyces are seen to extend into the tenth inter- costal space. In Fig. 38 the upper calyx extends well into the eleventh intercostal space. In Fig. 13 the right pelvis lies opposite the second and third lumbar vertebrae, and the left pelvis opposite the first and second. The normal lateral limits of the renal pelvis are not as variable as the horizontal. The situation of the pelvis is usually fairly uniform in its proximity to the vertebrae. Its median border is commonly in close proximity to or overlapping the shadow of the transverse processes. Should the pelvis lie in front of the vertebral column, or at a con- siderable distance away from it, its position must be re- garded as abnormal. Relation of Pelvis and Ureter. — The lower portion of the true pelvis usually tapers gradually into the upper ureter, causing a pyramidal outline in the pyelogram. THE NORMAL PELVIS 1 The first portion of the ureter, extending as far as the first point of narrowing, is usually broader than the ureter below it. This is illustrated in Fig. 13. The ureter usually leaves the pelvis at a point where the median and lateral borders meet. It may, however, leave the median border of the pelvis at some distance above the lowest portion of the lateral border. Whenever the ureter leaves the pelvis Fig. 38. — Normal pelvis. in an upward direction, it is evident either that the kidney is movable and has rotated laterally or that a congenital anomaly is present. When the ureter leaves the pelvis from its lateral border, it may be inferred that either a horseshoe kidney or an anomalous rotation exists. In Fig. 19 the right ureter leaves the pelvis in a lateral and cephalic di- rection, while the left leaves in a lateral and caudad di- rection. 72 PYELOGRAPHY The angle formed by the ureter with the lower surface of the pelvis is usually broad and rounded. When the angle is acute, it indicates either marked rotation as the result of renal excursion or pelvic dilatation. In Fig. 39 the angle between the ureter and the lower border of the pelvis (particularly on the left side) is acute. This is due to the position of the kidney, since the pelvis itself is normal. Fig. 39. — Normal pelvis. When the pelvis is incompletely filled and an opaque catheter is used, the ureter may appear to leave the pelvis at unusual angles. This may be explained by the fact that the elasticity of the ureter permits the catheter to move in unusual positions, while the absence of the colloidal silver fails to outline the ureteropelvic juncture. In Fig. 40 the outline of both pelves is unusual, largely because of incomplete distention of the true pelvis. Of particular interest is the direction of the opaque catheter as it leaves THE NORMAL PliLVIS 73 the pelvis. The absence of the injected medium in both ureters gives an erroneous impression of the position of the ureteropelvic juncture. The Normal Ureter. — Because of the elasticity of the walls of the ureter, and because of the technical difficulty of completely filUng it with an opaque fluid, it is usually impossible to demonstrate the complete outline of the en- tire ureter. As a result of the incomplete distention the Fig. 40. — Normal pelvis and ureter. outline of the ureter may appear more or less irregular. The areas of anatomic narrowing are frequently visible in the outline of the ureter a short distance below the uretero- pelvic juncture, and where the ureter enters the wall of the bladder. The portion of the ureter extending from the true pelvis to the first point of narrowing is usually more fully distended and its lumen appears larger. It is ap- parently a part of the true pelvis, from which it tapers gradually to the point of narrowing. The next visible 74 PYELOGRAPHY point of narrowing is where the ureter enters the wall of the bladder, beyond which the ureteral lumen suddenly narrows. The course of the normal ureter is, as a rule, fairly uni- form unless it is altered by pressure of a stiff catheter or marked renal excursion. Occasionally angulation in the Fig. 41. — Normal pelvis and ureter. course of the ureter, particularly in the first portion near the pelvis, is visible without apparent reason. In Fig. 41 the right ureter turns sharply to the right as it leaves the pelvis, and then proceeds in an S-shaped course. In Fig. 42 a sinuous curve is noted in the course of the ureter at about the ureteropelvic juncture. THE NORMAL PELVIS 75 Fig. 42. — Normal pelvis. Fig. 43. — Normal pelvis and ureter. 76 PYELOGRAPHY When the catheter is in the ureter, the ureteral outhne depends to a great extent on the degree of return flow along- side the catheter, and on the elasticity of the ureteral wall. With a profuse return flow the resulting outline may be easily confused with that of pathologic dilatation. How- ever, the dilatation occurring with pathologic conditions is, as a rule, more uniform and not so irregularly localized Fig. 44. — Normal pelvis and ureter. as with marked return flow in the normal ureter. In Fig. 43 the outline of the pelvis and ureter is normal. There is but a slight degree of return flow alongside the catheter, and but little distention of the ureteral wall is visible. Note the comparative large size of the ureter from where it leaves the true pelvis as far as the first point of narrow- ing. In Fig. 44 the degree of return flow alongside the catheter is rendered clearly visible in the right ureter. THE NORMAL PELVIS 77 The outline of the left ureter is not visible because of in- sufficient distention. In Fig. 13 the irregular outline caused by return flow is also well illustrated. In Fig. 45 the ure- teral outline is markedly irregular as the result of profuse Fig. 45. — Normal but low pelvis; normal but tortuous ureter. return flow. The course of the ureter is tortuous, because of the low position of the kidney. The portion of the ureter located in the wall of the blad- der is not, as a rule, outlined in the ureterogram. An opaque catheter may be visible in this portion of the ureter, 78 PYELOGRAPHY but the injected solution will usually appear only in the por- tion of the ureter above the wall of the bladder. The degree of elasticity of the normal ureter is frequently quite remarkable. When the ureteral lumen is com- pletely occluded by the catheter and considerable pressure used in introducing the fluid, the normal ureter may oc- casionally become distended to a width of two or three Fig. 46. — Normal pelvis and ureter. centimeters. As a result of several areas of partial occlu- sion by the catheter, the ureteral outline may be irregular and nodular. In Fig. 46 the upper ureter is apparently duplicated in a portion of its course. The condition, how- ever, is the result of the ureteral catheter kinking in an elastic and partially filled ureter. CHAPTER IV ABNORMAL POSITION The position of the normal kidney is not fixed, and it is difficult to place any arbitrary limits to the extent of nor- mal change in position. Nevertheless, a marked deviation from the usual position should be regarded as abnormal. Abnormal position of the kidney may be the result of the following conditions: (1) Movable kidney; (2) renal tor- sion; (3) dystopic or pelvic kidney. MOVABLE KIDNEY As a result of various anatomic conditions, the kidney may become movable, and its position will vary, depending upon the attitude assumed by the patient. Movable kid- ney is commonly found in the ill-nourished, with lack of tone in the abdominal muscles and a deficiency of perirenal fat. The condition is usually accompanied by functional nervous disturbances which are reflected by a series of sub- jective symptoms that may render it difficult to identify any actual pain which might result from renal excursion. Defi- nite objective evidence of a pathologic lesion as the result of the renal excursion is, therefore, often necessary before op- erative interference is indicated. The problem then arises, what objective data are of value in determining whether a movable kidney should be operated on? The relative position and the degree of excursion of the two kidneys may be difficult to ascertain by means of pal- pation alone. These data, together with the course of the 79 80 PYELOGRAPHY ureter, may be determined in the radiogram with the as- sistance of the shadow-casting catheter. However, be- cause of various technical reasons, the resulting radiogram is frequently unsatisfactory in determining the exact course of the ureter and in identifying the nature of possible ob- struction to the ureteral catheter. The pyelogram offers better means not alone to show the relative position of the renal pelvis and the relation of the pelvis and ureter, but to demonstrate as well the existence and character of any pathologic complication. Frequently a second pyelogram with the patient in the erect position may be of value in order to determine the comparative degree of renal excur- sion. Excursion in the position of the kidneys, even though marked, would give no objective data for surgical inter- ference unless accompanied by evidence of mechanical dila- tation in the pelvis or ureter. It would be difficult to con- ceive of the existence of actual constriction of the ureter to any definite degree without causing more or less dilatation of the ureter and pelvis above it. Therefore, with both pelves dystopic, even though they were situated as low as the brim of the bony pelvis, if neither of them showed in their out- line any evidence of mechanical dilatation, we would have no objective data to warrant operation. Further, if the ureter showed angulation at any portion of its course, even though it were well marked and acute, unless dilatation of the ureter and pelvis existed above it, no objective data to warrant surgical interference would be present. It may be conceivable, however, that subjective data may be so dis- tinct as to warrant an operation in selected cases. This would rarely be the case when both renal pelves are found to be extremely low. ABNORMAL POSITION 81 The pelvis of the movable kidney is frequently seen to be unusually large, and the calyces in particulai* may appear to be distended and broader than normal. Occasionally the increase in size is so great as to approach the border- line stage, where the differential diagnosis from actual hy- dronephrosis may be difficult. In all probability the kid- Fig. 47. — Movable kidney; abnormal position of kidney. ney assumes certain positions, so that the interference with the urinary drainage, although not prolonged or marked, is sufficient slightly to dilate the pelvis. In Fig. 47 the pelvis of the right kidney is situated opposite the fourth lumbar vertebra, just above the crest of the ilium. It is normal in size and contour. Although there is marked angulation in 6 82 PYELOGRAPHY the ureter just below the ureteropelvic juncture, there is no evidence that it is the cause of any symptoms. The local- ized irregular areas of evident dilatation are caused by profuse return flow. In Fig. 19 the right pelvis is unusu- ally low, being situated on a level with the crest of the ilium. The caudad direction of the calyces shows that the kidney was partially rotated. Although incompletely filled, the calyces are unusually large and probably slightly Fig. 48. — Abnormal position of kidney. dilated. Acute angulation of the ureter is visible a short distance below the ureteropelvic juncture. The pelvis of the left kidney is indistinct, but its position is seen to be unusually low. In Fig. 48 the right pelvis is considerably lower than the left. The calyces are distinctly broader and more elongated than those of the left pelvis. Evidently a temporary obstruction has been present and caused this slight degree of pelvic dilatation. In Fig. 49 the renal ABNORMAL POSITION 83 pelvis is situated at the level of the fourth lumbar vertebra. It has rotated slightly so that the middle calyces extend caudad. The ureter has been displaced by the lower pole of the kidney so that it overlies the fifth lumbar vertebra. In Fig. 50 the right pelvis lies at a level of the third lumbar vertebra, the left at a level of the second lumbar vertebra. Fig. 49.— Abnormal position of kidney. The calyces of the right pelvis are evidently but partially filled. The pelvis of the movable kidney may occasionally be smaller than that of the other kidney. This may be due to the fact that the pelvis is but partially distended by the injected fluid. In fact, it may be quite difficult to outline 84 PYELOGRAPHY Fig. 50. — Abnormal position of kidney. Fig. 51. — Kink in ureter — otherwise normal. ABNORMAL POSITION 85 fully the pelvis of the movable kidney because of marked re- turn flow, which not infrequently occurs. In Fig. 51 the pelvis is situated opposite the fouith lumbar vertebra. It is less than average size, although the calyces are normal. Angulation of the ureter is visible a short distance below /^ Fig. 52. — Abnormal position of kidney. the ureteropelvic juncture. In Fig. 52 the right pelvis is situated at the level of the fourth lumbar vertebra, the left opposite the first and second lumbar vertebrae. The right pelvis, although but partially filled, is evidently smaller than the left pelvis. 86 PYELOGRAPHY The course of the ureter varies considerably with the degree of the renal excursion. As a rule, the course is more or less tortuous and may show one or more rather acute angles in its course, which are usually at or near the ureteropelvic juncture. It must be remembered, however, that the course of the ureter as seen in the ureterogram may be greatly altered by the catheter within the ureter. The Fig. 53. — Abnormal p()>i(ion of the kidney. outline of the ureter made by an injected fluid, as a rule, is more exact than the one made by a shadow-casting catheter. More or less angulation of the ureter is to be expected with the patient in the erect position. It is of more importance if the angulation is present in a dorsal or slightly Trendel- enburg position. In other words, permanent angulation, when marked in spite of the position, would be indicative of possible obstruction, particularly if evidence of dilata- ABNORMAL POSITION 87 tion in the pelvis is present. In Fig. 53 the right pelvis is situated opposite the fifth lumbar vertebra. The calyces are normal, and thus demonstrate that no marked ureteral obstruction is present. The course of the ureter is outlined by the opaque catheter. If silver solution had outlined its course, it would have been more tortuous and would not have been displaced so far to the left. In Fig. 54 marked Fig. 54. — Abnormal position of kidney. angulation of the ureter is visible a short distance below the ureteropelvic juncture. The dilatation of the ureter above this point, as well as the evidence of dilatation in the calyces, demonstrates the existence of actual obstruction. In Fig. 55 the right pelvis lies distinctly lower than the left. An acute angulation of the right ureter may be seen a short distance below the ureteropelvic juncture, in contrast to the normal course of the left ureter. The absence, however. 