Postgrad Med J: first published as 10.1136/pgmj.5.59.193 on 1 August 1930. Downloaded from X-RAY EXAMINATION OF THE URINARY TRACT 193 X-RAY EXAMINATION OF peak, double screens, and the Bucky grid are essential points in the production of radio- THE URINARY TRACT. grams of the necessary quality. By S. COCHRANE SHANKS, URINARY CALCULUS. M.B., C .B. The presence or absence of a urinary Radiologist to the Prince of Wales' General Hospital; stone of any considerable size can be Assistant Radiologist to Charing Cross Hospital. determined radiographically with as great WITH the gradual improvement in radio- certainty as in almost any diagnostic proce- the dure in medicine or surgery. The occur- logical technique during past twenty rence of a stone so as to cast no years, X-ray examination has assumed a transparent greater importance in the diagnosis of shadow in a radiogram is sufficiently rare to disease of the urinary tract than almost any excite comment when it does occur. The other ancillary method. Indeed, no investi- shadow cast by a calculus depends on its gation of the urinary tract from the surgical radiopacity compared with that of the sott can be as without tissues (the latter being equal approximately aspect regarded complete to that of water), and depends on three X-ray examination. In many cases the and its chemical diagnosis is settled by that means, and in factors: its size, its structure, others the field of narrowed composition. possibilities by The effect of the first two is obvious; the exclusion, say, of calculus, hydronephrosis, and &c. larger the stone the denser the shadow, Preparation of the Patient.-This is of the more porous the stone the less dense. ofcopyright. some importance. It is desirable that the Chemical Cormtposition.-The radiopacity canal be as as an element, i.e., its capacity for arresting patient's alimentary empty X-rays varies directly with its atomic number. possible; both fluid, faecal and gaseous the contents may obscure the radiographic The higher the atomic number, greater picture. With modern technique, in which is this capacity. contrast is the Below is appended a table of atomic great desideratum, any numbers of importance in radiology. considerable collection of gas in the colon http://pmj.bmj.com/ might literally " black out" the renal areas H. i. Na. 1. K. I9. Ba. 56. in the negative. The routine preparation is He. 2. Mg. 12. Ca. 20. Pb. 82. as follows : C. 6. Al. I3. Br. 35. Bi. 83. (I) An aperient on the day before. Salines N. 7 P. I5. Ag. 47. should not be used, because of their compo- 0. 8. S. I6. I. 53. sition and tendency to cause gaseous disten- An atom of any element is composed of sion. Castor oil is probably the most an equal number of protons and electrons. on September 25, 2021 by guest. Protected satisfactory. Hydrogen contains one of each. In all the (2) On the day of the examination an other atoms the arrangement is in the form enema may be given, if the result of the of a nucleus containing all the protons and aperient has not been satisfactory. As little half the electrons, the remaining, or plane- food as possible should be taken, the quality tary, electrons being arranged planet-wise in being unimportant. shells round the nucleus. The atomic (3) The bladder should be emptied number corresponds with the number of immediately before the examination. planetary electrons. It is supposed that Technique.-Ingeneral, screen examination the rays are arrested by striking the electrons, is of no value. As a routine, radiograms and that the more there are of them the should be taken to include the whole tract. more radiopaque the substance is. A low kilovoltage, in the region of 70 kv. The soft tissues are composed in the main Postgrad Med J: first published as 10.1136/pgmj.5.59.193 on 1 August 1930. Downloaded from 194 X-RAY EXAMINATION OF THE URINARY TRACT of C, H, O and N, all of them elements with they can be displaced from side to side by a low atomic number. Any calculus con- moving the patient. If the stone be in a taining in quantity elements of a higher vesical diverticulum no displacement takes atomic number will cast a shadow in a place. Their shape is usually round, oval radiogram. or ovoid, and a common and typical Types of calculi with reference to their appearance is lamination of their shadow. opacity :- Pure Uric Acid Stone.-No shadow. DIFFERENTIAL DIAGNOSIS OF URINARY Ammonium Urate Stone.-A faint CALCULI. shadow. Phosphatic Stone. - A moderate The following may simulate urinary shadow. calculi :- Oxalate Stone.-A dense shadow, Renal. because of a large percentage of Intestinal Contents, Enteroliths, Shot from calcium. Game.-Re-examination after further pre- Cystine and xanthine stones, if pure, paration will distinguish between these. cast no shadow, but usually they Calcified Abdominal Glands.-These typi- contain some calcium. cally show an irregular density and outline, Virtually the opacity of a stone which distinguishes them. depends on its calcium and Calcified Gall-stones.