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A Roentgen-Ray Sign in the Diagnosis of Unilateral Renal Tuberculosis
A ROENTGEN-RAY SIGN IN THE DIAGNOSIS OF UNILATERAL RENAL TUBERCULOSIS RALPH L. DOURMASHKIN New York
Recently I became impressed with the regularity with which a marked asymmetry in the course of the shadowgraph catheters was noted as they traversed the bony pelvis in tuberculous patients. On the affected side the normal pelvic curve was obliterated and the catheter was observed to run up to the kidney almost in a straight line. As measured from the tip of the iscbial spine the distance from the catheter to the side of the pelvis was, as a rule, decidedly greater on the affected than on the normal side. In going over the records of 42 cases of renal tuberculosis, I came across 13 films which showed opaque catheters on both sides. Many films were given away to patients as they were thought not to be of unusual interest. In some of the earlier cases no roentgen-ray examination of the urinary tract was made, the diagnosis being based upon cystoscopic and microscopical findings. In 6 cases the diagnosis was made by exclusion; on the finding of tubercle bacilli in the bladder urine and on the appearance of the ureteral orifice on the affected side as it was not possible to insert a catheter into the ureter on account of an impassable tuberculous stricture. The frequency with which the asymmetry was noted was a striking feature. In the 13 cases preserved on my files the sign was present in all but 2 cases, which would place its incidence at 84.6 per cent. The presence of this sign, because of the regularity with which it occurs, should lead one at once to suspect the possibility of a tuberculous infection in doubtful cases, or in cases when the latter is not considered at all. In this series, the diagnosis was clear cut in all cases with two exceptions, in which I 455
456
RALPH L. DOURMASHKIN"
failed to find tubercle bacilli in the kidney specimen of unne. The history in one of the latter cases was as follows: A woman, aged thirty-nine, whom I saw in February, 1925, complained of pain over the sacral region, frequency, burning on urination and nocturia for three weeks prior to my examination. The bladder
Fm. Fm.
1.
FIG, 2
1
A TYPICAL X-RAY FILM SHOWING OBLITERATION OF THE PELVIC CuRvE OF THE URETER ON THE AFFECTED SIDE IN A CASE OF ADVANCED RENO-URETERAL TUBERCULOSIS
(Case 5 in table) Fm.
2.
OBLITERATION OF THE PELVIC CURVE ON THE AFFECTED SIDE
(Case 7 in table)
showed evidence of cystitis with bullous edema. The right ureteral orifice was somewhat edematous, otherwise it presented no unusual characteristics. Catheters were passed to both kidneys without obstruction and hazy urine was obtained from the right side, clear from the left. The phthalein output was equal and good on both sides. The smears made from the bladder urine showed two acid-fast bacilli, which looked like tubercle bacilli. There were no other organisms.
- - - - - - - - - - - - - - - - - - - ~ - - - ~ - - - - - - - ~ - - - - - - - ----------------- -
DIAGNOSIS OF UNILATERAL RENAL TUBERCULOSIS
457
The right urine showed innumerable pus cells but after an exhaustive search no tubercle bacilli were found. The left urine was negative.
FIG. FIG.
3.
3
FIG.
4
OBLITERATION OF THE PELVIC CURVE ON THE AFFECTED SIDE IN CASE OF INCIPIENT TUBERCULOSIS
(Case 3 in table) FIG.
4.
OBLITERATION OF PELVIC CURVE IN A DOUBTFUL CASE OF RENAL TUBER-
CULOSIS IN WHICH THE TUBERCLE B-(1.CILLI COULD NOT BE ISOLATED FOR A LONG TIME EITHER IN SMEARS OR BY GUINEA-PIG INOCULATION
(Case cited in text)
Another specimen of urine was obtained from the right kidney one week later which again failed to show tubercle bacilli. Some of the urine · was_ innoculated into a guinea pig with negative results. The patient was then lost from observation. In looking over her x-ray films which were still in my possession, I
458
RALPH L. DOURMASHKIN
noted that the shadowgraph catheter went up to the right kidney almost in a straight line which at once suggested to me a tuberculous infection. An inquiry has disclosed the fact that the patient came under the care of Dr. P. Goldfaber who studied the case very carefully and who finally
Fm. Fm.