88 PYELOGRAPHY Fig. 55. — Abnormal position of kidney. Fig. 56. — Abnormal position of the kidney. ABNORMAL POSITION 89 of any dilatation of the pelvis or calyces excludes actual obstruction. In Fig. 56 the right ureter bends back on it- self after leaving the pelvis in an upward direction. The right kidney is movable and the pelvis is situated at a level of the third lumbar vertebra with the patient in the dorsal position. The normal outline of the pelvis excludes any pathologic obstruction. In Fig. 51 the pelvis is situated low, even though the pyelogram was made in the dorsal position. Fig. 57. — Movable kidney. The degree of lateral excursion of the kidney, when mov- able, is not, as a rule, so apparent in the pyelogram as the perpendicular. Occasionally the pelvis is situated so that it lies in close apposition to, or partially overlying, the verte- brae. Seldom, however, is it found entirely over the ver- tebrae. In Fig. 57 the pelvis is situated opposite and partially overlapping the third lumbar vertebra. Although 90 PYELOGRAPHY the general outline is rather large, there is no evidence of hydronephrosis. In Fig. 49 the outline of the pelvis is situated nearer to the vertebrae than usual, as the result of slight lateral excursion. A comparison of pyelograms made with the patient in the dorsal and erect positions may be of value. On physical examination one kidney only — usually the right — may be Fig. 58. — Movable kidney (dorsal posture). found movable. The pyelogram taken in the dorsal posi- tion usually corroborates the abdominal palpation. A sub- sequent pyelogram made in the erect position often shows as great a degree of mobility in the left kidney as in the right. In Fig. 58 (made in the dorsal position) the right pelvis is situated but slightly lower than the average pel- vis, while the position of the left pelvis is normal. On ab- dominal palpation the right kidney could be plainly felt on ABNORMAL POSITION 91 respiration, while only the lower pole of the left kidney could be palpated. In Fig. 59 the pyelogram was made immediately after the preceding with the patient in the erect position. Both pelves are seen at the level of the crest of the ilium. In order to correct the anatomic condition it Fig. 59. — Movable kidney (same as preceding in erect posture). would be necessary to anchor both kidneys. The patient's subjective symptoms were referred largely to the right ab- domen, but the absence of any dilatation in the pelvis or ureter and the demonstration of equilateral mobility would render the advisability of operation doubtful. A similar con- dition is demonstrated in Figs. 60 and 61. On abdominal 92 PYELOGRAPHY Fig. 60. — Movable kidney (dorsal posture). / % > <^^' Fig. 61. — Movable kidney (same as preceding, but in erect posture) ABNORMAL POSITION 93 Fig. 62. — Movable kidney (dorsal posture). Fig. 63. — Movable kidney (same as preceding, but in erect posture). 94 PYELOGRAPHY palpation the right kidney only was easily felt, while in the pyelogram made in the erect position the excursion of both kidneys is evidently equal. In Figs. 62 and 63 the excursion of the right pelvis is much greater than that of the left. In fact, the degree of excursion in the left pelvis, when out- lined in the erect position, may be considered within normal limits. RENAL TORSION Although the direction of the calyces with movable kid- ney may be unusual because of partial rotation of the kid- ney, complete reversal of the normal direction of the calyces and of ureteral insertion rarely complicates the ordinary movable kidney. With renal torsion the outline of the renal pelvis is completely reversed. Instead of the calyces having in a general way a lateral direction, they now ex- tend toward the vertebrae. The ureter, instead of leading toward and parallel to the vertebrae, now leaves the pelvis at the usual situation of the lateral border. The position of the kidney may cause it to be unusually prominent on abdominal palpation, and might be easily confused with tumor. Unless the position of the other kidney is ascer- tained by means of an opaque catheter or pyelogram, this condition might be confused with a horseshoe kidney, which may have a similar arrangement of calyces and ure- ter. In Fig. 64 the renal pelvis is situated at an unusual dis- tance from the vertebral border. This may be explained by the lateral displacement of the entire kidney as the result of torsion. The true pelvis is unusually large, possibly as the result of partial obstruction. The calyces extend from the median border, instead of the lateral, as in the normal, while the ureter leaves the pelvis from the lateral border in- stead of the median. ABNORMAL POSITION 95 DYSTOPIC OR PELVIC KmNEY A moderate deviation from the normal position, or even a freely movable kidney, is not necessarily considered a con- genital anomaly. When, however, the kidney is found ly- ing fixed to the bony pelvis, and when its blood-supply comes from adjacent arteries, it must be regarded as a true Fig. 64. — Kidney rotated on long axis. Large pelvis. congenital anomaly. Although the relative position of a pelvic kidney can frequently be ascertained by means of the shadow-casting catheter, the possibility of error when the opaque catheter is otherwise obstructed must always be considered. Further, the position of the kidney and its relation to the ureter, as well as any pathologic complica- tion which may be present, may better be ascertained by means of the pyelogram. It may be difficult to distinguish 96 PYELOGKAPHY between a low-lying pelvis of a fused kidney and a pelvic kidney. As a rule, however, the distance between the pelvis of an ectopic kidney and the pelvis of the normally situated kidney will be much greater than that separating the two pelves of a fused kidney. Further, lateral or posterior insertion of the ureters into the pelves would aid in differ- entiating the two conditions. The ectopic kidney may be Fig;. 65. — Anomaly of the pelvic kidney. felt as a suprapubic tumor, and it is in the identification of the same that the pyelogram may disclose the condition present. Not infrequently will the pelvic kidney be un- usually small, and its size would then be suggested by that of the pelvic outline. The relation of the ureter to the pelvis in the pyelo- ureterogram is usually anomalous. It leaves the pelvis at unusual angles, more often extending upward and posteriorly ABNORMAL POSITION 97 before taking its downward course. Not infrequently, how- ever, the catheter cannot be introduced into the ureter of the pelvic kidney to its full extent because of the anom- alous course of the ureter. However, obstruction to the ureteral catheter is also frequently encountered because of anatomic and various physiologic conditions in the course of the ureter where the position of the kidney is quite normal. The pyeloureterogram would be effectual in identifying the condition. In Fig. 65 the pelvis of the dystopic kidney is situated opposite the lower portion of the sacrum. The outline is small and shows evidence of atrophy. The course of the ureter is anomalous in that it leaves the pelvis in a prox- imal and lateral direction. The ureter is unusually short. CHAPTER V MECHANICAL DILATATION The renal pelvis, as well as the ureter, may become di- lated as a result of the following conditions: (1) Mechanical obstruction; (2) infection; and (3) tumor. As a result of persistent mechanical obstruction to the ureter, that portion above the obstruction and the renal pelvis will become dilated to a varying degree. As a result, the outline of the pelvis and ureter, as seen in the pyelogram, will demonstrate distinct deviation from the normal. The dilatation caused by mechanical obstruction is usually char- acterized by regularity of outline in contrast to the irregu- larity of inflammatory or tumor dilatation. The various forms which mechanical dilatation assumes may best be demonstrated by describing the changes which may be found, first, in the pelvis (hydronephrosis), and, second, in the ureter (hydro-ureter). THE PELVIS— HYDRONEPHROSIS The various changes in the pelvic outline resulting from mechanical obstruction are best described by considering them according to degree. As demonstrated by the pyelo- gram, the following deviations from the normal pelvic out- line may result from hydronephrosis : 1. Early hydronephrosis. (a) Flattening of terminal irregularities. (b) Broadening of the base of the calyx. (c) Increase in size of true pelvis. (d) Shortening of papillae. 98 MECHANICAL DILATATION 99 2. Moderate hydronephrosis. (a) Broadening of entire calyx. (6) Shortening of papilla;. (c) Change in angle of insertion of ureter. (d) Increase in size of pelvis. (e) Changes of secondary infection. 3. Large hydronephrosis. (a) Partially filled calyces. (6) Rounded individual areas. (c) Single calyces. (d) Diffuse outline of rounded sac. (e) Dim areas suggestive of diluted opaque fluid. Early Hydronephrosis. — In the diagnosis of hydro- nephrosis the greatest problem is presented in definitely demonstrating the existence of early hydronephrosis with a capacity of from 15 to 25 c.c. Ordinarily, with hydrone- phrosis of moderate degree the demonstration of more or less obstruction in the upper ureter by means of the catheter and, following this, the existence of residual urine beyond the obstruction, would suffice to call our attention to the prob- able existence of a hydronephrosis. Should any doubt arise, the condition could be further demonstrated by means of the overdistention method. Thus, if an ounce or more of fluid can be injected into a renal pelvis without any evi- dence of return flow before pain is caused, it may be safe to infer that hydronephrosis is present. However, if on distention a pelvis will hold from 15 to 25 c.c, the question arises are we dealing with a pelvis the normal capacity of which is from 5 to 10 c.c, but which is now dilated to two or three times its normal capacity, or with an unusually large normal pelvis? The existence of a small amount of 100 PYELOGRAPHY residual urine in the pelvis might easily be confused with the rapid flow of hypersecretion. In order, therefore, to demon- strate the exact condition present, the outline of a well- distended pelvis, as seen in the pyelogram, may be of more definite diagnostic value than any other data. Probably the first deviation from the normal to be noted in the pyelogram with early hydronephrosis is a flattening Fig. 66. — ^Hydronephrosis. of the terminal irregularities seen in the normal minor calyces. The apex of the major calyx often becomes flat- tened, and only an occasional vestige of the minor calyx may remain. In Fig. No. 66 the ends of the minor calyces are seen to be flat. As a result, the outline of the calyx appears squared and has been compared to a "plug hat." Accompanying the shortening of the minor calyx there is usually also a broadening of the entire major calyx. In Fig. MECHANICAL D I LATATI O N 101 67 the minor calyces are either effaced oi- inarkfidly abbre- viated. The major calyces are elongated and broadened throughout their extent, while the true pelvis is but sHghtly dilated. In Fig. 68 the broadening and elongation of the major calyces in the right pelvis are more prominent than the abbreviation in the minor calyces. The changes in Fig. 67. — Hydronephrosis. the minor calyces are due to an increase in breadth rather than to a decrease in length. In Fig. 69 the broaden- ing of the major calyces is more prominent in the upper and lower calyces. Several of the minor calyces are markedly enlarged, and might even be considered as sec- ondary major calyces. The terminal irregularities are 102 PYELOGRAPHY Fig. 68. — Hydronephrosis. Fig. 69. — Hydronephrosis. MECHANICAL DILATATION 1 Oo flattened and squared. The true pelvis is distinctly larger than normal. Immediately following or accompanying these changes may be noted an increase in the size of the true pelvis. With the increase in size of the pelvis a shortening or flat- tening of the papillae projecting between the major calyces may be noted. Occasionally the increase in size of the true Fig. 70. — Hydronephrosis. pelvis may be the only apparent change, and the outline of the calyces may remain practically normal. In Fig. 70 the enlargement of the right true pelvis is the predominating feature. The papillae usually projecting between the calyces are almost effaced, in contrast to those in the normal left pelvis. The major calyces are greatly abbreviated, with the exception of the lowest, which is evidently incom- pletely distended. In Fig. 71 the dilatation in the left 104 PYELOGRAPHY true pelvis is the predominating feature. Although the major calyces are probably not fully distended, they are fairly well outlined and are but slightly dilated, while the terminal irregularities are effaced. The intercalyx papillae are unusually well preserved. Considerable difficulty may be found in differentiating the early hydronephrosis from the large normal pelvis, since the outline of either the true pelvis or of the major calyces in a normal kidney is not infrequently of unusual Fig. 71. — Hydronephrosis. size. The changes from the normal must be well marked in order to identify a condition of hydronephrosis. In Fig. 72, although the true pelvis is unusually large, the terminal irregularities of the minor calyces are normal and there is no broadening or elongation of the major calyces. The ab- sence of projecting papillae and the direct communication of the minor calyces with the true pelvis are unusual. In Fig. 73 the calyces, both major and minor, are seen unusually broad. The terminal irregularities are fairly well preserved, however, and the papillary indentations are well defined. MECHANICAL DILATATION 105 Fig. 72. — Normal pelvis. Fig. 73. — Normal pelvis (border-line). 