-These are com- phosphorus content, as do the monly ringed, and, if multiple, facetted. A bones. lateral radiogram shows them in the anterior part of the abdomen, while renal stones liecopyright. POINTS IN THE RADIOGRAPHIC DIAGNOSIS posteriorly. OF CALCULI. Calcified Tuberculous Kidney.--Here the Kidney.-The shape is usually angular if shadows are mottled and diffuse. small, in which case they are commonly Papilloma of Skin on Back.-Inspection multiple. If large, they are branching, and will exclude this. tend to form a " cast" of the renal pelvis http://pmj.bmj.com/ and calyces. They are typically uniform in Ureteric. texture. A satisfactory radiogram will show Calcified Abdominal Glands. the outline of the kidney, and the shadow Tip of Lumbar Transverse Process.-This must be within this area. may be very dense compared with the rest Ureter.-As these are formed in the kidnev of the transverse process, and if, as it not the shape is that of a small renal stone. infrequently is, in the form of an acces- They are in the line of the ureter. This sory epiphysis, may closely simulate a on September 25, 2021 by guest. Protected passes down across the tips of the transverse stone. processes of the lumbar vertebrae, over the Calcareous Iliac Artery : Calcified Sacro- line of the sacro-iliac joint, and finally sciatic Ligament.-These give irregular sweeps round medial to tlhe shadow of the striated shadows. brim of the true pelvis to reach the bladder. Phleboliths.-These are the commonest If the stone is oval the long axis should be source of confusion. They occur very fre- in that of the ureter. Passage of an opaque quently in the iliac veins in the pelvis. If ureteric catheter will indicate the site of the single and in the ureteric line they cannot opacity relative to the ureter. be distinguished from ureteric stones with- Bladder.-Vesical calculi cast their shadow out the use of an opaque catheter. As a a little above the symphysis pubis, and in rule they are multiple, and their irregular or near the mid-line. If the bladder be full distribution gives the clue to their nature. Postgrad Med J: first published as 10.1136/pgmj.5.59.193 on 1 August 1930. Downloaded from

X-RAY EXAMINATION OF THE URINARY TRACT 195 Bladder. the administration should be stopped when Prostatic Calculi and Calcification. The lumbar pain occurs, or when Io c.c. has shadows are rather low for the vesical area, been given. In some cases of hydrone- lying as they do behind the symphysis, and if phrosis renal pain does not occur with the calculi are multiple, or the calcification distension, and it is therefore unwise to extensive, the prostate is outlined. inject more than IO c.c. unless an appreciable Fcecal mass in rectum, particularly if quantity of urine has been previously drawn opaque medicines, such as bismuth, have off from the renal pelvis. been taken. A purge, followed by re- After a satisfactory outline of the renal examination, will settle the matter. pelvis has been obtained, the ureter can be Calcified Fibroid.-The irregular striation outlined fully by withdrawing the catheter will usually distinguish this rather rare almost out of the ureter, and then, while condition. the exposure is being made, keeping the Pelvic Dermoid.-If this contains teeth or ureter distended by pressure from the bone, a shadow will be cast. The recogni- syringe. tion of a tooth crown decides the nature in The pyelogram is of value in demonstrat- these cases. ing the following conditions. Calcareous Seminal Vesicles.-A rare con- Hydronephrosis.-A pyelogram will give dition, giving an irregular shadow. clear and unequivocal evidence of hydrone- Phlebolith. phrosis in all but the very earliest cases. Foreign body, introduced by a hysterical The earliest change is clubbing of the patient. This may form the nucleus of a calyces, broadening and shortening of the stone. calycal necks, and gradual distension of the renal pelvis. The junction of ureter and OTHER RADIOGRAPHIC AIDS IN DOUBTFUL pelvis becomes demarcated, and the uretercopyright. CASES OF CALCULUS. and lower margin of the pelvis form an Opaque Catheter.-The tip of an opaque increasingly acute angle. Finally the whole catheter may not coincide with the shadow becomes converted into a more or less of a renal calculus, but should at least be loculated sac. near it. The shadow of the catheter must Calculous Pyonephrosis.-A pyelogram will coincide with that of a ureteric stone, and show the latter element, and so will indicate moreover, must coincide in radiograms the operation of choice. taken from varying angles. Renal Neoplasm.-A pyelogram may show http://pmj.bmj.com/ The only exception to this rule would be definite changes, the following being the a small calculus lying loose in a grossly most characteristic: dilated ureter. (I) Partial or complete obliteration of Pyelography.-The opaque injection will calyces and/or renal pelvis (" filling defect "). blot out the shadows of renal calculi, or (2) " Spider pelvis," in which the calyces show them in relief if they are large and become narrow pointed processes.