Fm.
5A
5B
5A. OBLITERATION oF THE PELVIC CuRVE IN A CASE OF RENAL TUBERCULOSIS
FIG.
5B.
A
PYELOURETEROGRAM IN THE SAME CASE SHOWING THE CATHETER
BISECTING DIAGONALLY THE DILATED LOWER END OF THE URETER
The dilatation of the ureter was undoubtedly due to a tuberculous stricture at its juxta-vesical portion. (Case 1 in table.)
succeeded in obtaining a positive guinea-pig inoculation test for tubercle bacilli with the urine obtained from the right kidney. The inoculation test was made by Dr. Nerb of the Brooklyn Hospital. A nephrectomy was advised which the patient refused to undergo.
DIAGNOSIS OF UNILATERAL RENAL TUBERCULOSIS
459
The pelvic curves described by the ureters as they entered the bladder vary greatly in different individuals, so unless the shadowgraph catheters are used on both sides and a marked asymmetry becomes apparent, the sign fa of little value. In 3 cases in this series, x-rays were taken with the catheter only. on the affected
FIG.
6. A
PYELOURETEROGRAM SHOWING THE STRAIGHTENING OUT OF THE URETER WITHOUT DILATATION
(Case 11 in table)
side and although the pelvic curve was either obliterated entirely or markedly diminished, they could not be considered diagnostic because the comparison with the other side was wanting. The explanation of this phenomenon probably lies in the shortening of the ureter or the retraction of the lower ureteral segment as a result of tuberculous lesion. It may also be argued, however.
TABLE 1 CASE
Side
E. G,
LeH
+ I Reddened
CA.S:ffi
and
I Somewhat
Intense trigon-! itis
3,
D. J.
Right
+
tumefied
Bladder involvement
2,
CASE
Right
Tubercle bacilli found in catheterized specimen of kidney urine Appearance of ureteral orifice
1, B. R.
reddened and ulcerated
Slight
CASE
4,
ZUNEN
I
Left
Slight congestion
CASE
5,
B. E.
CASE
S, K.
Right
CASE
7,
C, ?IL
fl::..
I Extreme
0
Right
+
Retractededem-1 Retracted and atous ulcerated inflamed
I Slight
6,
0:,
Right
+
+ I Normal
I
I Normal.
Blood escaping from right kidney
Normal
+ I Reddened
and
edematous
Extensive trigonitis
;rj
::,,. t:-<
>rj
Ureteral obstruction
Elimination of dye from diseased kidney
Operative findings
X-ray sign present
Definite ob-! struction at lower end of ureter passed with difficulty Good
None
Difference in course of both / 14 n1m. ureters as measured by distance from ischial spine
Obstruction at 18 cm.
I None
None
None
~
t:-< t;;j
0
c1
Poor on both sides. Co-existing nephritis
Operation con-1 Nephrectomy. traindicated. Large tuberPatient culous cavicardiac ties and many tubercles. Ureter not involved
Yes
None
Yes 7mm.
Good
Faint
Fairly good
Diminished
Good
~::,,.
U1
~
Pi H
N ephrectorny. 0 ne small area of cheesy necrosis. Kidney othenvise normal
Operation refused
N ephrectomy. Kidney studded with tuberculous cavities. Ureter tu bercuIous to bladder
Yes
Yes
Yes
14mm.
10mm.
23 mm,
Opera.ti on refused
No
Nephrectomy. Numerous large tuberculous cavitieE<
Yes
20 mm.
z
CAHE ~, S. S.
Side Tubercle bacilli found ('atherized specimen kidney urine
I Right in of
Appearance of ureteral orifice
9,
P. B.
CASE:
Right
+
I I Retracted ated
Bladder involvement
CA:-;E
l\I. M.