106 PYELOGRAPHY Hydronephrosis would, therefore, be excluded. In Fig. 74 the outline of the upper and lower calyces is suggestive of the broadening and flattening which accompany early hy- dronephrosis. However, the remaining calyces and the true pelvis are quite normal. The peculiar appearance of the lower calyx is probably explained by the shadow of an un- derlying secondary major calyx. The pelvis must, there- fore, be considered normal. Fig. 74. — Normal pelvis. In the demonstration of these small hydronephroses it may be of value to make a bilateral pyelogram in order to compare the outlines of the two pelves. As a rule, an unusual increase in size, if normal, will appear bilateral. The outline of the pelvis on one side appearing two or three times as large as that on the other should be corroboratory evidence of pathologic distention. In Fig. MECHANICAL DILATATION 107 68 the outline of the pelvis of the right kidney is distinctly larger than that of the left. Any doubt as to the existence of dilatation in the right pelvis would be excluded by com- parison of the two pelves. In Fig. 71 the true pelvis of the left kidney is seen to be considerably larger than that of the right. The calyces are broadened and the terminal ir- regularities lost to some extent. On overdistention the Fig. 75. — Hydronephrosis (border-line). capacity of this pelvis was found to be 24 c.c. Such a pyelogram would definitely demonstrate early hydrone- phrosis and would remove any question should the diagnosis be first attempted by means of the ureteral catheter and the overdistention method. Care must be taken to show the outhne of the pelvis of the kidney fully distended in order to demonstrate these early changes. If the calyces were but partially filled, the 108 PYELOGRAPHY normal terminal irregularities of the minor calyces might not be shown, and with a normally broad major calyx the resulting pyelogram might suggest the early changes of a beginning hydronephrosis. Furthermore, unless the pelvis is fairly well distended, the size of the major calyces may not appear to be abnormally large, even in a well-marked hydronephrosis. In Fig. 75 the true pelvis is evidently Fig. 76. — Hydronephrosis. partially filled, while the calyces are probably but slightly distended, giving an erroneous impression of the exact outline. In Fig. 76 the outline of the true pelvis is irregularly elongated and broadened. The calyces are narrow, as though partially filled, and are well separated by the flat- tened papillae. In all probability, however, this pelvis is not fully distended; otherwise the contour of the true pel- vis would be more round and more regular, and its relative MECHANICAL DILATATION 10<» size would not be so much greater than the calyces. The difference in the outlines of a partiallj^ and more completely- filled hydronephrosis is illustrated in Figs. 77 and 78. In Fig. 77 the calyces appear as short, narrow streaks, and the true pelvis is elongated, but not unusually broad. Be- cause of marked ureteral obstruction, but a small amount of the injected fluid entered the pelvis. In Fig. 78 the out- Fig. 77. — Hydronephrosis. line of the same pelvis is more completely distended, and as a result the calyces and true pelvis appear markedly dilated. Another source of confusion in the interpretation of changes subsequent to early hydronephrosis is caused by respiration or motion on the part of the patient while the pyelogram is being taken. In Fig. 3 (normal pelvis), al- though the outline of the true pelvis is not abnormally 110 PYELOGRAPHY large, the minor calyces appear to be broadened, and their outline is indistinct and blurred. The apparent increase in size is explained by the fact that the patient moved or breathed at the time the pyelogram was taken. A point of interest in the diagnosis of hydronephrosis of early or moderate degree is the change frequently seen in the angle where the ureter leaves the pelvis. The course Fig. 78. — Hydronephrosis. of the normal ureter varies considerably, depending upon the relative position of the kidney and the first segment of the ureter. As has been previously stated, the angle formed by the lower border of the true pelvis and the first portion of the ureter is usually wide. With the dilatation of the true pelvis it may, however, become acute. With a low- lying kidney, otherwise normal, the ureter may be seen leaving the pelvis by a circuitous route. However, when MECHANICAL DILATATION Hi the angle at the ureteropelvic juncture is acute, with a dis- tinct increase in the size of the pelvis and definite changes in the outline of the calyces, the course of the ureter may be of corroboratory value in demonstrating hydronephrosis. In Fig. 76 the upper ureter is seen to lie close to the vertebra a short distance below the ureteropelvic juncture. Above this it is tortuous to the point where it leaves the pelvis. Fig. 79. — Hydronephrosis. The contour of the pelvis is unusually elongated, and the major calyces are suggestive of an incompletely distended early hydronephrosis. The course of the upper ureter may be an etiologic factor of the distention. In Fig. 79 the two large rounded shadows are the outlines of the dilated calyces and demonstrate the existence of hydronephrosis to a marked degree. Of particular interest is the tortuous course of the first third of the ureter after leaving the pelvis. 112 PYELOGEAPHY In Fig. 80 the dilated calyces and dim outline of the under- lying pelvis are typical of a large hydronephrosis. The course of the ureter as outlined by the impregnated catheter would be impossible. The position of the catheter is ac- counted for by the large pelvic sac in which it is coiled. The outline of the ureter itself is not visible. Moderate Hydronephrosis. — With increase in size of the hydronephrosis the major calyx is seen to have become con- Fig. 80. — Hydronephrosis. siderably broader in its entire extent, while the terminal irregularities will usually have been effaced. In Fig. 81 the major calyces are short and broadened throughout, while the apices are squared, with the terminal irregularities effaced. The true pelvis is dilated to a considerable ex- tent, and the resulting evenly curved border is typical of mechanical distention in contradistinction to inflammatory MECHANICAL DILATATION 113 Fig. 81. — Hydronephrosis. 837 Fig. 82. — Hydronephrosis. 114 PYELOGRAPHY distention. In Fig. 82 the true pelvis is dilated to a mod- erate degree. Although the upper major calyx alone ap- pears markedly broader, the other calyces are not evident because of insufficient distention. At operation the ca- pacity of the pelvis was found to be approximately 120 c.c. Fig. 83. — Hydronephrosis. In Fig. 83 the pelvis is situated on a leve] of the fourth lumbar vertebra. Judging from the caudad direction of the calyces, the kidney has rotated laterally. The true pel- vis is dilated and evenly rounded from mechanical obstruc- tion. The major calyces are greatly enlarged, and are evi- MECHANICAL DILATATION 115 dently narrower at the base. The ureter is seen to be very tortuous below the ureteropelvic juncture, and evidently leaves the pelvis posteriorly and from below instead of in a median direction. In Fig. 84 the greatly dilated major calyces are visible, with a distinctly pyramidal enlargement, broad at the Fig. 84. — Hydronephrosis. apex and narrow at the base. The minor calyces are en- tirely effaced. The outline of the dilated true pelvis is suggested by a faint shadow underlying that of the major calyces. The pelvic outline is dim, probably as a result of the dilution of the injected solution by retained urine. The course of the upper ureter is markedly tortuous, and evi- 116 PYELOGRAPHY dently leaves the pelvis posteriorly. The position of the calyces would suggest rotation of the kidney. As the degree of pelvic dilatation increases the major calyces become shorter as well as broader. The abbrevia- tion of the calyx may proceed to such an extent that one or two irregular indentations in the otherwise rounded contour of the true pelvis alone may remain. In Fig. 85 the major calyces are shallow and open widely at their base into the Fig. 85. — Hydronephrosis. lumen of the true pelvis. In Fig. 86 the outline of a rela- tively large true pelvis is visible. The uppermost calyx is broadened and shortened, while the other calyces are sug- gested by irregular indentation of the general contour. Accompanying these changes in the outline of the calyx marked increase in the size of the true pelvis will usually The pelvic outhne is usually even and well rounded occur. along its free border, typical of mechanical distention. Its MECHANICAL DILATATION 117 size now makes it easily distinguishable from a very large normal pelvis. This increase in size of the true pelvis may be out of proportion to the more moderate changes seen in the calyces. With increase in size of the true pelvis the papillae, which normally project between the major calyces well into the pelvic lumen, become distinctly shorter and may become so flattened as to be practically effaced. In Fig. 86. — Hydronephrosis. Fig. 86 the papillae are reduced to mere indentations partially separating the abbreviated major calyces. In Fig. 87 the true pelvis is dilated greater in proportion than the calyces. Its smooth, round border is typical of mechanical dilatation. In Fig. 88 the true pelvis is dis- tinctly larger than normal. The calyces appear small, ow- ing to the fact that the pelvis is but partially filled. The capacity of the entire pelvis would be approximately 100 c.c. 118 PYELOGRAPHY .^ ■s ' .^ Fig. 209. — Ureteral stone (ureterogram of Fig. 208j. Fig. 210. — Ureteral shadow. 230 PYELOGRAPHY Fig. 211. — Ureteral stone (ureterogram of Fig. 210). Fig. 212. — ^Ureteral shadow. URETERAL STONE 231 ureter which is apparently dilated in the immediate vicinity of the stone. In all probability the ureter, if fully distended, would appear larger throughout its course. In Fig. 212 a shadow is visible in the area of the left lower ureter. In Fig. 213 a nodular dilatation is apparent in the outline of the lower ureter which corresponds to the position of the stone shadow in Fig. 212. The shadow may therefore be Fig. 213. — Ureteral stone (ureterogram of Fig. 212). regarded as intra-ureteral. In Fig. 214 a stone shadow is situated in the region of the lower portion of the right ureter. In Fig. 215 the opaque catheter is in close apposi- tion to the shadow. The injected solution has returned alongside the catheter so that it has partially enveloped the stone shadow, showing that the shadow in question is within the ureter. If a marked localized sacculation of the ureter or a divertic- 232 PYELOGRAPHY Fig. 214. — Ureteral shadow. Fig. 215. — Ureteral stone (ureterogram of Fig. 214). URETERAL STONE 233 ulum is present at the site of the stone, the exact condition would be demonstrated in the ureterogram. If the rela- tion of a stone so situated to an opaque catheter were re- lied upon, the distance separating the two would easily lead one to believe the stone to be extra-ureteral. Such local- Fig. 216. — Ureteral stone and dilatation. ized dilatation at the site of the stone may be indicative of marked periureteritis or even of perforation of the ureter caused by the stone. Dilatation Above Ureteral Shadow.— The extent of the dilatation which may be apparent above a stone in the ureter will vary with the degree of obstruction. The dila- 234 PYELOGRAPHY tation may be so slight that it is difficult of differentiation from the shadow caused by return flow of the injected fluid which is frequently seen in a flaccid ureter. Further, a ureter may be dilated to a considerable extent, but unless it is fully distended, the dilatation may not be rendered vis- ible in the ureterogram. As a rule, however, a moderate degree of dilatation will be readily demonstrated in the Fig. 217. — Ureteral shadow. ureterogram. Marked ureteral dilatation may be difficult to outline completely because the injected fluid is diluted by the fluid retained in the ureter. In Fig. 216 the stone shadow is visible at a short distance below the dilated ureter. The ureter is well dilated above the ureterovesical juncture as the result of stone obstruction. In Fig. 217 a small shadow is visible in the region of the right lower ureter. In Fig. 218 a slight degree of dilatation is apparent extending URETERAL STONE 235 Fig. 2 18. ^Ureteral stone (ureterogram of Fig. 218). Fig. 219. — Ureteral stone (pyeloureterogram of Fig. 218). 236 PYELOGRAPHY above the shadow. In Fig. 219 the upper ureter is sHghtly tortuous and the pelvic outline shows minor dilatation in the calyces. In Fig. 220 a shadow is visible in the left kid- ney area. In Fig. 221 the same shadow has shifted its position to the region of the upper ureter. That the ureter is markedly dilated may be inferred from the absence of any Fig. 220. — Shadow in the renal area. trace of the diluted solution injected into the ureter. A marked degree of hydronephrosis is apparent resulting from evident mechanical obstruction caused by the stone. In Fig. 222 a small shadow is visible in the area of the right lower ureter. In Fig. 223 the stone shadow is apparently continuous with the outline of the partially distended ureter. This is caused by the injected fluid partially enveloping the URETERAL STONE 23- stone. In Fig, 224 the ureter is more fully distended and the relation of the stone to the dilated ureter is more apparent. Difference in degree of ureteral dilatation occurs with ob- struction at different levels in the ureter. Stone at the Fig. 221. — Ureteral stone (pyelogram of Fig. 220). ureterovesical juncture is usually attended with greater dilatation than when it is situated in the upper ureter. With stone in the lower ureter, the ureteral dilatation will usually diminish in extent as the ureter nears the renal pelvis. It occasionally happens that considerable dilatation is visible in the ureterogram, while at operation the ureter may appear 238 PYELOGRAPHY Fig. 222. — Ureteral shadow. Fig. 223.— Ureteral stone (ureterogram of Fig. 222 partially injected). URETERAL STONE 239 to be but slightly enlarged. This is to be explained \jy the great degree of elasticity in the ureteral wall which may per- mit the ureter to return nearly to its normal caliber when it is not distended. In Fig. 225 the ureteral dilatation ap- parently gradually ceases at about the level of the third Fig. 224. — Ureteral stone (ureterogram of Fig. 222 more fully distended). lumbar vertebra. Above this point the ureter as well as pelvis are normal in outline. With stone in the lower ureter the renal pelvis is fre- quently, though not always, dilated to a greater or less ex- tent. Flattening and broadening of the minor calyces and elongation of the major calyces are the first evidences of 240 PYELOGRAPHY ureteral obstruction visible in the pelvic outline. The dila- tation in the calyces usually remains proportionately larger than that in the true pelvis. When the lower ureter is but partially filled by the injected solution and its outline is un- certain, the existence of ureteral dilatation may be inferred from evidence of dilatation in the renal pelvis, a fact which Fig. 225. — Ureteral dilatation caused by stone in the ureter. may be of considerable importance in the identification of shadows in the lower ureter. With stone in the lower ureter, considerable ureteral dila- tation may be present with little or no change in the out- line of the renal pelvis. However, when the stone is in the upper ureter, more or less pelvic dilatation will always be seen. Absence of changes in the outline of the renal pelvis with a shadow in the upper ureter would demonstrate its URETERAL STONE 241 extra-ureteral nature. In Fig. 226 the outline of the peh'is is normal throughout, although considerable dilatation is apparent in the lower ureter as the result of stone (Figs. 210 and 211). That the radiogram may occasionally fail to show the shadow of a stone, particularly when in the lower ureter, Fig. 226. — Ureteral stone (pyelogram of Fig. 210). is well known. In case of a negative radiogram, when the clinical and cystoscopic data are suggestive of stone in the ureter, characteristic dilatation of the ureter, as demon- strated in a pyelo-ureterogram, would permit the diagnosis of lithiasis. A small stone which the original radiogram has failed to show will occasionally become apparent following a pyelogram because of absorption of the colloidal silver. 