By the early 1930s the use of positive contrast agents (barium sulphate) was well developed (O’Sullivan BJR 1932; 5(50): 97-106) as this paper by John O’Sullivan shows. Endoscopy was primitive by modern standards and gastroscopy with a rigid tube was dangerous. A most interesting paper appeared in February 1932 written by David Levi and H Courtnéy Gage on gastro-photography (Levi and Courtnéy Gage BJR 1932; 5(): 107-114) utilising a pin-hole camera on a rubber tube inside a metal cylinder.
Image source: O’Sullivan BJR 1932; 5(50): 97-106
AE Barclay, as lecturer in radiology at the University of Cambridge, wrote a masterly accounts on the normal mechanism of swallowing (Barclay BJR 1930; 3(36): 534-546) and the position and movements of the diaphragm (Barclay BJR 1930; 3(31): 295-303). Barclay made major contributions to gastrointestinal radiology and his books are in our historical book collection.
The Silvanus Thompson Memorial Lecture for 1934 was given by the pioneer gastrointestinal radiologist HH Berg from Hamburg (Berg BJR 1935; 8(87): 137-143) http://dx.doi.org/10.1259/0007-1285-8-87-137 on the radiology of the digestive mucosa.
KJ Yeo from University College Hospital (Yeo BJR 1931; 4(46): 510-512) demonstrated an interesting example of gastric syphilis.
Alfred E Jordan described colonic abnormalities related to acquired bands (Jordan BJR 1931; 4(44): 387-390) in August 1931 and the undescended colon in October 1937 (Jordan BJR 1931; 10(118): 743-752).
The Graham test to visualise the gall-bladder was introduced in 1924. In March 1935 there was a good review of the technique for cholecystography by BR Kirklin from the Mayo Clinic (Kirklin BJR 1935; 8(87): 170-183) and then a full review by A Craig Mooney from Plymouth in July 1935 (Mooney BJR 1935; 8(91): 403-425) with full description of the technique. This remained the standard technique for investigation of the gall bladder until it was replaced by ultrasound in the 1980s.
Image source: Mooney BJR 1935; 8(91): 403-425
Chest and cardiac radiology
Peter Kerley was Assistant Radiologist to Westminster Hospital and Radiologist to the Royal Chest Hospital gave a masterly account of the pathology of early pulmonary tuberculosis as revealed by X-rays (Kerley BJR 1930; 3(33): 404-417). Kerley made major contributions to chest radiology and is remembered today by his “B” lines.
In March 1932 Kerley discusses congenital lung diseases (Kerley BJR 1932; 5(51): 234-240) and in May 1933 we find him discussing congenital heart disease (Kerley BJR 1933; 6(65): 257-265). At that time radiology was only supplementary to clinical features and electrocardiography and relied on the plain chest radiograph.
In September 1934 he presented a paper on bronchiectasis (Kerley BJR 1934; 7(81): 531-539) with an account of the technique of bronchography using Lipiodol. In March 1939 Kerley described the plain film appearances of intrathoracic aneurysm (Kerley BJR 1939; 12(135): 158-162).
Image source: Kerley BJR 1939; 12(135): 158-162
Another great radiologist EW Twining from Manchester (Twining BJR 1931; 4(48): 658-679) wrote in 1931 a beautifully illustrated and thoughtful description of the often confusing appearances shown on the chest radiograph. The paper should be read by all interested in the development of chest radiology. As Twining said: “Radiograms of the chest are not self explanatory, but they are records of fact, and the student should set himself to learn his X-ray physical signs by daily practice as simply and naturally as he learns his other physical signs.”
Kymography was a technique developed to study and record cardiac movement and was of some value and was described for the BJR in December 1934 by Peikart Stumpf from Munich (Stumpf BJR 1934; 7(84): 707-727) and I Seth Hirsh from New York (Hirsh BJR 1934; 7(84): 728-754). It is difficult to be certain how common the uses of this apparatus became. Kymography was discussed in the BJR editorial of December 1934 by Peter Kerley (Kerley BJR 1934; 7(84): 705-706) and it is apparent that nothing changes. Kerley writes: “It behoves the radiologists to look to their laurels and make sure that the method does not become the prerogative of clinical cardiologists with consequent damage to the prestige of radiology and perhaps to the advancement of science.” There is nothing new in turf wars and radiologists and cardiologists were to meet again with the techniques of ultrasound, angiography and MRI.
AE Barclay and others including Sir Joseph Barcroft from the Nuffield Institute for Medical Research in Oxford wrote a detailed and well illustrated experimental animal angiographic study on the closing of the ductus arteriosus in September 1938 (Barclay, Barcroft, Barron and Franklin BJR 1938: 11(129): 570-585). A further paper by AE Barclay and others showing the circulation through the heart in the adult and fetus appeared in September 1939 (Barclay, Barcroft, Barron and Franklin BJR 1939; 12(141): 505-517). These studies considerably added to our knowledge of the ductus arteriosus and the fetal and adult circulations.
Image source: Barclay, Barcroft, Barron and Franklin BJR 1939; 12(141): 505-517
James Brailsford was a radiologist from Birmingham and made many contributions to diagnostic radiology. He discusses radiology as a speciality in January 1936 (Brailsford BJR 1936; 9(97): 17-29).