Left
+
and ulcer-1 Tumefied reddened
I Very slight
10,
+ and
I Moderate
I Normal
I
CASE
11,
J. L.
GAHR
Right
I Left
Found prcviously (?)
I
Smne,vhat flamed
l\onnal
None
in-
I
12,
C. L.
CASE13,I,W.
Right
+
-1-
Reddened and retracted
,\rea around urete markedly ulcerated and reddened. Not retracted
None
:Harked. Studded with tubercles and ulcers
m H m
q
tJ H P>-
@ 0
0
>zj
Uretera.1 obstruction
Obstruction at 5 cm. which was passed by
Obstruction at 5 cm.
Noue,
None
None
Slight, at juxta-vesi cal portion
Elimination of dye from dbeased kidney
Decidedly diminished
Very goocl
Decidedly diminished
Good
Markedly diminished
Slightly
diminished
z
~
8
[zj
Operative findings
X-ray sign present
N ephrectomy. Large hydronephrotic cavities ~ontained fluid pus, cheesy necrotic rnaterial. Ureter tuberculous
Yes
Difference in course of both [ 21 rnrn. ureters as 1neasured by distance from ischial spine
Lost frorn observation
Yes
20 nun.
Lost from observation
Yes
15 nun.
Operation contraindicated because of diabetes
Yes
27 nnn.
Nophrectomy. Rerr10val of upper 4 inches of ureter. Cortex studded with tubercles. A number of large tuberculous abscesses. Some papillae broken down ,vith cheesy necrosis. Ureter 1narkedly tuberculous
Nephrectomy. Single large calci lied tuberculou patch. Few tu bercles. Kidney small. Ureter not involved
Yes
No. Right kidney line much enlarged containing mot tled area of calci fication, typically tuberculous in appearance
7 1nm.
;:rj
P>-
r
;:rj t,j
z ~ r 8
q IJ:j [zj
;:rj 0
d
None
r
0 m H m
f+'-
0, r--'
462
RALPH L. DOURMASHKIN
that in a dilated ureter secondary to a tuberculous stricture at the juxta-vesical junction, an inserted catheter by keeping close to the inner wall, would give the appearance on x-ray films of being away from the ischial spine. It would not seem plausible, how-
Fm. Fm.
7A.
Fm.
7A
OBLITERATIOK OF THE PELVIC CURVE IN A CASE
7B OF NaN-TUBERCU-
LOUS RENO-URETERAL INFECTION ASSOCIATED WITH A STRICTURE AT THE URETERAL ORIFICE
(From the Urological Department, St. Mark's Hospital, service of Dr. H. S. Jeck) Fm.
7B. SAME CASE SHOWING HuGE DILATATION OF THE ENTIRE URETER
On cystoscopic examination the ureteral orifice on the affected side appeared to be much inflamed, puckered and stenosed. It was with great difficulty and after one fruitless attempt that a small olive tip catheter passed through it. The urine obtained from the affected side was laden with pus and the phenolsulphonephthalein output was practically nil. Cultures showed a colon bacillus infection.
