1980, British Journal of Radiology, 53, 381 APRIL 1980

Correspondence
synchronized cells were irradiated with 250 cGy (rad) near abnormality was detected. We were fairly certain that the
the end of Gi (the most resistant phase for these cells), there
pregnancy was abnormal, but as in all such "firsts" there
was a radiation-induced delay of 3.6 hours before the onset was the nagging doubt that perhaps we might be wrong and
of DNA synthesis; thus the normal 20-hour cycle time was were condemning a normal pregnancy to therapeutic abortion.
increased to be very nearly in synchrony with the irradiationAs a result, we tried one more test before arriving at a
time. Accordingly, in an unsynchronized population the final decision. This brings us to the crux of this letter.
survivors from the first dose, which will be mostly those in In 1963, Thomas et al. reported a technique of fetal
their most resistant phase of the cell cycle, will also be inpyelographya method for detecting fetal life. This test
their most resistant phase for the second dose. The syn- consisted of injecting urographic contrast medium into a
chrony will progressively increase and with it the shape of maternal vein and radiographing the maternal abdomen
the survival curve will also change from that of an unsyn- three and 20 minutes later looking for opacification of fetal
chronized population to that of cells in the most resist- kidneys. A live fetus would excrete the contrast while a dead
ant phase. A change in the relative distribution of cells in one would not. A 47% accuracy rate was claimed. We tried
the cell cycle measured by the distribution of the DNA this test in our patient at 19 weeks' gestation and saw no
per cell after protracted irradiation has already been noted opacification of fetal kidneys. This, of course, was due to the
experimentally (Kal and Barendsen, 1973). The protection fact that there were no kidneys. However, in a case in which
resulting from this synchronizing effect will be partly offset
there are functioning kidneys present, we really do not know
by the decreased ability to absorb sublethal damage after how often we might expect to see them. Because of the
many fractions (McNally and de Ronde, 1976). More ex- radiation involved, it is not feasible to run a series to see how
periments using multifractionated doses and different cell often fetal kidneys opacify with this technique. Conceivably,
lines are required to establish the most relevant parameters with newer equipment, faster films and intensifying screens,
for daily and other multifraction treatments. fetal kidneys might be seen more often nowadays than they
Yours, etc., might have been in 1963 when Thomas et al. wrote their
D. L. DEWEY. paper.
Gray Laboratory, The purpose in writing this letter is to ask you to publish
Mount Vernon Hospital, it in your journal. Perhaps there are those among your
Northwood, Middlesex HA6 2RN. readers who within the last several years have had indication
to perform an intravenous pyelogram on a patient before 20
{Received August 1979) weeks gestation or inadvertently did so. Perhaps they have
seen fetal kidney opacification or visualized the fetal abdo-
men on such a radiographic study and did not see the fetal
REFERENCES kidneys. If they could communicate their findings to us, we
KAL, H. B. and BARENDSEN, G. W., 1973. Radiosensitivity might be able to gather some information about this sub-
of surviving cells in tumours pretreated with continuous ject. With the wide circulation your journal has, we might
irradiation. British Journal of Radiology, 46, 1083. expect some results.
MCNALLY, N. J. and DE RONDE, J., 1976. The effect of It is our opinion that we will be able to make a diagnosis
repeated small doses of radiation on recovery from sub- of renal agenesis using ultrasonography. If we look long and
lethal damage. International Journal of Radiation Biology, hard enough, we are able to see the urinary bladder when it
29,221-234. is present and the kidneys are functioning. The presence of
SUIT, H., REIMUT, W., and LINDLEY, R., 1967. Analysis of oligohydramnios seems to be another helpful corroborating
tumour-recurrence times. Radiology, 88, 311 -321. sign of renal agenesis. Nevertheless, it would be useful to
ZEITZ, L. and MCDONALD, J. M., 1978. Pitfalls in the use of know if fetal pyelography has any use at all in this type of
in vitro survival curves for the determination of tumour investigation.
cell survival with fractionated doses. British Journal of Yours, etc.,
Radiology, 57,637-639. M. MlSKIN.
ZEITZ, L., 1979. Reported n and D q values can be mis- The Prenatal Genetic Clinic at the University of Toronto,
leading. British Journal of Radiology, 52, 674675. Department of Radiological Sciences,
Mount Sinai Hospital,
600 University Avenue,
Toronto, Ontario M5G 1X5.
Diagnosis of renal agenesis using ultrasonography {Received July 1979)
THE EDITORSIR, REFERENCE
We recently had an interesting diagnostic problem thrust THOMAS, C. R., LANG, E. K. and LLOYD, F. P., 1963. Fetal
upon us. pyelographya method for detecting fetal life. Obstetrics
We were asked to study a pregnancy in a patient who had and Gynecology, 22, 335-340.
previously had a baby with renal agenesis. Serial ultrasound
examinations at 16, 17 and 19 weeks gestation showed oligo-
hydramnios. The fetal urinary bladder could not be seen on
any of these studies. We did not spend much time looking
for the fetal kidneys as it has been our experience that these
are extremely difficult to see even in the normal fetus.