(3) Irregular enlargement, from traction on September 25, 2021 by guest. Protected transparent. ind ulceration of portions of the pelvis and Technique oJ Pyelography. calyces. The patient must be conscious, as the The " spider pelvis " appearance may also breath must be held during the exposure, as be seen in polycystic disease and atrophic the surgeon requires to know the onset of pyelonephritis. pain in the loin as an index of distension of Congenital and Postural Abnormalities of the renal pelvis. The administration of the Kidney.-These include such conditions hyoscine and morphine makes it difficult to as nephroptosis, horse-shoe kidney, double obtain breath-held skiagrams, if the amnesia kidney, torsion of the kidney, kinking of the is considerable. Spinal anaesthesia is satis- ureter, and as a rule give evidence of their- factory but abolishes the pain on distension presence in a pyelogram. In horse-shoe of the renal pelvis. After preliminary cysto- kidney the lower part of the pelvis and scopy the opaque catheter is passed and 6 inferior calyx may be prolonged down- to io c.c. of a sterile solution of sodium wards and inwards as a process lying bromide or sodium iodide is run in. No behind the ureter, which it may partially considerable pressure should be used, and obstruct. Postgrad Med J: first published as 10.1136/pgmj.5.59.193 on 1 August 1930. Downloaded from

196 REVIEWS Cystography. spa treatment, local applications, massage, This is used to demonstrate the position light and electricity are all considered briefly and size of a vesical diverticulum. Radio- but plainly. One chapter deals with treat- grams should be taken in two planes after ment by vaccine, sera and foreign proteins. filling the bladder with a 5 per cent. solution The later chapters discuss the treatment of of sodium bromide. individual diseases, which are considered in detail. There is an excellent chapter on Intravenous Urography. emergency therapeutics, and the book con- During the past year a new method has cludes with an appendix dealing with the evolved by which the urinary tract may be doses, incubation and quarantine periods. outlined in a radiogram. Forty grm. of The book can be recommended to of "Uroselectan " (an iodine-phenol-pyridine students and practitioners, who will find in compound) dissolved in 80 c.c. of double- it much useful and practical information. distilled water, and sterilized in the auto- There are many illustrations and charts, clave, are injected intravenously. Within which are well produced and help to explain fifteen minutes the uroselectan is being the text. excreted by the kidney in sufficient con- centration to cast a shadow. The kidney CANCER OF THE LUNG AND OTHER INTRA- substance is increased in density and the THORACIC TUMOURS. By Maurice renal pelvis, ureter and bladder are visual- Davidson, M.A., M.D., B.Ch.(Oxon.), ized. The shadow is not nearly so dense F.R.C.P.(Lond.), Physician to the as in a pyelogram, and meticulous technique Brompton Hospital for Consumption is essential. Radiograms are taken fifteen, and Diseases of the Chest, and Dean of forty-five and seventy-five minutes after the Brompton Hospital Medical School: The method also affords a Physician to the Miller General Hospital injection. copyright. chemical method of estimation of renal for South-East London; Consulting efficiency. Physician to St. Luke's Hospital, It is still in the experimental stage, Chelsea. Bristol: John Wright and but with improved technique it will pro- Sons, Ltd. I930. Pp. 170, with 60 bably tend to replace pyelography in those illustrations. Price Ijs. 6d. cases in which cystoscopy is not necessary As the author explains, the object of this for diagnosis. book has been to correlate the different of aspects primary lung cancer, and at the http://pmj.bmj.com/ same time to indicate the varieties and scope REVIEWS. of treatment nowadays applicable to this condition; in view, moreover, of the fact HANDBOOK OF THERAPEUTICS. By David that a comprehensive study in book form of Campbell, M.C., M.A., B.Sc., M.D., the subject has not previously been pub- Pollok Lecturer in Materia Medica and lished in the English language, we feel that Pharmacology in the University of Dr. Davidson's monograph should be Glasgow; Assistant Physician to the granted a very cordial welcome at the on September 25, 2021 by guest. Protected Western Infirmary of Glasgow, &c. present time. Edinburgh: E. and S. Livingstone. The opening chapter is devoted to 1930. Pp. 411. Price 12s. historical details and statistical records As the author points out, the teaching of which the author lucidly interprets as treatment is apt to be neglected in the proving not only an absolute but also a medical curriculum. In this book, which is relative increase in lung cancer. written for the practitioner and serious The pathological aspect is dealt with student, a reasoned view of the various clearly and comprehensively, and the some- therapeutic methods are given. what vexed question of aetiology is reviewed The first seven chapters are devoted to with commendable precision. the principles of treatment. They include There follows an excellent account of the an account of the prescription, how it clinical manifestations of primary lung should be written, incompatibles and the cancer which summarizes the observations general action of drugs. The effect of diet, of famous clinicians past and present, also