ever, that such a course should be pursued by catheters in all cases in this series. Because of positive diagnosis, based actually on the finding of tubercle bacilli, a pyelogram was done only in two cases. One of them (fig. 5b) showed that the ureteral cath-
DIAGNOSIS OF UNILATERAL RENAL TUBERCULOSIS
463
eter bisected diagonally the dilated lower end of the ureter, which would disprove, at least in this case, the above stated possibility. Table 1 would tend to show that this phenomenon is present in incipient cases as well as in those with extensive renal destruction; in cases having advanced bladder involvement as well as in those in which the changes were slight or altogether absent. The amount of vesical involvement does by no means go hand in hand with changes which take place in the ureter and kidney, so that the appearance of the bladder as determined by a cystoscopic examination being no criterion, the degree to which the ureteral curve is straightened out will entirely depend upon the extent of tuberculous changes in the ureter. The obliteration of the pelvic curve of the ureter has been observed in conditions other than tuberculosis. It has been noted in extensively dilated, displaced atonic ureters, resulting from calculous obstruction or in megalo-ureter, resulting either from congenital or acquired inflammatory strictures at its juxta-vesical portion (figs. 7a and 7b). If tuberculosis is definitely excluded, the sign if present should call for a careful pyeloureterographic study. There is a group of cases, however, in which no lesion was apparently found and in such cases straightening out of the ureter probably was produced by a stiff catheter acting as a splint. In one of these cases there was a history of a diagnosis of a tuberculous kidney being make by cystoscopic investigation twenty years ago in London. As stated before, the striking frequency with which the straightening out of the ureter was noted in tuberculous patients, imparts especial significance to the sign as an aid in the diagnosis of reno-ureteral tuberculosis. The sign, as far as I could gather from rather an extensive survey of the American and European literature, periodical as well as non-periodical, was prnbably not described before. Joseph in his recent visit to the United States, spoke of straightening of the wall of a tuberculous bladder as noted on cystograms. Although all of the observations cited in this article were made independently, I hesitate to claim full credit for priority unless convinced that the sign has not been described elsewhere.
---------------------------------
464
RALPH L. DOURMASHKIN SUMMARY
1. Obliteration of the pelvic curve of the ureter, as determined
by a shadowgraph catheter on the affected side was noted in 84.6 per cent of cases of unilateral renal tuberculosis. 2. As the pelvic curve of the ureter varies greatly in different individuals, the sign is of value only when both ureters are outlined by opaque catheters, in which case a marked asymmetry will be noted. 3. The obliteration of the curve is probably due to a shortening of the ureter as a result of tuberculous lesion. 4. The sign may be present in conditions other than tuberculosis and if observed should call for uretero-pyelographic study. 5. The sign may be observed in cases with no apparent lesion, probably due to straightening out of the ureter by a stiff catheter acting as a splint. 6. The frequency with which it occurs in tubercuious patients should render it of value in doubtful cases or where the tuberculous infection is not suspected at all.
Recently I became impressed with the regularity with which a marked asymmetry in the course of the shadowgraph catheters was noted as they traversed the bony pelvis in tuberculous patients. On the affected side the normal pelvic curve was obliterated and the catheter was observed to run up to the kidney almost in a straight line. As measured from the tip of the iscbial spine the distance from the catheter to the side of the pelvis was, as a rule, decidedly greater on the affected than on the normal side. In going over the records of 42 cases of renal tuberculosis, I came across 13 films which showed opaque catheters on both sides. Many films were given away to patients as they were thought not to be of unusual interest. In some of the earlier cases no roentgen-ray examination of the urinary tract was made, the diagnosis being based upon cystoscopic and microscopical findings. In 6 cases the diagnosis was made by exclusion; on the finding of tubercle bacilli in the bladder urine and on the appearance of the ureteral orifice on the affected side as it was not possible to insert a catheter into the ureter on account of an impassable tuberculous stricture. The frequency with which the asymmetry was noted was a striking feature. In the 13 cases preserved on my files the sign was present in all but 2 cases, which would place its incidence at 84.6 per cent. The presence of this sign, because of the regularity with which it occurs, should lead one at once to suspect the possibility of a tuberculous infection in doubtful cases, or in cases when the latter is not considered at all. In this series, the diagnosis was clear cut in all cases with two exceptions, in which I 455
456
RALPH L. DOURMASHKIN"
failed to find tubercle bacilli in the kidney specimen of unne. The history in one of the latter cases was as follows: A woman, aged thirty-nine, whom I saw in February, 1925, complained of pain over the sacral region, frequency, burning on urination and nocturia for three weeks prior to my examination. The bladder
Fm. Fm.
1.