Amniocentesis at 16 weeks yielded a small volume of yellow- Diagnosis of renal agenesis using ultrasonography
orange fluid. All signs pointed to another pregnancy with
renal agenesis. Based on these findings and one further test THE EDITORSIR,
to be described presently, therapeutic abortion was recom- I read with interest Dr. Miskin's letter concerning the
mended and was carried out. Post mortem examination ultrasound diagnosis of renal agenesis. I cannot agree with
showed that not only were there no kidneys present, but him that ultrasound will not reliably detect the fetal kidneys
that the ureters and urinary bladder were also absent. early in pregnancy and in our institution we regularly view
We have seen five other patients to date who have had the fetal kidneys as early as 15 weeks of gestation (Meire,
babies with renal agenesis. Ultrasound studies of their sub- 1979).
sequent pregnancies showed normal volumes of amniotic During the past two years we have been asked to examine
fluid and functioning urinary bladders. The case described five patients with severe oligohydramnios in the mid tri-
above was the first of this group of patients in whom any mester with a view to excluding renal agenesis. In four cases
381
VOL. 53, No. 628
Correspondence
the fetal kidneys were identified and the fetal bladders were
also seen to contain urine. In the fifth case neither kidneys
nor bladder could be identified and this case was subse-
quently shown to have renal agenesis. In 12 other cases with
severe oligohydramnios in the first trimester of pregnancy
imaging of the fetal kidneys has proved unreliable and in all
12 cases normal kidneys were subsequently shown to be
present.
We therefore conclude that, at the present state of the
art, ultrasound will reliably diagnose or exclude renal
agenesis early in the second trimester of pregnancy and
Book reviews
The Radiology of Joint Disease. By D. H. Forrester, J. C.
Brown and J. W. Nesson, pp.xii +626.Second Edition, 1979.
(W. B. Saunders Co., Philadelphia, U.S.A.).
ISBN 0-7216-3822-8
The first edition of this book was warmly received in this
Journal in 1976 and the present reviewer endorses those
comments on reading the new edition.
One of a series of monographs invited by the publishers,
the authors present, in an interesting way, the potentially
dull subject of arthropathies by considering the way in
which each major joint or group of joints may be affected by
varying disease processes. A chapter is devoted to each of
the major limb joints, the extremities and the spine, and at
the end of each chapter there is a quiz to test how well you
have been concentrating. This anatomical approach inevi-
tably means that each disease process is discussed several
times, under each area; however, this is no serious disad-
vantage to a radiologist who frequently goes to a textbook to
look up a puzzling appearance on a radiograph, and it means
that the book is useful for reference as well as being a
pleasure to read for its own sake.
A further recommendation is that in the new edition a
further section is added on the differential diagnosis of
arthritis which cuts across the anatomical format and
discusses disease entities as separate topics. In this section
the radiological appearances are correlated with the clinical
and pathological findings; this is particularly enlightening to
a radiologist who may be frightened off formal pathological
texts. It also means that the book is valuable to clinicians as
well as radiologists.
The style of the text is informal but it is full of sound
common sense and, as the reviewer of the first edition
suggested, its wit and wisdom earn it a place not only in the
library but at one's bedside!
J. T. PATTON.
382
thus obviate the need for other invasive procedures such as
fetal pyelography.
Yours, etc.,
HYLTON B. MEIRE.
Clinical Research Centre,
Harrow, Middlesex HA1 3IJ
{Received October 1979)
REFERENCE
MEIRE, H. B., 1979. Diagnostic ultrasound. British Journal
of Radiology, 52, 685-703.
Arthrography of the Knee Joint. By C. J. P. Thijn, pp.xi +
155, illus. (Springer-Verlag, Berlin/Heidelberg/New York),
$53.90.
ISBN 3-540-09129-7
This slim monograph expresses the author's experience
with double contrast technique in the knee, having apparen-
tly turned his attention from the same technique in the
colon. There is a brief introduction and historical resume
followed by chapters dealing with technique, meniscal
lesions, patellofemoral joint diseases, cruciate ligaments,
capsular, ligamentous and hyaline cartilage abnormalities.
Each is supplied liberally with illustrations. There is a
cumulative bibliography of the literature up to early 1978
and a reasonable index.
Your reviewer was able to read this volume in an evening.
The English is good but much of the terminology quaint and
the use of latin anatomical names stressed my schoolboy
knowledge of the language. However, it is understandable
and confusion will evaporate with perseverance. The layout
is generous and clear. The good quality illustrations are
spoilt by production in the positive mode. The author
verifies his findings with reference to arthroscopy which may
be laudable but is not helpful since the final arbitration of
arthrotomy is not offered. The reviewer was tempted to nit
pick with the described technique but the author is com-
pletely vindicated by the images which have been achieved.
This is an expensive little book. It does offer, however, a
good basic illustrated guide to knee arthrography. One
could not justify its inclusion on the shelves of most depart-
ments but it will be a welcome bonus when arthrography is
being taught and its nuances mastered.
I. WATT.