16 242 PYELOGRAPHY In Fig. 227 the lower left ureter is slightly dilated above the ureterovesical juncture. The original radiogram was re- ported negative. The predominant symptoms were re- peated colic referred to the left kidney. If any doubt arises whether the lower ureter was actually dilated, it would be removed by evidence of dilatation in the pelvis, ■as demonstrated in Fig. 228. Definite dilatation is visible Fig. 227. — Ureteral dilatation caused by stone (original a-'ray negative). only in the calyces as the result of the mechanical obstruc- tion caused by stone which is probably situated in the ves- ical portion of the ureter. The portion of the ureter which lies in the bladder-wall will not, as a rule, be dilated to the extent of the ureter im- mediately above. Stone in the intramural portion of the ureter, particularly when near the meatus, usually causes little or no dilatation in that portion of the ureter. The URETERAL STONE 243 Fig. 228. — Ureteral stone (pyelogram of Fig. 227). Fig. 229. — Ureteral shadow. 244 PYELOGRAPHY characteristic ureterogram of an intramural stone, there- fore, would show an area of undistended ureter extending above the stone shadow as far as the ureterovesical juncture, beyond which it becomes abruptly dilated. In Fig. 229 a stone-shadow is visible in the region of the left lower ureter. In Fig. 230 the outline of the shadow is still ap- Fig. 230. — Ureteral stone (ureterogram of Fig. 229). parent, while the ureter immediately around it is not mark- edly dilated. A short distance above, which corresponds to the position of the ureteropelvic juncture, the ureter is well dilated. The stone is situated in the vesical portion of the ureter. In Fig. 231 a shadow is visible in the area of the left lower ureter. In Fig. 232 the outline of the dilated ureter is seen above the original shadow, but separated from URETERAL STONE 245 Fig. 231. — Ureteral shadow. Fig. 232. — Ureteral stone (ureterogram of Fig. 231) 246 PYELOGRAPHY it by a distinct break in its outline. This is due to the fact that the stone is situated in the intramural portion of the ureter, which does not dilate to the degree of the ureter above the bladder-wall. Dilatation of the Ureter Below the Stone. — When dila- tation of the ureter is visible below the outline of the stone, Fig. 233. — Ureteral stone. it is usually the result of inflammatory changes in the ure- teral wall subsequent to secondary infection. It is charac- terized by a uniform enlargement of the ureteral lumen in contrast to the irregular nodular dilatation which ac- companies return flow of the injected fluid. Evidence of inflammatory dilatation may sometimes be the only evi- URETERAL STOXE 247 dence of the existence of a previous infection. Occasion- ally ureteral dilatation below a stone shadow may have been caused by mechanical obstruction of a stone previously passed. In Fig. 233 the dilatation visible in the outline of the ureter below the stone shadow is the result of secondary infection. Immediate Return Flow. — Although the urine may flow by a stone in the ureter with its usual volume, it is peculiarly true that often a solution injected from below will be unable to pass beyond the stone. Immediate return of the injected medium at the site of a suspected shadow identi- fies its intra-ureteral position. It may occur wdth a small as well as a large stone, and at any portion of the ureter. It occurs with the majority of stones in the vesical ureter, since this portion of the ureter does not dilate as does the ureter above. Occasionally a slight amount of injected solution may pass beyond the shadow and may appear as a diffuse blur in the ureter above, or even as an isolated shadow in the renal pelvis. When a small stone in the ureter permits no injected fluid to pass by, the constriction of the ureteral lumen at the site of the stone is frequently caused by secondary inflammatory stenosis. The demonstration of immediate return flow is particularly of value in the differ- entiation of anatomic from pathologic obstruction. It must be remembered, however, that with obstruction to the ureteral catheter as the result of anatomic conditions in the vesical portion of the ureter it may occasionally be im- possible to inject any fluid beyond the obstruction. In Fig. 233 two stone shadows are visible in the right kidney area. The lower and larger of the two is situated at the first point of narrowing in the upper ureter. Below it the dilated 248 PYELOGRAPHY ureter is visible, while no evidence of the injected solution is apparent above the stone shadow. Extra-ureteral Shadow. — The relation of a shadow in the area of the ureter to an opaque ureteral catheter has been generally accepted as the best method to determine whether the shadow is intra-ureteral. It was found, however, that a shadow may be extra-ureteral and still appear to be adjacent Fig. 234. — Extra-ureteral shadows. to the outline of the opaque catheter. Further dilatation in the ureter may permit a shadow to be at a distance of a centi- meter from the outline of the opaque catheter and still be within the ureter. The pyelo-ureterogram has been found more exact than the opaque catheter in the recognition of extra-ureteral shadows. Even though the shadow in question is in direct line with the ureter, if the outline of the latter is normal throughout, the shadow may be regarded as being URETERAL STONE 249 situated outside of the ureter. In Fig. 234 two shadows are visible along the course of the left lower ureter. If their relation to an opaque catheter were relied upon, one would infer that the shadows were both intra-ureteral. The ab- sence of any dilatation in the ureter, however, would defin- itely determine that the shadows are extra-ureteral. In Fig. 235 a shadow suggestive of stone is visible in the areas of Fig. 235. — Extra-ureteral shadows. both right and left lower ureters. That these shadows are extra-ureteral may be inferred from the absence of dilatation in the course of the ureter. The presence of a normal out- hne in both upper ureters and pelves evident in Fig. 236 would corroborate this. In Fig. 237 the ureteral catheter is adjacent to an apparent stone shadow. The normal out- line of the pelvis and the absence of dilatation in the ure- 250 PYELOGRAPHY Fig. 236. — Extra-ureteral shadows (pyelo-ureterogram of Fig. 235). Fig. 237. — Extra-ureteral shadow. URETERAL STONE 251 ter, however, determine the extrarenal nature of the shadow. In Fig. 238 the shadow in the right ureter area is apparently Fig. 238. — Extra-ureteral shadow. adjacent to the ureteral catheter. The absence of any di- latation in either pelvis or ureter excludes the possibility of a ureter stone. CHAPTER IX RENAL TUMOR A CHANGE in the nature and outline of the renal paren- chyma as the result of the various types of tumor affects the outline of the renal pelvis to a variable degree. The tumor-forming conditions which may affect the pelvic out- line are neoplasm, polycystic kidney, and solitary cyst. RENAL NEOPLASM Of the different types of tumor, the greatest degree of pelvic deformity will usually be caused by neoplasm. Marked deformity of the renal pelvis is visible on cross- section of a kidney with tumor involvement. Although it is usually impossible to differentiate the forms of neo- plasm by the changes in the pelvic outline, the most extensive pelvic deformity will accompany sarcoma. Deformities in the outline of the renal pelvis resulting from neoplasm may be classified as follows : 1. Retraction of (a) one or more calyces or (6) the true pelvis. 2. Encroachment on the pelvic lumen causing (a) flat- tening of the general pelvic outline, (6) narrowing of the individual calyces, and (c) obliteration of the true pelvis. 3. Secondary necrosis. 4. Abnormal position of the renal pelvis. 5. Deformity at the ureteropelvic juncture. Retraction of the Calyces. — Probably the earliest de- formity of the pelvis resulting from renal tumor is character- 252 RENAL TUMOR 253 ized by a retraction of one or more calyces. As the tumor enlarges toward the periphery it retracts the calyx involved with it. When the tumor is confined to either pole of the kidney, retraction may be confined to the adjacent calyx. As a rule, the retraction is accompanied by distinct narrow- ing of the lumen of the calyx and effacement of its terminal Fig. 239. — Normal pelvis — elongated calyx. irregularities. It should be remembered, however, that in the normal pelvis there may occasionally be one or more calyces unusually elongated. Usually the general contour of the major calyx and the irregularity of the minor calyces will then be found quite normal. Such congenital elonga- tions are apt to occur in both kidneys, although sometimes 254 PYELOGRAPHY it is found in but one side. In order to interpret the pelvis as pathologic, retraction as well as deformity of the calyx must be well marked. In Fig. 239 the upper calyx is symmetrically retracted in both kidneys. The outline of the calyx is otherwise normal, and the terminal irregularities are well retained. In Fig. 240 the proximal calyx is curved and retracted to unusual length, its lumen Fig. 240. — Renal tumor — neoplasm. is markedly narrowed, and the terminal irregularities are effaced. At operation a hypernephroma was found in- volving the upper pole of the kidney. In Fig. 241 the upper calyx is so narrowed that but a dim curved streak remains. The lateral calyx is retracted as well as narrowed. At oper- ation a hypernephroma involving the upper half of the kid- ney was found. The number of calyces involved increases with the size RENAL TUMOR 255 of the tumor. With retraction of multiple calyces, the larger portion of the kidney is usually involved. The calyces may be retracted to unusual lengths — sometimes as far as four or five inches. This will occur more frequently with large tumors. The different calyces retracted in vari- ous directions give a very bizarre appearance in the pyelo- gram, which might well be designated as a ''spider-leg" deformity. The lumen of the calyces in such cases may Fig. 241. — Renal tumor — neoplasm. vary considerably. At times nodular dilatation is visible in their course. Again, there may be narrowing, causing their outUne to appear as irregular narrow streaks. Should the calyces be incompletely filled, their dilated portions alone may appear in the plate. As a result, irregular shadows may be seen scattered over an unusually wide kid- ney area. In Fig. 242 the calyces are retracted irregularly in a manner peculiar to neoplasm. While the calyces are 256 PYELOGRAPHY generally narrowed as well as extended, in areas they be- come retracted laterally and are irregularly broadened. The true pelvis is relatively small. In Fig. 243 the calyces are markedly retracted. The upper calyx extends from the eleventh rib downward parallel to the spine to a dis- Fig. 242. — Renal tumor — neoplasm. tance of three inches, where it joins the other calyces. The caudal calyx extends as far as the upper surface of the fifth lumbar vertebra. It is visible as a narrow, irregular streak running parallel and close to the lateral border of the verte- bra. The middle calyx is also moderately retracted later- Fis- 243. — Renal tumor — neoplasm. ^^^ ?^ 17 Fig. 244. — Renal tumor — neoplasm. 257 258 PYELOGRAPHY ally. The true pelvis is evidently largely obliterated. In Fig. 244 the irregular narrow streaks which extend over a large area in the right kidney region outline the fine crevices resulting from the retraction and narrowing of the calyces by renal neoplasm. The tumor tissue evidently extends down to the first point of narrowing of the ureter, and has largely obliterated the true pelvis. In Fig. 245 the calyces Fig. 245. — Renal tumor — neoplasm. in the left pelvis are retracted in several directions and are markedly narrowed. The outline of the true pelvis is ir- regularly squared. The tumor evidently involves the en- tire kidney. The right pelvis is normal in contrast. The shadow of the tumor tissue outlined adjacent to that of the retracted calyx gives additional evidence of its ab- normality. In Fig. 246 the shadow of the tumor tissue is seen adjacent to a lateral calyx, which extends markedly RENAL TUMOR 259 narrowed and elongated. The lower calyx is probably largely effaced by the tumor tissue. The drainage of the injected fluid from the ends of the tumor-deformed calyces may be very slow. The demonstra- tion of the opaque medium retained in the calyces for more than twenty-four hours after the pyelogram is made may be of corroboratory value in the diagnosis of renal tumor. Fig. 246. — Renal tumor — neoplasm. A single small area of the injected fluid may be seen at some distance from the true pelvis. In Fig. 247 scattered areas of colloidal silver are visible over the right kidney area. The plate was made twenty-four hours subsequent to Fig, 244, and demonstrates the slow drainage of the injected medium which occasionally occurs. Encroachment on the Pelvic Lumen. — When the tumor involves the true pelvis to any great extent, the usual re- 260 PYELOGEAPHY suit is encroachment on the pelvic lumen. With a moderate degree of involvement but one portion of the pelvis may be invaded; with general involvement of the kidney, either irregular narrow spaces may remain or total obliteration of the true pelvis may result. In case of the latter, no evi- dence of the injected medium would be found in the kidney area, but it would be seen extending as far as the uretero- Fig. 247. — Renal tumor — neoplasm. pelvic juncture, ending with a more or less irregular shadow. The tumor tissue may extend down into the upper ureter to a variable extent, indicated by the outline of the ureter remaining. In Fig. 248, as the result of complete invasion by the neoplasm, there is no evidence of a pelvic outline. The outline of the upper ureter is seen to be irregular and evidently filled with tumor tissue for a distance of several RENAL TUMOR 261 ^ Fig. 248. — Renal tumor — neoplasm. Fig. 249. — Renal tumor — neoplasm. 