FIG, 2
1
A TYPICAL X-RAY FILM SHOWING OBLITERATION OF THE PELVIC CuRvE OF THE URETER ON THE AFFECTED SIDE IN A CASE OF ADVANCED RENO-URETERAL TUBERCULOSIS
(Case 5 in table) Fm.
2.
OBLITERATION OF THE PELVIC CURVE ON THE AFFECTED SIDE
(Case 7 in table)
showed evidence of cystitis with bullous edema. The right ureteral orifice was somewhat edematous, otherwise it presented no unusual characteristics. Catheters were passed to both kidneys without obstruction and hazy urine was obtained from the right side, clear from the left. The phthalein output was equal and good on both sides. The smears made from the bladder urine showed two acid-fast bacilli, which looked like tubercle bacilli. There were no other organisms.
- - - - - - - - - - - - - - - - - - - ~ - - - ~ - - - - - - - ~ - - - - - - - ----------------- -
DIAGNOSIS OF UNILATERAL RENAL TUBERCULOSIS
457
The right urine showed innumerable pus cells but after an exhaustive search no tubercle bacilli were found. The left urine was negative.
FIG. FIG.
3.
3
FIG.
4
OBLITERATION OF THE PELVIC CURVE ON THE AFFECTED SIDE IN CASE OF INCIPIENT TUBERCULOSIS
(Case 3 in table) FIG.
4.
OBLITERATION OF PELVIC CURVE IN A DOUBTFUL CASE OF RENAL TUBER-
CULOSIS IN WHICH THE TUBERCLE B-(1.CILLI COULD NOT BE ISOLATED FOR A LONG TIME EITHER IN SMEARS OR BY GUINEA-PIG INOCULATION
(Case cited in text)
Another specimen of urine was obtained from the right kidney one week later which again failed to show tubercle bacilli. Some of the urine · was_ innoculated into a guinea pig with negative results. The patient was then lost from observation. In looking over her x-ray films which were still in my possession, I
458
RALPH L. DOURMASHKIN
noted that the shadowgraph catheter went up to the right kidney almost in a straight line which at once suggested to me a tuberculous infection. An inquiry has disclosed the fact that the patient came under the care of Dr. P. Goldfaber who studied the case very carefully and who finally
Fm. Fm.
Fm.
5A
5B
5A. OBLITERATION oF THE PELVIC CuRVE IN A CASE OF RENAL TUBERCULOSIS
FIG.
5B.
A
PYELOURETEROGRAM IN THE SAME CASE SHOWING THE CATHETER
BISECTING DIAGONALLY THE DILATED LOWER END OF THE URETER
The dilatation of the ureter was undoubtedly due to a tuberculous stricture at its juxta-vesical portion. (Case 1 in table.)
succeeded in obtaining a positive guinea-pig inoculation test for tubercle bacilli with the urine obtained from the right kidney. The inoculation test was made by Dr. Nerb of the Brooklyn Hospital. A nephrectomy was advised which the patient refused to undergo.
DIAGNOSIS OF UNILATERAL RENAL TUBERCULOSIS
459
The pelvic curves described by the ureters as they entered the bladder vary greatly in different individuals, so unless the shadowgraph catheters are used on both sides and a marked asymmetry becomes apparent, the sign fa of little value. In 3 cases in this series, x-rays were taken with the catheter only. on the affected
FIG.
6. A
PYELOURETEROGRAM SHOWING THE STRAIGHTENING OUT OF THE URETER WITHOUT DILATATION
(Case 11 in table)
side and although the pelvic curve was either obliterated entirely or markedly diminished, they could not be considered diagnostic because the comparison with the other side was wanting. The explanation of this phenomenon probably lies in the shortening of the ureter or the retraction of the lower ureteral segment as a result of tuberculous lesion. It may also be argued, however.
TABLE 1 CASE
Side
E. G,
LeH
+ I Reddened
CA.S:ffi
and
I Somewhat
Intense trigon-! itis
3,
D. J.
Right
+
tumefied
Bladder involvement
2,
CASE
Right
Tubercle bacilli found in catheterized specimen of kidney urine Appearance of ureteral orifice
1, B. R.
reddened and ulcerated
Slight
CASE
4,
ZUNEN
I
Left
Slight congestion
CASE
5,
B. E.
CASE
S, K.
