Psoriatic arthropathy in the Roentgenogram

292

American

Journal

of Surgery

Progress

The author describes a case in a man aged sixty-five with symptoms which suggested obstruction of the intestine, possibIv from tumor. The first roentgen examination was negative. A second one showed a shadow not far beyond the duodenojejuna1 angIe the size of a mandarin, connected with the intestine. Its Iower outIine was irreguIar and varied on different examinations. It was movabIe IateraIIy and upward around a fixed point near its upper poIe. It retained opaque matter after the smaI1 intestine was empty. Pressure over the shadow did not cause any muscIe rigidity and onIy shght pain. It did not move much on change of position. In twentyfour hours it was empty. Because of the Iack of uniform density of the shadow the author made a diagnosis of cystic tumor of the jejunum. Operation showed a diverticuIum whose waIIs were made up of a11 three coats of the intestine. UneventfuI recovery. NICHOLS, B. H. Interpretation of the pyeIographic shadow. Radiology, June, 1926, vi, 469-473. The roentgenoIogist must have a thorough knowIedge of a11 anomaIies of the kidney to be abIe to make a cIear diagnosis of the pathoIogica1 conditions. Errors in the interpretation of pyelograms are due to faiIure to recognize anomalies and aIso to incompIete IiIIing of the kidney peIvis. The important anomaIies incIude the foIIowing: (I) Variations in the kidney peIvis size from the smaI1 embryonic form to the Iarge type with numerous caIyces; (2) the calyx may vary from the eIongated cephaIic type to the type with bifurcation of the peIvis and ureter as far as the bIadder; (3) the peIvis may be sIightIy rotated or aImost inverted as in the horseshoe kidney; (4) the innumerabIe bizarre formations of congenitaIIy abnorma1 pelves and of the peIves of mispIaced kidneys. The embryonic peIvis may be.found in congenita1 atrophy of the kidney and may be confused with the contracted peIvis of pyeIitis. The dumbbe shape of the cephaIic caIyx is an important Iead in the interpretation of a bifurcation of the ureter when the upper caIyx aIone is IiIIed. This condition shouId be differentiated from a tumor of the Iower poIe. A ureterogram shouId be made if bifurcation of the ureter is suspected. The mispIaced kidney shouId be differentiated from the floating kidney by hIms in both the upright and horizonta1 positions. The rotated kidney may easiIy be recognized. The inverted type of peIvis with a caIyx drooping downward is characteristic of the horseshoe kidney. Hydronephrosis in an earIy stage is to be

in Surgery

MARCH.

192,

suspected when the minor caIyces are obIiterated and the caIyces and peIvis are dilated. The degree of hydronephrosis is no criterion of the severity of the obstruction. The pyeIogram does not discIose an empyemic kidney. PyeIonephrosis is not evident on the pyeIogram unless a perinephritic abscess has formed and has ruptured into the peIvis or ureter. CIubbing of the caIyces and moderate diIatation are earIy evidences of chronic pyeIitis. Contraction may take pIace Iater producing a smaI1 distorted peIvis. Pyonephrosis is evidenced by a diIated peIvis and caIyces, by areas of necrosis shown by abscess cavities, by areas of connective tissue repair in the kidney, and by enIargement of the kidney. TubercuIosis of the kidney is a pyonephrosis and may show a characteristic irreguIar pyelographic outIine with an ostrich pIume appearance. Phosphatic stones in the kidney peIvis usuaIIy assume the shape and size of the pelvis; if they are spherica they may simuIate tumor. Adenocarcinoma and hypernephroma usuaIIy originate in the.poIe of the kidney and encroach on the caIyces, or they may invoIve the peIvis and produce Iong spindIe shaped caIyces with cIubbed ends. PoIycystic kidney is usuaIIy not pyelographed, but when this is done characteristic cystic areas encroaching on the peIvis are seen. G., and REMENOVSKY, F. Psoriatic arthropathy in the roentgenogram. Fortschr. a. d. Geb. d. R&tgenstrahlen, January, 1926, vi, 98-r 13.

NOBL,

The psoriatic joint diseases appear to be a definite disease entity reIated to the primary chronic types of poIyarthritis from which they are distinguished by certain characteristics. There appears to be a causa1 reIationship between the skin affection and the joint disease aIthough the mechanism remains unexpIained. The process deveIops first as a pureIy inffammatory change in the joint capsule, very soon accompanied by bone atrophy and destructive processes in the cartiIage and in the bone. AS a resuIt of connective tissue or osseous proIiferation in addition to contracture of the capsuIe and high grade there resuIt ankyIoses contractures. The characters that set this condition apart as a distinct entity are the coincidence and distinct interreIationship of the arthritis with the skin invoIvement, and the apparent prediIection for the maIe sex. The changes are seen best in the roentgenograms of the hands or feet, aIthough they may be found in a11 the other joints. ApparentIy no joint remains unattacked. The end resuIt depends on the pre-