262 PYELOGRAPHY Fig. 250. — Renal tumor — neoplasm (post-operative specimen). Fig. 251. — Renal tumor — neoplasm. RENAL TUMOR 2()3 inches below the pelvis. In Pig. 249 the few irregular streaks indicate the crevices remaining in the pelvis as the result of invasion by tumor tissue. In Fig. 250, which was taken in a postoperative specimen, the tumor has invaded the renal pelvis to such an extent that in one portion but a few irregular narrow crevices remain. The outline of the Fig. 252. — Renal tumor — neoplasm. tumor tissue is apparent in the lower pole. In Fig. 251 a few irregular shadows are seen scattered in the right kidney area which represent markedly retracted and narrow calyces. The true pelvis is represented by an irregular streak, and the upper ureter is irregularly retracted and dilated and is displaced over the vertebra as the result of tumor en- croachment. The streaks visible in the left kidney area are 264 PYELOGRAPHY caused by intestinal shadows and might be confused with those of scattered colloidal silver. When the tumor tissue grows toward the pelvis from either pole, it may encroach upon the outline of the true pelvis so as to flatten it. In such cases one or several of the calyces may be narrowed without retraction. In Fig. 252 the outline of the tumor tissue may be made out as a large, Fig. 253. — Renal tumor — neoplasm. dim, rounded shadow adjacent to and extending below the true pelvis. The pelvic outline is diminished in size and is flattened along its lower border. The lower major calyx is so flattened and narrowed as to form a crescent-shaped streak in keeping with the contour of the tumor shadow. Dilatation of the True Pelvis. — Occasionally, instead of encroachment, irregular dilatation of the true pelvis may result either from retraction or from necrosis of the surround- RENAL TUMOR 265 ing tissue. The condition may occasionally be inferred by determining the presence of residual urine in the pelvis or by the introduction of 25 or 30 c.c. of fluid into the dilated pelvis before causing pain. Dilatation will occur more frequently with carcinoma, since the condition tends to destroy the tissues without retraction of the calyces. In Fig. 253 the outline of the true pelvis is irregularly cylindric. Fig. 254. — Renal tumor — neoplasm. The calyces are largely effaced. The ureteropelvic juncture is' situated at the upper portion of the pelvis. At opera- tion a large carcinoma of the kidney was found. In Fig. 254 the irregular area is suggestive of necrotic areas fre- quently seen with extensive pyonephrosis. At operation a diffuse carcinoma with considerable necrosis and secondary infection of the pelvis was found. Abnormal Position of the Renal Pelvis. — Since the normal 266 PYELOGRAPHY excursion of the kidney may be considerable, the demon- stration of a low-lying pelvis alone would not necessarily be indicative of a pathologic renal condition. Marked lateral or median displacement of the pelvic outline, how- ever, is frequently caused by some abnormal condition. A Fig. 255. — Renal tumor — neoplasm. tumor in the kidney may grow so as to cause considerable displacement of the pelvic outline. As a rule, in such cases deformity of the pelvis, characterized by elongation and flattening of the general contour of the pelvis, as well as of the calyces, will also be present. It must be remembered, RENAL TUMOR 267 however, that extrarenal tumor may also cause lateral or median displacement. This usually occurs to a lesser extent than with renal tumor, and the contour of the pelvis will be normal. In Fig. 255 the pelvis is displaced upward as far as the Fig. 256. — Renal tumor — neoplasm. lower border of the tenth rib, and laterally at an abnormal distance from the vertebrae. Such a tumor would mani- festly be difficult to palpate. The outline of the true pelvis is irregularly elongated and narrow as the result of tumor compression. The calyces are flat and broad, while 268 PYELOGRAPHY the terminal irregularities are largely effaced. In Fig. 256 marked median displacement of the pelvis is demon- strated. The pelvic outline overlies the first and second lumbar vertebrae, and in fact merges with their shadows. The calyces are elongated and irregularly narrowed in a manner which is characteristic of tumor deformity. The outline of the tumor tissue extends laterally and caudad from the pelvis as a large rounded hazy shadow as far as the crest of the ilium. Fig. 257. — Renal tumor — neoplasm. Deformity at the Ureteropelvic Juncture and Upper Ureter. — When the tumor involves the pelvis to a consider- able extent, it may also encroach upon the adjacent portion of the ureter. As in the pelvis, such involvement may either cause retraction of the walls of the ureter or oblitera- tion of its lumen. With tumor retraction of the upper ureter its lumen is usually of the same size and merges with that of RENAL TUMOR 2(39 the true pelvis. In Fig. 257 the pelvic outline, although dim, is irregularly squared, the lower calyx being effaced. The upper ureter is unusually wide as the result of retrac- tion of the surrounding tumor tissue for a short distance be- low the ureteropelvic juncture. If the ureter is involved by invading tumor tissue, its out- line becomes obliterated to the extent of the tumor invasion. Fig. 258. — Pelvic deformity simulating renal tnmor. Occasionally a blood-clot may coagulate in the pelvis and upper ureter and simulate tumor involvement. In case of partial obliteration by either blood-clot or tumor, the re- maining space would be demonstrated by irregular streaks. In Figs. 258 and 259 the pelvic outline is obliterated, while that of the ureter is visible as an irregular spiral shadow ex- tending from a point several inches below the ureteropelvic juncture to the upper portion of the sacrum. The peculiar 270 PYELOGEAPHY outline was due to a blood-clot which obliterated the lumen of the pelvis and first portion of the ureter and partially filled the portion of the ureter outlined by the spiral shadow. At operation the pelvis and ureter were found moderately distended by a well-coagulated blood-clot. The kidney ap- Fig. 259. — Ureteral deformity simulating tumor. peared to be normal on exploration and the hematuria was evidently of the so-called essential type. Occasionally the tumor tissue may displace the upper ureter to a considerable extent without otherwise involv- ing it. In such cases displacement is more often median. RENAL TUMOR 271 The ureter would then appear curved by evident adjacent tumor tissue over the vertebral column. In Fig. 260, while the distribution and size of the two calyces are unusual, typical tumor deformity is not apparent. The true pelvis and ureteropelvic juncture are, however, situated unusually Fig. 260. — Renal tumor — ureteral displacement. near the vertebrae, while the upper ureter is displaced medi- ally so as to lie over them. Sources of Error. — Many difficulties may arise to pre- vent obtaining a successful pyelogram in the case of tumor. The possible sources of error in making the pyelogram are as follows: (1) Errors resulting from faulty pyelographic technic ; (2) obstruction to the ureteral catheter from vari- 272 PYELOGRAPHY ous abnormalities in the course of the ureter, extrarenal pressure upon the ureter, or ureteric metastasis; (3) the inability sufficiently to distend the pelvis of the kidney and ureter because of immediate return of fluid; (4) dilution of the injected fluid by means of retained fluid in the pelvis; (5) obscuring of the pelvic outline by overlying tumor tissue ; (6) error in interpretation. Fig. 261. — Pelvic deformity simulating renal tumor. With marked renal colic at the time of examination the subsequent contraction of the pelvis might leave an ir- regular outline which might easily be confused with the encroachment of tumor tissue. In Fig. 261 the renal pelvis is represented by an irregular streak in the center of a dim shadow which was interpreted to be the outline of the kid- ney. After carefully injecting 3 c.c. of fluid, the patient complained of severe renal pain. The pyelogram was made immediately after, and the contracted pelvic outline is evi- RENAL TUMOR 273 dently physiologic as the result of pain. At operation, a greatly distended gall-bladder was found to overlie a normal kidney. If a normal pelvis with a long normal calyx is incompletely filled, a detached shadow might give the appearance of a retracted calyx. A detached shadow of a retracted calyx incompletely filled might also simulate that caused by stone. Therefore a preliminary plate of every tumor should be made first to exclude the possibility of lithiasis. It will not be possible to make pyelographic demonstra- tion of pelvic deformity in every neoplasm. \Mien the tumor is small or confined to one pole, it often will not cause enough deformity to be of diagnostic value. Practically every tumor involving more than one-third of the kidney will have recognizable deformity. A comparatively small tumor, when situated adjacent to the pelvis, may also cause marked deformity. Again, the tumor, when situated at some distance from the pelvis, may attain considerable size and cause little or no deformity. Interstitial hypernephroma, unless advanced to a marked degree, should cause no de- formity. Obstruction to the ureteral catheter at or below the pelvic juncture may be a source of confusion. Such obstruction would not necessarily indicate a palpable abdominal tumor on that side to be intrarenal. Obstruction met by the ureteral catheter in the upper ureter may be physiologic, or it may be due to pressure from extra-ureteral or extra- renal tumor. If the pyelogram shows that little or no fluid can pass such an obstruction, it may be inferred that the obstruction is pathologic and is either in the ureter or in the kidney. Contra-indications to Pyelography. — (1) If it is evident 18 274 PYELOGRAPHY from the cystoscopic examination that renal tumor is pres- ent, pyelography should not be employed, since, as has been described, the silver solution may act as an irritant when- ever its drainage is interfered with. (2) A pyelogram should not be made in case of tumor when the patient is markedly emaciated or weakened. The possible irritation from the cystoscopic examination alone, not to mention that derived from ureteric catheterization and injection of colloidal silver, may suffice to hasten the patient's death. Differential Diagnosis. — The identification of tumor in the upper lateral abdomen by means of palpation is uncer- tain, since what may appear on palpation to be renal tumor may prove at operation to be tumor of a perirenal organ. Not infrequently tumor may be palpated in the lateral ab- domen, which, from the clinical data, will not be regarded as renal, but which at operation is found to involve the kid- ney. On the other hand, if the tumor involves the upper pole in a high-lying kidney and the abdomen is very large or muscular, it frequently cannot be definitely palpated, even though it may be of considerable size. Further, a large, low-lying kidney may on palpation appear abnormally large and suggestive of tumor. Congenital conditions, such as renal torsion, pelvic and fused kidneys, may be the cause of the evident abdominal tumors best identified by means of pyelography. If a tumor can be demonstrated in the pyelo- gram where palpation is of doubtful value, the diagnosis is certain, while a normal pelvic outline to a great extent excludes renal involvement. It may be difficult to identify clinically a closed renal tumor. The three more common forms, e. g., pyonephrosis, neoplasm, and hydronephrosis, may occasionaUy be diffi- cult to differentiate on cystoscopic examination, particularly RENAL TUMOR 275 when an impassable obstruction is found in the upper ureter. Although none of the injected fluid may enter the pelvis, the outline of the ureter below it may be of differential value. A dilated ureter from ureteritis indicates chronic infection and is to be expected with inflammatory tumors. With an outline of a small ureter below the tumor, the existence of neoplasm may be inferred, since the ureter may become atrophied from disuse. Pyelography is of considerable value in determining the cause of renal hematuria in which the etiologic factor can- not be otherwise ascertained. In the differential diagnosis of obscure neoplasm and chronic infection with hematuria, it may be the only method available. The demonstration of a normal pelvis in a case of hematuria is of definite value in the identification of the so-called essential hematuria. It is particularly useful in the identification of abdominal tumor, where the previous history of hematuria has been indefinite or uncertain and where an examination of the urine is negative or shows but few microscopic elements present. With complete clinical and cystoscopic data, the differential diagnosis of hematuria occurring with hydro- nephrosis, renal neoplasm, or infection is usually not diffi- cult. Occasionally, however, the pyelogram may be the only method whereby a diagnosis can be made. In Fig. 262 no evidence of the pelvic outline is visible. The out- line of the ureter is apparent as far as the ureteropelvic juncture, where it abruptly ends. In case of tumor the outline of the upper ureter would be more diffuse and ir- regular, depending upon the degree of ureteral invasion by the tumor tissue. In case of closed pyonephrosis a greater degree of ureteral dilatation would be expected. The pa- tient's subjective symptoms were largely those of repeated 276 PYELOGEAPHY hematuria and finding of tumor. At operation a large closed hydronephrosis was found. TUMOR OF THE RENAL PELVIS When a tumor originates within the pelvis itself, it will naturally occlude its lumen to a variable degree, depending upon the nature of the neoplasm. The majority of such Fig. 262. — Renal tumor — closed hydronephrosis. tumors being malignant, the outline of the pelvic wall will be markedly altered. If the growth is papillomatous, the pelvic lumen will be obliterated to a variable degree, caus- ing an irregular, narrow outline in the pyelogram. As would be expected, the greater deformity would be found in the true pelvis. The calyces would not be retracted nor neces- sarily obliterated, as occurs with tumor originating in the kidney substance. RENAL TUMOR 277 Angiomatous change of a papilla or a small papilloma would not necessarily cause recognizable deformity. Villous proliferation of the mucosa as the result of a chronic inflam- mation in the pelvis would be accompanied by the changes in outline characteristic of the latter condition. EXTRARENAL TUMOR While the radiographic shadow of extrarenal tumor tissue in its relation to that of the kidney may frequently be of value in identifying an extrarenal tumor, it cannot always be relied upon. More often the outline of the tumor-mass is indistinctly defined and obscurely merged with a more or less indefinite renal shadow. If, however, the renal pelvis is demonstrated in the pyelogram, with a normal outline lying at some distance or in impossible relationship to an adjoining tumor shadow, its extrarenal nature may be defi- nitely ascertained. In Fig. 263 the outline of a normal renal pelvis is seen lying at some distance median to the outline of an extrarenal tumor. Although the renal outline as well as that of the tumor is fairly distinct, the outline of the pelvis is normal and too far distant from the tumor shadow to per- mit the latter to be intrarenal. The outline of the tumor-mass may be situated on a line with the kidney, and the pelvic outline then appears to be within it. If the outline of the renal pelvis is normal, the probability of the surrounding tumor being of renal origin would be slight. Confusion might arise in interpretation when an unusually small pelvis or one with anomalous branching and arrangement of calyces lies in the center of a shadow of a possible renal tumor. In Fig. 261 a distended gall-bladder cast a shadow simulating that of a possible renal tumor. In the center of this shadow is seen a narrow 278 PYELOGEAPHY streak, which might easily be mistaken for a deformed renal pelvis. In this case, however, it represents a small pelvis in a state of marked contraction as a result of overdistention. Displacement of the pelvic outline may be caused by pressure from extrarenal tumor. As a rule, it is more mod- erate in degree than that caused by renal tumor. Retro- peritoneal tumor will probably cause the greatest degree of Fig. 263. — Extrarenal tumor. change in