Right
CASE
7,
C, ?IL
fl::..
I Extreme
0
Right
+
Retractededem-1 Retracted and atous ulcerated inflamed
I Slight
6,
0:,
Right
+
+ I Normal
I
I Normal.
Blood escaping from right kidney
Normal
+ I Reddened
and
edematous
Extensive trigonitis
;rj
::,,. t:-<
>rj
Ureteral obstruction
Elimination of dye from diseased kidney
Operative findings
X-ray sign present
Definite ob-! struction at lower end of ureter passed with difficulty Good
None
Difference in course of both / 14 n1m. ureters as measured by distance from ischial spine
Obstruction at 18 cm.
I None
None
None
~
t:-< t;;j
0
c1
Poor on both sides. Co-existing nephritis
Operation con-1 Nephrectomy. traindicated. Large tuberPatient culous cavicardiac ties and many tubercles. Ureter not involved
Yes
None
Yes 7mm.
Good
Faint
Fairly good
Diminished
Good
~::,,.
U1
~
Pi H
N ephrectorny. 0 ne small area of cheesy necrosis. Kidney othenvise normal
Operation refused
N ephrectomy. Kidney studded with tuberculous cavities. Ureter tu bercuIous to bladder
Yes
Yes
Yes
14mm.
10mm.
23 mm,
Opera.ti on refused
No
Nephrectomy. Numerous large tuberculous cavitieE<
Yes
20 mm.
z
CAHE ~, S. S.
Side Tubercle bacilli found ('atherized specimen kidney urine
I Right in of
Appearance of ureteral orifice
9,
P. B.
CASE:
Right
+
I I Retracted ated
Bladder involvement
CA:-;E
l\I. M.
Left
+
and ulcer-1 Tumefied reddened
I Very slight
10,
+ and
I Moderate
I Normal
I
CASE
11,
J. L.
GAHR
Right
I Left
Found prcviously (?)
I
Smne,vhat flamed
l\onnal
None
in-
I
12,
C. L.
CASE13,I,W.
Right
+
-1-
Reddened and retracted
,\rea around urete markedly ulcerated and reddened. Not retracted
None
:Harked. Studded with tubercles and ulcers
m H m
q
tJ H P>-
@ 0
0
>zj
Uretera.1 obstruction
Obstruction at 5 cm. which was passed by
Obstruction at 5 cm.
Noue,
None
None
Slight, at juxta-vesi cal portion
Elimination of dye from dbeased kidney
Decidedly diminished
Very goocl
Decidedly diminished
Good
Markedly diminished
Slightly
diminished
z
~
8
[zj
Operative findings
X-ray sign present
N ephrectomy. Large hydronephrotic cavities ~ontained fluid pus, cheesy necrotic rnaterial. Ureter tuberculous
Yes
Difference in course of both [ 21 rnrn. ureters as 1neasured by distance from ischial spine
Lost frorn observation
Yes
20 nun.
Lost from observation
Yes
15 nun.
Operation contraindicated because of diabetes
Yes
27 nnn.
Nophrectomy. Rerr10val of upper 4 inches of ureter. Cortex studded with tubercles. A number of large tuberculous abscesses. Some papillae broken down ,vith cheesy necrosis. Ureter 1narkedly tuberculous
Nephrectomy. Single large calci lied tuberculou patch. Few tu bercles. Kidney small. Ureter not involved
Yes
No. Right kidney line much enlarged containing mot tled area of calci fication, typically tuberculous in appearance
7 1nm.
;:rj
P>-
r
;:rj t,j
z ~ r 8
q IJ:j [zj
;:rj 0
d
None
r
0 m H m
f+'-
0, r--'
462
RALPH L. DOURMASHKIN
that in a dilated ureter secondary to a tuberculous stricture at the juxta-vesical junction, an inserted catheter by keeping close to the inner wall, would give the appearance on x-ray films of being away from the ischial spine. It would not seem plausible, how-
Fm. Fm.