New Srries

VOI..1I, No. 3

Progress

in Surgery

dominance of either destruction or fibrosis and osseous proliferation in the joint so that two types may resuIt, one an ulcerous type where the destructive processes have been excessive and the other an indurative or capsuIar type. Brief reports are presented of 3 cases observed by the authors. In addition, the Iiterature on the subject is reviewed and the facts seem to indicate that this disease deserves a name which wouId indicate its inflammatory nature and for this reason it shouId be calIed psoriatic arthritis or arthritic psoriasis. PAZZI, ERMANNO. Roentgen study of a case of calcufous pyonephrosis of the Ieft kidney and hepatic calculus. Arch. di radiol., hlar.June, 1926, ii, 128-135. A woman aged sixty-three was admitted with fever, pain in the Ieft kidney region and pus in the urine. Fifteen years before she had haci a history of hepatic coIic with icterus. The spleen was enlarged and hard and beIow it a painful tumor occupied the left kidney region. The liver was sIightIy painfu1 on deep pressure, but its Iower margin was reguIar and normal in consistency. CIinicaI and roentgen examination showed calculous pyonephrosis of the left kidney and left pararenaf abscess. Functional examination showed the right kidney normaI. Owing to the patient’s condition nothing couId be done but open the pararena abscess, on which she improved and her temperature returnecf to normal. Roentgen examination stil1 showed the stones in the Ieft kidney and two shadows in the right hypochondrium in the hepatorenal region. The normaf function of the right kidney did not prove that they were not kidney stones, for sometimes kidney stones do not affect function if they are not in the peIvis and there are no septic complications. While the shadows on the left were a IittIe in front of the spinal column those on the right were much farther in front of it and mo\-ed freely in a11 directions. And in the dorsoventra1 position instead of being clearer, as kidney stones are from being nearer to the fifm, they were hidden by the spinal column. The patient was discharged but was obIiged to return for extirpation of the Ieft kidney. In the meantime she had had pain in the Iiver region and the liver was more painfu1 on pressure than before. InsufFIation of oxvgen around the kidney n-as practiced to ‘differentiate between kcdnc\- and liver stones. In the ventrodorsa1 picture the right kidney was seen somewhat enfargeci; the margin of the Iiver couId be seen clearly with the stones above it. In the right Iatcraf picture the kidney couId be seen beside the spin4 cofumn and the stones far in front of it. They seemeci to Iie in a slight,

circumscribed, rounded opacity which the author took to be the gaI1 bladder. Though the patient has not been operated upon, and probabIy will not be, for the stones on the right side, the author is convinced that they were gallstones and not kidney stones. POLGAR, FRANZ, and SzEhIzo, GEOKG. hIuftipIe caIcifications in the liver and the spleen (angioma?). Forts&w. a. d. Ceb. d. Riintgenstrahlen, January, 1926, sxxiv, I~I-144. A report is given of the findings in a woman who showed the characteristic aged sixty, symptoms of gastric ulcer. The roentgen examination confirmed this diagnosis of a niche in the Iesser curvature. There was in addition a very unusuaf picture in the region of the spleen: nutnerous smaI1 caIcium shaciolvs confined within the boundary of the spleen. These shadows were diagnosed as phIeboIiths, and a smaf1 number of them were aIso located in the liver. Since phIeboIiths occur in large numbers mostfy in cavernous angiomas, anti since angiomas are relativefy common in the liver and spIeen, it wouId appear that the diagnosis of hepatic and spfenic angioma probably appIies to this case. One cannot, however, exclude the possibility that the phleboliths occurred as a resuIt of thrombosis clue to some other etiology,’ as for instance typhoid fever. No symptoms of hepatoIiena1 disease could be found nor were there any disturbances of the porta circuIation in this case. SHARPE, WILLIAhf, and PETERSON, CARL A. The danger in the use of Iipiodof in the diagnosis of obstructive lesions of the spina cord. Ann. Surg., January, 1926, Ixsxiii, 32-41. The authors injected I C.C. of Iipiodof (Lafap) by Iumbar or cisterna magna puncture into the spina theta of 3 patients for the accurate IocaIization of the upper and lower IeveIs of spinal block. These were seIected cases in which no definite diagnosis and localization could be made by careful neurological examination. The resuIts were of definite diagnostic vaIue in a11 3 cases; but in one case such an inflammatory reaction occurred to the arrested Iipiodof at the site of spina bIock in the mid-dorsal region that the patient’s symptoms and signs were aggravated to a degree necessitating remova of the oi1 at a later operation of Iaminectorn\-. This operation, five months after the injection, discIoseci two encysted gIobuIes of Iipiodof surrounded by numerous newly formeci adhesions. Repeated roentgenograms in the other 2 cases strongIy suggest that the unabsorbed Iipiodol is aIso encysted there. However, since the Iipiodo1 was injected in these 2 patients by lumbar puncture it. fortunately collected in the lowest