position. Displacement of the upper ureter will usually be slight, even though the position of the kid- ney is changed. Although pressure by extrarenal tumor will not often cause much change in the outline of the pelvis, occasionally it may flatten it to a moderate degree. POLYCYSTIC KIDNEY Abnormality in the pelvic outline accompanying poly- cystic kidney will not be apparent in the pyelogram as fre- RENAL TUMOR 279 quently as with renal neoplasm. It was present in but 12 of the 21 cases of polycystic kidney where a pyelogram was made. The changes in the outline of the renal pelvis which may occur with polycystic kidney are as follows: (1) Short- ening or obliteration of one or more of the calyces, giving the pelvic outline an oval or irregularly squared contour; (2) broad, irregular retraction of the calyces; (3) change in Fig. 264-. — Renal tumor — polycystic kidney. position and axis of the pelvis; (4) inflammatory changes consequent to secondary infection. Obliteration of the calyces may be confined to but one portion of the pelvis, leaving one or more calyces well out- lined. The partial or complete obliteration of the calyces is caused by the encroachment of the cortical cysts. As a rule, the degree of deformity increases with the size and number of the cysts. Occasionally only the remnant of one 280 PYELOGKAPHY calyx will remain, giving the outline of the pelvis a peculiar rounded form; again, the encroachment of the cysts may affect all the calyces and so compress the pelvis as to give it a cylindric outline. Complete obliteration of the pelvis it- self, such as occurs with neoplasm, would hardly be possible. In Fig. 264 the outline of the true pelvis is oval. The calyces Fig. 265. — Renal tumor — polycystic kidney. are dimly outlined and almost obliterated. The pelvic outline is typical of polycystic kidney. In Fig. 265 the right pelvis is displaced downward and median. The out- line of the true pelvis is irregularly oblong, and the calyces are largely obliterated. The course of the ureter may be observed extending over the vertebral column as a curved dim streak. It is evidently displaced by the cystic enlarge- RENAL TUMOR 281 ment in the lower pole of the kidney. In Fig. 2(30 the left pelvis is markedly compressed by the multiple cysts, so that but a narrow streak remains. The calyces are com- pletely obliterated, and the true pelvis markedly flattened and elongated. Upward and lateral displacement of the kidney is evident. The right pelvis shows abbreviation of Fig. 266. — Renal tumor — polycystic kidney. the calyces, but increase in size of the true pelvis, so as to simulate a moderate degree of hydronephrosis. Retraction of the calyces as the result of polycystic growth occurs less frequently than with neoplasm. When it does occur, the retraction causes broad spaces in contrast to the narrow streaks typical of neoplasm. At times the calyx retraction occurring in the polycystic kidney may be so broad and irregular in outline as to suggest pyonephrosis. 282 PYELOGRAPHY The absence of pus in the urine and of inflammatory dila- tation in the outhne of the ureter, however, should exclude the inflammatory nature of the pelvic deformity. In Fig. 267 marked deformity of the pelvic outline is visible. The calyces are widely retracted and broadened throughout; their outline is suggestive of pyonephrosis, but the absence of any evidence of infection in the urine would exclude in- Fig. 267. — Renal tumor — polycystic kidney. flammatory dilatation. At operation a polycystic kidney was found. In Fig. 268 the calyces are retracted to a more moderate degree and are irregularly broadened at their apices. At operation, marked polycystic formation was discovered. Secondary infection will not infrequently cause the patient with polycystic kidney to consult a surgeon. The inflam- matory changes consequent to secondary infection in poly- RENAL TUMOR 283 Fig. 268. — Renal tumor — polycystic kidney. Fig. 269. — Renal tumor — polycystic kidney. 284 PYELOGRAPHY cystic kidney will vary considerably in extent. As a rule, cortical areas are more irregular and larger in extent than is usually seen with the uncomplicated inflammatory pelvic dilatation. The recognition of the actual condition may be difficult, however, and the pelvic outline may easily be con- fused with that of pyonephrosis. In Fig. 269 an irregular pelvic outline is visible on both sides. Although incompletely distended, the calyces, particularly in the left pelvis, are dilated as the result of inflammatory change and their out- lines are suggestive of pyonephrosis. Cystoscopic examina- tion demonstrated infected urine from that kidney. Surgical exploration revealed a polycystic kidney, with secondary infection and tissue degeneration. Encroachment upon the calyces and pelvis by large cysts may cause a change in the relative position of the pelvis. As a result, the pelvic outline may either be displaced to unusual situations or its axis may extend horizontally or even caudad instead of upward, as in the normal. In Fig. 264 the axis of the pelvis extends horizontally and down- ward instead of in the usual upward direction. In Fig. 265 the pelvis is displaced toward the median line and down- ward as the result of polycystic change. The axis of the pelvis is horizontal and slightly caudad. In one case which came under observation a large cyst had ruptured into the pelvis of the kidney. The ruptured cyst was only partially filled with the injected medium, and consequently the resulting outline, although rather indefi- nite, was suggestive of hydronephrosis. In another case of polycystic kidney the kidney was ruptured through trauma some months prior to examination. In the pyelo- gram indistinct areas of the opaque medium were widely scattered, suggestive of diffuse retraction of the calyces RENAL TUMOR 285 usually seen with neoplasm. Similar deformity may often be seen with the usual ruptured kidney. The existence or degree of the pelvic deformity will not necessarily be dependent upon the size of the kidney ex- amined. When with polycystic kidney one kidney only is markedly enlarged, on palpation the deformity is occasion- ally found greater in the pyelogram of the kidne}^ which could not be palpated. Fig. 270. — Renal tumor — solitary cyst. SOLITARY CYST A not infrequent cause of symptomless abdominal tumor is a large solitary renal cyst. The urinary and cystoscopic data may be negative and the nature of the tumor remain unrecognized. When the cyst becomes so large or is so situ- 286 PYELOGRAPHY ated as to compress the pelvis, the resulting deformity may be outlined in the pyelogram. A large cyst may cause con- siderable change in the position and axis of the kidney, possibly as the result of increased weight in one pole. In Fig. 270 marked compression by a large solitary cyst in- volving the entire lower pole and part of the upper is ap- Fig. 271. — Renal tumor — solitary cyst. parent. The outline of the pelvis is cylindric, and is similar to that seen with polycystic kidney. Only the upper calyx, which is abbreviated, remains. The upper portion of the ureter is displaced medially to a moderate degree. In Fig. 271 the direction of the pelvic axis is displaced horizontally and caudad and appears to be pulled downward. The change in position was the result of a large solitary cyst involving RENAL TUMOR 287 the lower pole. In Fig. 272 the anomalous position of the pelvis and arrangement of its calyces were due to pressure from an adjacent Wolffian cyst. The pelvis was displaced laterally by the intervening cyst, which also caused the kid- ney to rotate partially. Fig. 272. — Renal tumor — cyst. THE URETER Renal neoplasm, particularly when involving the lower pole and the lower portion of the pelvis, may involve the first portion of the ureter and retract it to a varying degree. The ureter may also dilate because of mechanical obstruc- tion caused by pressure from extra-ureteral tumor. Such obstruction is frequently observed with various pelvic tumors. In Fig. 257 the pelvis is so encroached upon that but a small space remains. The upper ureter is dilated to a 288 PYELOGRAPHY short distance beyond the ureteropelvic juncture by the surrounding tumor tissue. When a retroperitoneal or abdominal tumor involves the ureteral wall, it may become retracted or constricted by ad- Fig. 273. — Tumor involving ureter. jacent tumor tissue, similarly to the renal pelvis. Such ureteral retraction will, as a rule, be irregularly localized. In Fig. 273 a retroperitoneal sarcoma involved the lower third of the ureter, causing irregularly localized dilatation. CHAPTER X CONGENITAL ANOMALY The clinical diagnosis of congenital anomaly in the kid- ney and ureter was first rendered possible bj^ the introduction of the shadow-casting ureteral catheter. The relative position of the two renal pelves, the course of the ureter, and the existence of dupUcation of the ureter or pelvis could frequently be rendered visible in the radiogram after intro- ducing an opaque catheter into the parts in question. With the development of pyelography, however, additional and more accurate data were acquired in the exact diagnosis of congenital anomaly. By its means we are able to ascer- tain the existence of congenital anomaly which cannot be ascertained by the opaque catheter alone, and the existence and nature of pathologic conditions which may comphcate the congenital anomaly. Anomahes in the kidney and ureter which may be demon- strated by means of pyelo -ureterography are as follows : 1. Duplication of the renal pelvis. 2. Duplication of the ureter. 3. Fused or horseshoe kidney. 4. Congenital increase or decrease in the size of the pelvis. 5. Dystopic kidney. DUPLICATION OF THE RENAL PELVIS Duplication of the renal pelvis may be partial or com- plete, and may vary in degree from an abnormal elongation of the upper calyx to two distinct and widely separated 19 289 290 PYELOGRAPHY pelves. The tendency toward duplication of the pelvis is frequently seen in the outline of an otherwise normal pelvis. The first evidence is apparent in the unusual elongation of the upper major calyx. The calyx may appear unusually large, and the secondary major calyces assume the size usually seen with primary calyces. The isthmus connecting the calyx with the true pelvis and the upper Fig. 274. — Duplication of the pelvis. calyx may be narrow and rudimentary. Such duplica- tion is necessarily always incomplete, since it lacks the separate ureter. In Fig. 20 the outline of the renal pelvis is evidently normal. Our attention, however, is called to the upper major calyx, which is larger than the other calyces and has a dichotomous branching. It is connected with the lower true pelvis by an elongated narrow isthmus which practically separates it. An attempt at pelvic re- CONGENITAL ANOMALY 291 duplication is distinctly present. In Fig. 274 a short isth- mus extends from the upper end of the elongated pelvis and separates it from what may be regarded either as a rudimentary second pelvis or a major calyx with secondary calyces. In Fig. 275 the separation of the upper calyx is seen more distinctly and is apparently a distinct pelvis divided into three secondary major calyces with their minor Fig. 275. — Duplication of the pelvis. calyces. The isthmus connecting the two pelves, or rather the two portions of the pelvis, is evidently narrow and rudi- mentary. In Fig. 276 the outhne of two pelves with their various portions which go to make a complete pelvis is clearly visible. The isthmus connecting the two true pelves is long and narrow. Had the connecting isthmus entered the ureter separately instead of the lower true pelvis, it would have been regarded as a branch of the ureter and the 292 PYELOGRAPHY Fig. 276. — Duplication of the pelvis. Fig. 277. — Duplication of the pelvis. CONGENITAL ANOMALY 293 pelvic duplication would have been complete. In Fig. 277 the major and minor calyces of both pelves are well marked. The isthmus connecting the two pelves is rudimentary and might be regarded as an extension of the common ureter. The ureter is markedly angulated as it leaves the caudal surface of the lower pelvis. In Fig. 278 the duplication of the pelvis is almost complete. Although the two pelves are Fig. 278. — Duplication of the pelvis. separate, they are in such close relation to each other that they might still be called portions of one large pelvis. In- stead of the isthmus connecting the two pelves directly, as in the preceding figures, it here enters directly into the ureter at the site of the ureteropelvic juncture. From a surgical point of view the duplication would hardly be complete. The true pelvis of the upper division is elongated and narrowed so that it i^ practically a division of the upper 294 PYELOGRAPHY branch of the ureter. The three branches of the upper pelvis or major calyces are quite distinct. The various degrees in the process of separation were demonstrated in the preceding figures. When the two pelves have separate paths of drainage into the ureter, the duplica- tion may be regarded as anatomically complete. However, unless the divisions of the ureter extend well beyond the Fig. 279. — Duplication of the pelvis. hilum, the duplication is hardly complete from a practical standpoint. In Fig. 279 the two divisions of the pelvis are quite distinct, but they unite within the kidney and the pel- vis could hardly be considered as completely duplicated. In Fig. 280 the separate pelves in the left kidney unite just beyond the hilum. A distinct demarcation of the outline of the ureter from that of the pelvis is apparent a short distance above the place of ureteral union. In Fig. 281 the duplica- CONGENITAL ANOMALY 295 Fig. 280. — Duplication of the pelvis. Fig. 28L — Duplication of the pelvis. 296 PYELOGRAPHY tion of the pelves is complete and the separate ureters unite a short distance beyond the hilum. Of particular interest is the demarcation of the outline of the upper division of the ureter from the narrow isthmus connecting the upper pelvis. In Fig. 282 the ureters unite a short distance beyond the ureteropelvic juncture of the lower pelvis, and, although the duplication is anatomically complete, bisection of the kid- Fig. 282. — Duplication of the pelvis. ney would be difficult. The relation of the upper branch of the ureter to the lower pelvis is unusual. With complete pelvic duplication the ureters may unite at different levels below the ureteropelvic juncture. In Fig. 283 the union of the two branches of the right ureter does not take place until the level of the fourth lumbar vertebra is reached. Partial reduplication of the pelvis is apparent in the left kidney. In Fig. 284 the ureters, in- CONGENITAL ANOMALY 297 Fig. 283. — Duplication of the pelvis. Fig. 284. — Duplication of the pelvis. 