7A.
Fm.
7A
OBLITERATIOK OF THE PELVIC CURVE IN A CASE
7B OF NaN-TUBERCU-
LOUS RENO-URETERAL INFECTION ASSOCIATED WITH A STRICTURE AT THE URETERAL ORIFICE
(From the Urological Department, St. Mark's Hospital, service of Dr. H. S. Jeck) Fm.
7B. SAME CASE SHOWING HuGE DILATATION OF THE ENTIRE URETER
On cystoscopic examination the ureteral orifice on the affected side appeared to be much inflamed, puckered and stenosed. It was with great difficulty and after one fruitless attempt that a small olive tip catheter passed through it. The urine obtained from the affected side was laden with pus and the phenolsulphonephthalein output was practically nil. Cultures showed a colon bacillus infection.
ever, that such a course should be pursued by catheters in all cases in this series. Because of positive diagnosis, based actually on the finding of tubercle bacilli, a pyelogram was done only in two cases. One of them (fig. 5b) showed that the ureteral cath-
DIAGNOSIS OF UNILATERAL RENAL TUBERCULOSIS
463
eter bisected diagonally the dilated lower end of the ureter, which would disprove, at least in this case, the above stated possibility. Table 1 would tend to show that this phenomenon is present in incipient cases as well as in those with extensive renal destruction; in cases having advanced bladder involvement as well as in those in which the changes were slight or altogether absent. The amount of vesical involvement does by no means go hand in hand with changes which take place in the ureter and kidney, so that the appearance of the bladder as determined by a cystoscopic examination being no criterion, the degree to which the ureteral curve is straightened out will entirely depend upon the extent of tuberculous changes in the ureter. The obliteration of the pelvic curve of the ureter has been observed in conditions other than tuberculosis. It has been noted in extensively dilated, displaced atonic ureters, resulting from calculous obstruction or in megalo-ureter, resulting either from congenital or acquired inflammatory strictures at its juxta-vesical portion (figs. 7a and 7b). If tuberculosis is definitely excluded, the sign if present should call for a careful pyeloureterographic study. There is a group of cases, however, in which no lesion was apparently found and in such cases straightening out of the ureter probably was produced by a stiff catheter acting as a splint. In one of these cases there was a history of a diagnosis of a tuberculous kidney being make by cystoscopic investigation twenty years ago in London. As stated before, the striking frequency with which the straightening out of the ureter was noted in tuberculous patients, imparts especial significance to the sign as an aid in the diagnosis of reno-ureteral tuberculosis. The sign, as far as I could gather from rather an extensive survey of the American and European literature, periodical as well as non-periodical, was prnbably not described before. Joseph in his recent visit to the United States, spoke of straightening of the wall of a tuberculous bladder as noted on cystograms. Although all of the observations cited in this article were made independently, I hesitate to claim full credit for priority unless convinced that the sign has not been described elsewhere.
---------------------------------
464
RALPH L. DOURMASHKIN SUMMARY
1. Obliteration of the pelvic curve of the ureter, as determined
by a shadowgraph catheter on the affected side was noted in 84.6 per cent of cases of unilateral renal tuberculosis. 2. As the pelvic curve of the ureter varies greatly in different individuals, the sign is of value only when both ureters are outlined by opaque catheters, in which case a marked asymmetry will be noted. 3. The obliteration of the curve is probably due to a shortening of the ureter as a result of tuberculous lesion. 4. The sign may be present in conditions other than tuberculosis and if observed should call for uretero-pyelographic study. 5. The sign may be observed in cases with no apparent lesion, probably due to straightening out of the ureter by a stiff catheter acting as a splint. 6. The frequency with which it occurs in tubercuious patients should render it of value in doubtful cases or where the tuberculous infection is not suspected at all.