298 PYELOGRAPHY stead of combining as they near each other, merely cross and pursue their independent courses. When the pelvis is duplicated completely, the lower pelvis is usually larger and more completely formed. The upper pelvis is usually smaller, has fewer calyces, and is often rudimentary. This disparity in size occurs so frequently that if, in the course of routine pyelography, the outline of the pelvis is unusually small and high lying, duplication of the pelvis should be inferred and attempts made to outline the lower pelvis. In Fig. 284 the lower pelvis is slightly larger and is more completely formed than the upper. In Fig. 282 the difference in size between the upper and lower pelves is striking. The outlines of both pelves are slightly dilated as the result of chronic infection. In Fig. 283 the size of the two pelves is approximately equal. In Fig. 277, however, the upper pelvis is larger and more completely de- veloped than the lower. A possible source of error may arise should the patient breathe while the pyelogram is being made. As a result, apparent duplication of the pelvis and upper ureter may be present. As a rule, the resulting lateral relation of the pelves with their evident overlapping calyces would be im- possible. With extensive respiratory excursion, however, the outlines of the pelves may be well separated. In Fig. 285 the apparent duplication of the pelvic outline and upper ureter was the result of respiration while the pyelogram was being made. The relative lateral position of the two pelvic outlines would be impossible and the technical error is manifest. Not infrequently duplication of the pelves is complete in regard to separate drainage through the ureters, but communication between the two pelves will remain through CONGENITAL ANOMALY 299 adjacent calyces. That is to say, the upper major calyx of the lower pelvis may merge with the lower major calyx of the upper pelvis. If fluid were injected into one pelvis, it would pass through the communicating calyces into the other pelvis. It is of practical importance to determine the amount of tissue which separates the two pelves. If a considerable distance separates the two pelves, the ease of Fig. 285. — Apparent duplication of the pelvis. surgical bisection is rendered greater. When the two pelves are in such close proximity that the calyces ap- parently overlap, bisection would be rendered more difficult. In Fig. 286 the upper calyx of the lower pelvis is directly continuous with the lower calyx of the upper pelvis, so that the connecting isthmus extends between calyces instead of the true pelvis, as in preceding cases. Methylene-blue solution injected into one ureter returned through the other ureter. 300 PYELOGRAPHY With duplication of the pelvis in one kidney, a tendency toward duplication or unusual increase in size is usually apparent in the other. Complete duplication of the pelves in both kidneys with separate ureters occurs rarely. In Fig. 283 the duplication of the pelves in the right kidney is complete. The left pelvis, although incompletely dis- tended, shows evidence of partial duplication. In Fig. 286 Fig. 286. — Bilateral duplication of the pelvis and ureter. the pelvis in the right kidney is incompletely duplicated, the two pelves communicating through adjacent calyces, as previously described. In Fig. 287 the pelvis in the left kidney of the same patient is completely duplicated. The outline of the upper pelvis is quite normal, while that of the lower pelvis shows evidence of considerable inflamma- tory dilatation. The amount of tissue separating the two pelves would easily permit of bisection of the kidney. At CONGENITAL ANOMALY 301 operation the lower half of the kidney was found largely destroyed by a pyonephrotic process and was removed from the upper portion. The remaining half of the kidney was later found to functionate. Fig. 287. — Duplication of the pelvis and ureter (same as Fig. 286). DUPLICATION OF THE URETER DupHcation of the ureter as in the pelvis may be complete or partial, and bilateral or unilateral. With complete duplica- tion the course of the ureters crosses twice before entering the bladder. The first crossing is usually visible at a short dis- tance below the ureteropelvic juncture. The second crossing is visible at a short distance above the bladder-wall. As a result, the ureter leading from the external and posterior meatus will be found to lead into the lower of the two renal pelves. When the upper crossing is visible, it may be inferred 302 PYELOGRAPHY that the duphcation of the ureter is complete. The points of crossing are at the site where union of the two branches in incomplete duplication usually occurs. In Fig. 288 the left ureter is completely duplicated. The separate ureters cross at a short distance below the ureteropelvic juncture of the lower Fig. 288. — Duplication of ureter and pelvis. pelvis. They cross for the second time at a short distance above the bladder-wall. In Fig. 284 only the upper portion of the duplicated ureters is visible. The two ureters cross at a short distance below the ureteropelvic juncture. The two ureters are usually separate and are situated at CONGENITAL ANOMALY 303 a variable distance apart througliout their course. Occa- sionally, however, the two ureters lie in close apposition, surrounded by a common fibrous sheath for a variable dis- tance in their course. In rare instances such closely ap- proximated ureters may anastomose in a portion of their course. The exact relationship between the two ureters can be demonstrated best by means of the ureterogram. The extent of the duplication, when partial, varies con- siderably. It may involve the greater portion of the ureter or be confined to either the proximal or distal segment. Partial duplication will more often involve the proximal portion of the ureter. With multiple branching of the first portion of the ureter, the place of the true pelvis may be taken by two or more branches of the ureter leading directly into independent calyces. The several branches usually unite at the usual site of the ureteropelvic juncture, and they may be regarded either as divisions of the ureter or as elongated renal pelves. Although, with division of the upper ureter, the different branches more often unite at or near the usual site of the ureteropelvic juncture, they frequently join at a variable distance below this point. In Figs. 280 and 281 the divisions of the ureter may either be regarded as such or as elongations of the duplicated pelves. In Fig. 278 the two divisions of the ureter extend from separate pelves as far as the ureteropelvic juncture, where they unite. In Fig. 283 the right ureter is single from the bladder meatus up to the level of the fourth lumbar vertebra. From this point the ureter is duplicated and extends into separate pelves. Had the opaque catheter alone been used, the existence of this duplication would have been overlooked. Further, had there been any pathologic complication in 304 PYELOGEAPHY either of the pelves, its existence could have been ascer- tained clinically only by means of the pyelogram. With duplication involving the lower portion of the ureter, the two ureters end in separate meati in the bladder. As a rule, the two meati are situated on the same side of the trigone, one meatus lying posterior and lateral to the Fig. 289. — Duplication of the ureter. other and separated by a distance of from 1 to 3 cm. Oc- casionally, however, one meatus will be found in an unusually median position while the other meatus may be situated posterior and lateral at a distance of several centimeters. When the duplication of the ureter is partial and confined to its lower segment, the two meati are usually situated nearer CONGENITAL ANOMALY 305 to one another than with complete duplication. In rare in- stances, when two meati are situated on the same side of the trigone, the ureterogram may show that one of them leads into a ureter which crosses above the bladder to the other side. Duplication confined to the lower end of the ureter is more often of but short extent. Frequently but one cathe- ter can be inserted, the other catheter meeting with ob- i ^^s- C. Fig. 290. — Bilateral duplication of the ureter. struction at a distance of a centimeter or more above the meatus or at the point of anastomosis. In Fig. 289 the outlines of the opaque catheters suffice to show the extent of the duplication, which extends but a short distance above the meatus before uniting. The picture would, however, have been more complete if a ureterogram had been made. With complete duplication of the ureter on both sides the 20 306 PYELOGRAPHY two meati are usually situated on either side of the trigone and the ureters are completely duplicated. Thus in Fig. 290, in the lower portion, the two ureters are seen crossing on either side at a short distance above the bladder-wall. They are again seen in the upper plate, Fig. 286, extending to the pelves and crossing a short distance below. FUSED KIDNEY Although the relative position of the two divisions of a fused kidney can often be determined by means of the shadow-casting catheter, nevertheless more accurate localiz- ing data can usually be obtained by means of the pyelo- gram. Further, the pathologic condition which so fre- quently complicates the anomaly can better be determined by its means. The two pelves of a fused kidney do not, as a rule, lie symmetrically with respect to the vertebral column. While the exact relationship is variable, the most frequent situation is such that the lower lying pelvis is visible near the median line and the upper lying pelvis is distinctly lateral and more nearly normal. Occasionally the relative position of the two pelves in a fused kidney may become confused with the po- sition of a median-lying dystopic kidney and a moderately low-lying kidney. As a rule, however, peculiarities in the position and character of the low-lying pelvis as well as in its ureter will identify the condition present. As with unilateral duplication of the pelvis, the upper pelvis of the fused kidney is usually distinctly smaller than the lower pelvis. In Fig. 291 the two pelves of a fused kidney are visible. The upper pelvis is unusually small, and is separated from the lower pelvis by enough tissue to permit of bisection. The lower pelvis is distinctly dilated, the hydronephrosis being caused CONGENITAL ANOMALY 3(J7 by constriction in the ureter a short distance below the pel- vis. The extent of the hydronephrosis is obscured by the shadow of the vertebrae. The course of the ureters and their relation to their re- spective pelves in the fused kidney are anomalous. The ureter is frequently markedly tortuous and circuitous in its Fig. 291. — Fused kidney — hydronephrosis in lower pelvis. course after leaving the pelvis. In Fig. 292 the two pelves of a horseshoe kidney are clearly visible. The upper pel- vis is normal in size, while the lower pelvis is distinctly dilated because of a constriction of the lower ureter. The ureter appears to be doubled back on itself before entering the posterior surface of the pelvis. The distance separating 308 PYELOGRAPHY the pelves shows that bisection of the kidney would be possible. In a unilateral pyelogram the possibility of a fused or horseshoe kidney should be considered if the ureter leaves the pelvis in a lateral direction instead of the normal median. Fig. 292. — Fused kidney — hydronephrosis in lower pelvis. In Fig. 293 the pelvis and ureter of the left segment of a horseshoe kidney are outlined. They are markedly dilated as the result of mechanical obstruction in the lower portion of the ureter and because of secondary infection. Of par- CONGENITAL ANOMALY 309 ticular interest is the direction in which the ureter leaves the pelvis. The ureteropelvic juncture is at the lateral border of the pelvis, instead of the usual median. Fig. 293. — Horseshoe kidney — pyonephrosis in left pelvis. CONGENITAL LARGE PELVIS With a congenital solitary or asymmetric kidney, the increase in the size and capacity of the pelvis is usually commensurate with that of the kidney. In Fig. 294, al- though the renal pelvis is unusually large, the outlines of the calyces and papillae are normal. The capacity of the pelvis was approximately 22 c.c, as ascertained by the over- distention method. The normal terminal irregularities, 310 PYELOGRAPHY the outline of the major calyces, and the shape of the true pelvis would exclude the possibility of any hydronephrosis being present. Not infrequently one kidney is found to be unusually large and without any apparent pathologic reason to explain it. In such cases the size of the pelvis is usually not com- mensurate with that of the kidney. Where a kidney becomes increased in size because of destruction of the other kidney, Fig. 294. — Solitary kidney. the size of the pelvis is not, as a rule, increased to a relative extent. Occasionally in the course of routine pyelography we are astonished to find the existence of unusually large pelves in patients who have little or no objective symptoms sug- gestive of renal lesion, and in whom we have no other cysto- scopic data indicative of mechanical obstruction in the ureter. The enlargement is usually bilateral, and is charac- terized by marked elongation of the true pelvis. The calyces CONGENITAL ANOMALY 311 are well formed, but are exceptionally broad at the base. The apices and minor calyces appear normal in contra- distinction to the marked changes which usually occur with pelvic enlargement with hydronephrosis. The condition should not be confused with a dilatation of the pelvis and ureter which is of congenital etiology and has been called congenital atony of the renal pelvis. This latter conditirjii Fig. 295. — Congenital large pelvis. is differentiated by an accompanying dilatation of the ureter throughout its extent, which does not occur with the congenital large pelvis. Further, with congenital atony, the outline of the renal pelvis is typical of a hydronephrosis. In Fig. 295 the pelves on both sides are found to be unusually large. The calyces, although broad, show the normal ter- minal irregularities and normal indentation of papillae. The true pelvis itself is elongated and shows a marked 312 PYELOGRAPHY tendency toward duplication, particularly on the right side. But one ureter is present, and it leaves the lower division of the pelvis. In all probabihty this condition is an attempt at duplication of the renal pelvis, with relative increase in the size of the kidney. In Fig. 296 the outline of the large pelvis is suggestive of a pyonephrosis. The terminal ir- Fig. 296. — Congenital large pelvis. regularities and indentations of the minor calyces are normal and well preserved. The urine from the kidney was normal in character. The ureter shows no evidence of inflamma- tory dilatation. Congenital decrease in the size of the pelvis occurs with congenital atrophy of the kidney. This condition, while rare, is occasionally seen, and is to be remembered when CONGENITAL ANOMALY 313 evidence of hypertrophy is apparent in the opposite kidney. As a rule, the diminished secretion and evidence of atrophy in the meatus and ureter call one's attention to the dimin- ished function. In the pyelogram the pelvic outline appears small. The calyces, while rudimentary, show no evidence of inflammatory change. Dystopic kidney has been considered in Chapter IV. BIBLIOGRAPHIC INDEX Albarran, 21, 24 Baker, 19 Blum, 27 Braasch, 20, 21, 22, 23, Bruce, 19, 23 Buerger, 27 Burkhardt, 18 Carot, 23 Childs, 21 Clark, 21, 24 DiETLEN, 19, 24, 26 Doderlein, IS Dohan, 26 Eisendrath, 31 Ekehorn, 27 Ertzbischoff, 21, 24 Fenwick, 17 Fowler, 20, 22, 23 Furniss, 23, 25, 27 HOFMAN, 29 Holland, 26 Illyes, 17 Jaches, 23, 25 Jervell, 27 Joseph, 25 Keene, 23, 24, 25, 26 Kelly, 19, 28 Key, 22, 24 Keyes, 18, 22 Kidd, 20, 25, 30 Klose, 17 24, 25, 26, 27 Kolischer, 17 Kronig, 18 Legueu, 23, 28 Lewis, 19, 28 Lichtenberg, 18, 19, 21, 22, 24, 25, 26, 37 Lowenhardt, 17 Maingot, 23 Mason, 28 Morgandies, 29 Necker, 23, 24 Nemenow, 25 Nogier, 21, 23, 24, 25, 26 Oehlecker, 19, 20, 23, 24, 25, 26, 27 Papin, 23, 28 Paschkis, 24 Pfahler, 18, 19 Polano, IS Rehn, 31 Reynard, 21, 23, 24, 25, 26 Roessle, 29 Rosenblatt, 29 Schmidt, 17 Schramm, 20 Schwarzwald, 28 Seelig, 25 Smith, 29 Spitzer, 21 Stanton, 19 Strassman, 30 Tennant, 28, 30 Thomas, 19 315 316 BIBLIOGRAPHIC INDEX Trendelenburg, 20, 21, 24, 40, 86, 143, 166, 168 Troell, 28 Tuffier, 17 Uhle, 18, 19, 26 Vest, 28, 29 Voelcker, 18, 21, 22, 23, 24, 25, 28, 37 von Illyes, 17 von Lichtenberg, 18, 19, 21, 22, 24, 25, 26, 37 Walker, 23, 28 Wolff, 287 Wossidlo, 30 Zachrisson, 27 NDEX OF SUBJECTS Abnormal position of kidney, 79 of pelvis in renal tumor, 265 Absence of shadow in radiography of renal stone, 192 Accidents in pyelography, history, 27 Alternating contraction and dilata- tion, 164 Anastomoses, apparent, of calyces, 63 Anomaly, congenital, of kidney, 289 of ureter, 289 Appearance of major calyces, 44, 55 of minor calyces, 44 of normal pelvis, 44 of true pelvis, 44 Areas of cortical necrosis in renal tuberculosis, 174 Argyrol in pyelography, 18 Atrophic contraction of pelvis, 165 Axis of pelvis, 54 Bibliography, 32-35 Bismuth emulsion in pyelography, 18 Calyces, apparent anastomoses of, 63 dilatation predominant in, 147 major, appearance of, 44, 55 minor, appearance of, 44 outline of, 65 retraction of, in renal tumor, 252 Calyx, renal stone in, 202 Capacity, functional, of kidney, esti- mate, 135 of true pelvis, 48 Carcinoma, dilatation of true pelvis in, 265 Cargentos in pyelography, 18 Cases, selection of, 36 Catheter, moderately opaque, for pye- lography, 40 Catheter, unusual length of, in diag- nosis of hydronephrosis, 125 ureteral, in diagnosis of large hy- dronephrosis, 120 Causes of ureteral obstruction, 136 Cicatricial constriction of ureter, 142 Colic, renal, in renal tuberculosis, 136 CoUargol in pyelography, 18 solution for injection, 37 Colloidal silver in pyelography, 18 persistence of, in hydronephrosis, 130 solution for injection, 37 Comparison of pyelograms, value of, 90 Congenital anomaly of kidney, 289 diagnosis, 25 of ureter, 289 large pelvis, 309 Constriction, cicatricial, of ureter, 142 Contour of pelvis, 54 Contraction and dilatation, alternat- ing, 164 of pelvis, atrophic, 165 Contraindications to pyelography of renal tumor, 273 Cortical stone, 207 Course of normal ureter, 74 Cyst, renal, solitary, 285 Cystoscope in diagnosis of large hy- dronephrosis, 120 Death after pyelography, 29 Deformity at ureteropelvic juncture in renal tumor, 268 of upper ureter in renal tumor, 268 pelvic, from renal neoplasm, 252 in sarcoma, 252 spider-leg, in renal tumor, 255 Destruction of pelvic outline, 160 317 318 INDEX OF SUBJECTS Diagnosis, differential, of gall-stone and renal stone, 217 of normal pelvis and early hydro- nephrosis, 104 of pyelitis and renal tuberculosis, 174 of renal stone, 190 tumor, 274 of congenital anomaly of kidney, 25 of early hydronephrosis, course of ureter in, 110 of hydronephrosis, 21, 22, 99 etiologic factors, 125 unusual length of catheter in, 125 value of pyelography in, 124 of hydro-ureter, pyelo-uretero- gram in, 136 of inflammatory changes, 23 of large hydronephrosis by cysto- scope, 120 by ureteral catheter, 120 of polycystic kidney, 25 of renal stone, 26 tuberculosis, 24, 172 tumor, 24 of small hydronephroses, bilateral pyelogram in, 106 of stricture of ureter, 27, 143 of ureteral obstruction, 26 stricture, 27 Diagnostic data, history of, 21 significance of immediate return flow, 247 value of pyelography, 21 Differential diagnosis of gall-stone and renal stone, 217 of renal stone, 190 tumor, 274 Dilatation above ureteral shadow in ureteral stone, 233 and contraction, alternating, 164 inflammatory, 145 involving entire pelvis, 154 mechanical, 98 of pelvis in renal stone, 189 nodular, of ureter in ureteral stone, 227 Dilatation of both ureters, causes, 143 of pelvis in renal stone, 186 tuberculosis, 174 of renal pelvis, 145 of true pelvis in carcinoma, 265 in renal tumor, 264 of ureter below ureteral stone, 246 from secondary infection, 246 predominant in calyces, 147 in pelvis, 152 in ureter, 155 Displacement of pelvic outline from extrarenal tumor, 278 Dorsal position for pyelography, 40 Duplication of lower end of ureter, 305 of renal pelvis, 289 of ureter, 301 Dystopic kidney, 95 Elasticity of ureter, 78 Electrargol in pyelography, 18 Enlargement of true pelvis in hydro- nephrosis, 103 Error in technic, sources of, 41 Estimate of functional capacity of kidney, 135 Estimation of renal function, 214 Etiologic factors in diagnosis of hy- dronephrosis, 125 Experiments, injection, on dogs, 31 on rabbits, 30 on sheep, 30 Extrarenal tumor, 277 displacement of pelvic outline from, 278 Extra-ureteral shadow, 248 Function, renal, estimation of, 214 Fused kidney, 306 Gall-stone, 216 and renal stone, differential diag- nosis, 217 Gas injection method, 18 pyelogram, 43 Gravity injection apparatus, 19 INDEX OF SUBJECTS 319 (Jravity method of injection, 38 advantages, 38 injury prevented by, 42 Hand sj^ringe method of injection, 38 Hematuria, renal, pyelography in. 275 History of accidents in pyelography, 27 of diagnostic data, 21 of pyelography, 17-32 Hydronephroses, large, 119 small, bilateral pyelogram in diag- nosis, 106 Hydronephrosis, 98 deviations of pelvic outline from, 98 diagnosis, 22, 99 unusual length of catheter in, 125 early, 99 and normal pelvis, differential diagnosis, 104 appearance of, 100 etiologic factors in diagnosis, 125 from movable kidney, 126 from scoliosis, 130 in renal stone, 190 intrarenal, 134 large, diagnosis by cystoscope, 120 by ureteral catheter, 120 moderate, 112 appearance of true pelvis in, 112 of pregnancy, origin of, 126 persistence of colloidaJ silver in, 130 post-operative course of, 132 secondary infection in, 127 value of pyelography in diagnosis, 124 Hydro-ureter, 135 pyelo-ureterogram in diagnosis of, 136 Identification of renal shadows, 26, 183 pyelographic data for, 184 of ureteral shadows, 26 Infection, secondarj', in hydro- nephrosis, 127 in polycystic kidney, 282 ureteral dilatation from, 246 Inflammation of ureter, 166 Inflammatory changes, diagnosis, 23 in renal stone, 187 dilatation, 145 stenosis, secondary, immediate re- turn flow from, 247 Injection by gravity method, 38 advantages, 39 by hand-syringe method, 38 coUargol solution for, 37 colloidal silver solution for, 37 experiments on dogs, 31 on rabbits, 30 on sheep, 30 medium, selection of, 37 method of making, 38 of .solution, pain in, 21, 39 silver iodid emulsion for, 37 solution, preparation, 37 Injurious results of pyelography, 41 Injury prevented by gravity method of injection, 42 Intrarenal hydronephrosis, 134 Involvement of ureter in renal tumor, 287 Kidney, abnormal position of, 79 congenital anomaly of, 289 diagnosis, 25 dystopic, 95 estimate of functional capacity of, 135 fused, 306 movable, 79 hydronephrosis from, 126 surgical interference in, 80 pelvic, 95 polycystic, 278 diagnosis, 25 secondary infection in, 282 Localization of renal shadows, 26 of shadow of renal stone, 192 320 INDEX OF SUBJECTS Location of stone shadows, solution for, 193 Mechanical dilatation, 98 of pelvis in renal stone, 189 Method of injection, 38 Movable kidney, 79 hydronephrosis from, 126 Nargol in pyelography, 18 Necrosis, cortical, areas of, in renal tuberculosis, 174 Neoplasm, renal, pelvic deformity from, 252 Normal ureter, 73 Outline of minor calyx, 65 of true pelvis, 46 Pain on injection of solution, 21, 39 Pathologic findings in renal tuber- culosis, 136 Patient, position of, 20 Pelvic deformity from renal neo- plasm, 252 in sarcoma, 252 dilatation predominant in calyces, 147 kidney, 95 lumen, encroachment of renal tumor on, 259 outline, destruction of, 160 deviations of, from hydronephro- sis, 98 displacement of, from extra- renal tumor, 278 Pelvis, abnormal position of, in renal tumor, 265 and ureter, relation of, 70 atrophic contraction of, 165 axis of, 54 congenital fused, 309 contour of, 54 dilatation of, in renal stone, 186 in renal tuberculosis, 174 predominant in, 152 entire, dilatation involving, 154 Pelvis, mechanical dilatation of, in renal stone, 189 normal, and early hydronephrosis, differential diagnosis, 104 appearance of, 44 outline of, relation of shadows to, 185 • renal, dilatation of, 145 duplication of, 289 tumor of, 276 true, appearance, 44 in moderate hydronephrosis, 112 capacity of, 48 dilatation of, in renal tumor, 264, 265 enlarged, in hydronephrosis, 103 outline of, 46 renal stone in, 193 Persistence of colloidal silver in hy- dronephrosis, 130 Plate, size of, for pyelography, 20 Plug-hat pelvis, 22 Polycystic kidney, 278 diagnosis, 25 secondary infection in, 282 Position, abnormal, of kidney, 79 of normal renal pelvis, 69 of patient, 20 Post-operative course of hydroneph- rosis, 132 Pregnancy, origin of hydronephrosis and consequent pj^elitis in, 126 Preparation of injection solution, 37 of solution used in pyelography, 20 Pyelitis, 145 and renal tuberculosis, differential diagnosis, 174 of pregnancy, origin of, 126 Pyelogram, gas, 43 Pyelograms, value of comparison of, 90 Pyelographic data for identification of shadows, 184 findings in renal stone, 187 Pyelography, death after, 29 diagnostic value of, 21 first attempt at, 17 INDEX OF SUBJECTS 321 Pyelography, history of, 17-32 of accidents in, 27 of technic, 17 in renal hematuria, 275 in renal tumor, contra-iiulications to, 273 sources of error in, 271 size of plate for, 20 strength of solution for, 21 technic of, 36 value of, in diagnosis of hj'dro- nephrosis, 124 Pyelo-ureterogram in diagnosis of hydro-ureter, 136 Pyelo-ureterography, 17 Pyonephrosis, 160 Radiography of renal stone, absence of shadow in, 192 Reaction from injection of colloidal silver, 27 Relation of pelvis and ureter, 70 Renal colic in renal tuberculosis, 130 cyst, solitary, 285 function, estimation of, 214 hematuria, pyelography in, 275 neoplasm, pelvic deformity from, 252 pelvis, dilatation of, 145 duplication of, 289 normal, position of, 69 tumor of, 276 shadows, identification, 26 localization, 26 stone, 183 diagnosis, 26 differential, 190 dilatation of pelvis in, 186 hydronephrosis in, 190 in calyx, 202 in cortex, 207 in true pelvis, 193 inflammatory change in, 187 localization of shadow of, 192 mechanical dilatation of pelvis in, 189 multiple, shadows of, 210 pyelographic findings in, 187 21 R{(nal stone, radiography of, absence of shadow in, 192 torsion. 94 tuberculosis, 172 and pyelitis, differential diag- nosis, 174 areas of cortical necrosis in, 174 diagnosis, 24, 172 dilatation of pelvis in, 174 pathologic findings, 136 renal colic in, 136 stricture of ureter in, 174 tumor, 252 abnormal position of pelvis in, 265 contraindications to pyelography of, 273 deformity at ureteropelvic junc- ture in, 268 of upper ureter in, 268 diagnosis, 24 differential. 274 dilatation of true pelvis in, 264 encroachment on pelvic lumen, 259 involvement of ureter in, 287 retraction of calyces in, 252 sources of error in pyelography of, 271 spider-leg deformity in, 255 Retraction of calyces in renal tumor, 252 Return flow, immediate, diagnostic significance, 247 from secondary inflammatory stenosis, 247 from ureteral stone, 247 Sarcoma, pelvic deformity in, 252 vScoliosis, hydronephrosis from, 130 Secondary infection in hydronephro- sis, 127 in polycystic kidney, 282 Selection of cases, 36 of injection medium, 37 Shadow, absence of, in radiography of renal stone, 192 extra-ureteral, 248 322 INDEX OF SUBJECTS Shadow, identification, 183 of multiple renal stone, 210 of- renal stone, localization of, 192 stone, solution for location of, 198 relation of, to outline of pelvis, 185 Silver iodid emulsion for pyelography, 19, 37 oxid for pyelography, 18 solutions, colloidal, in pyelography, IS Size of plate for pyelography, 20 Solitary renal cyst, 285 Solution for injection, preparation of, 20 for location of stone shadows, 193 for pyelography, strength of, 21 Sources of error in pyelography of renal tumor, 271 Spider-leg deformity in renal tumor, 255 Stenosis, secondary inflammatory , immediate return flow from, 247 Stone, renal, 183 and gall-stone, differential diag- nosis, 217 differential diagnosis, 190 dilatation of pelvis in, 186 hydronephrosis in, 190 in calyx, 202 in cortex, 207 inflammatory change in, 187 in true pelvis, 193 localization of shadow of, 192 mechanical dilatation of pelvis in, 189 multiple, shadows of, 210 pyelographic findings in, 187 radiography of, absence of shad- ow in, 192 shadows, solution for location of, 193 ureteral, 227 dilatation above ureteral shadow in, 233 of ureter below, 246 immediate return flow from, 247 nodular dilatation of ureter in, 227 Stricture of ureter, diagnosis, 27, 143 in renal tuberculosis, 174 Surgical interference in movable kid- ney, 80 Technic of pyelography, 36 history, 17 Technical error, sources of, 41 Torsion, renal, 94 Trendelenburg position for pyelogra- phy, 40 Tuberculosis, renal, 172 and pyelitis, differential diag- nosis, 174 areas of cortical necrosis in, 174 diagnosis, 172 dilatation of pelvis in, 174 pathologic findings, 136 renal colic in, 136 stricture of ureter in, 174 Tumor, extrarenal, 277 displacement of pelvic outline from, 278 of renal pelvis, 276 pressure from, cause of ureteral dilatation, 139 renal, 252 abnormal position of pelvis in, 265 contraindications to pyelogra- phy of, 273 deformity at ureteropelvic junc- ture in, 268 of upper ureter in, 268 differential diagnosis of, 274 dilatation of true pelvis in, 264 encroachment on pelvic lumen, 259 involvement of renal tumor in, 287 retraction of calyces in, 252 sources of error in pyelography of, 271 spider-leg deformity in, 255 Ureter and pelvis, relation of, 70 cicatricial constriction of, 142 congenital anomaly of, 289 INDEX OP^ SUBJECTS 323 Ureter, course of, in diagnosis of early hydronephrosis, 110 dilatation of, below ureteral stone, 246 from secondary infection, 246 predominant in, 155 duplication of, 301 elasticity of, 78 inflammation of, 166 involvement of, in renal tumor, 287 lower end, duplication of, 305 nodular dilatation of, in ureteral stone, 227 normal, 73 course of, 74 stricture of, diagnosis, 143 in renal tuberculosis, 174 upper, deformity of, in renal tumor, 268 Ureteral dilatation caused by pressure from tumor, 139 Ureteral dilatation, conditions caus- ing, 140 obstruction, 124 causes of, 136 diagnosis, 26 shadows, dilatation above, in ure- teral stone, 233 identification of, 26 stone, 227 dilatation above ureteral shadow in, 233 of ureter below, 246 immediate return flow from, 247 nodular dilatation of ureter in, 227 Ureteritis, 166 Urcteropelvic juncture, deformity at, in renal tumor, 268 Ureters, both, causes of dilatation of, 143 Xeroform in pyelography, 18 JAN 3 1950