In February 1931 there is reprinted his masterly account of “Chondro-Osteo-Dystrophy” (Brailsford BJR 1931; 4(38): 83-89). This was an account of a child “with dislocation of vertebrae” and describes the syndrome. He discussed skeletal dystrophies further in September 1935 (Brailsford BJR 1935; 8(93): 533-569) and developmental abnormalities in April 1936 (Brailsford BJR 1936; 9(100): 239-271).
In November 1933 Brailsford describes spondylolisthesis (Brailsford BJR 1933; 6(71): 666-684), tumours of bone in April 1934 (Brailsford BJR 1934; 7(76): 233-236) and a long and detailed article on the forms of osteochondritis in February 1935 (Brailsford BJR 1935; 8(86): 87-134). As a result of these papers Brailsford was awarded the Rontgen Award for 1933/4 and 1934/5. Brailsford’s highly influential book “The Radiology of Bones and Joints” was published in 1934 and is dedicated to Robert Jones.
In March 1937 he discussed the value of radiology in the early diagnosis of skeletal neoplasia (Brailsford BJR 1937; 10(111): 171-195) in a long and well illustrated study.
In August 1938 he wrote on Paget’s disease (Brailsford BJR 1938; 11(128): 507-532) in a characteristically detailed and well illustrated paper. In February 1939 with the prospect of a European war on the horizon Brailsford described a simple method for the localisation of foreign bodies (Brailsford BJR 1939;12(134): 65-75).
Image source: Brailsford BJR 1939;12(134): 65-75
Every radiologist is familiar with the growth arrest lines described by HA Harris from University College London in 1923. The BJR printed a beautifully illustrated paper by Harris (in two parts) in 1931 (Harris BJR 1931; 4(47): 561-588) (Harris BJR 1931; 4(48): 622-640). The paper is illustrated by radiographs and histological studies.
In the 1920s and 1930s the maternal mortality was still high (43/1000 for emergence cases sent into hospital at short notice and 3.2/1000 for those with antenatal care). Florence Stoney wrote on the pelvis and maternal mortality in 1930 (Stoney BJR 1930; 3(33): 426-428) and discusses its prevention. In 1931 Noel Hypher gave a very thoughtful account of the value of radiography in obstetrics (Hypher BJR 1931; 4(40): 171-177). Also in 1931 LA Rowden (Rowden BJR 1931; 4(45): 432-439) demonstrated a simple and effective technique for X-ray pelvimetry and he gave the Mackenzie Davidson Memorial Lecture in 1940 on the subject of maternal mortality and the use of radiology (Rowden BJR 1940; 13(150): 185-192). A detailed historical review of x-ray pelvimetry written by Alexander Orley appeared in June 1933 (Orley BJR 1933; 6(66): 345-359). Pelvic abnormalities were much more common then than they are today. In the 1930s it was believed that there was no danger to the fetus from short diagnostic exposures but that there would be a very real danger from radiotherapy.
Radiology was also used to assess the fetus in these days before ultrasound. RE Roberts from Liverpool reviewed the topic of the assessment of fetal maturity in October 1935 (Roberts BJR 1935; 8(94): 601-606) and then published a detailed study in July 1936 (Roberts BJR 1936; 9(103): 415-430). Many papers on this important topic appeared.
Image source: Roberts BJR 1936; 9(103): 415-430
An important paper appeared in December 1931 on the new water soluble iodinated ionic contrast agent Abrodil (Heathcote and Gardner BJR 1931; 4(48): 641-651). The paper was by R St A Heathcote and RA Gardner from Cairo and was a detailed pharmacological study of the new agent. They found it superior to Uroselectan, non-toxic and giving good radio opacity. In November 1932 they published a detailed experimental study of Uroselectan B (Gardner and Heathcote BJR 1932; 5(59): 836-849). Uroselectan B was marketed as an improvement to the original Uroselectan. This paper was important since there had been little published on Uroselectan B up to that point. In 1935 the technique of intravenous urography was well developed and was reviewed by IB Barclay and JB Baird from Birmingham (Barclay and Baird BJR 1935; 8(88): 201-217). The image quality is excellent.
Ronald Grainger from Sheffield reviewed the history and development of contrast media in his Mackenzie Davidson Memorial Lecture (Grainger BJR 1982; 55(649): 1-18).
Russell J Reynolds described his apparatus for cine-radiography in July 1934 (Reynolds BJR 1934; 7(79): 415-424). Reynolds was a true pioneer in this technique and had started his experiments in 1921. The idea of cinematography as applied to radiology had been raised by John Macintyre in Glasgow in 1896 and this work is beautifully illustrated in the editorial for that issue (BJR 1934; 7(79): 386-390).
In October 1935 AE Barclay was examining colonic movements with cine-radiology (Barclay BJR 1935; 8(94): 652-658).
The technique of conventional tomography had been developed independently by a number of workers in the 1920s. In December 1935 G Grossmann from Berlin (Grossmann BJR 1935; 8(96): 733-751) described his tomogram. There were reproduced many tomograms and the technique was described full. EW Twining from Manchester developed a simple tomographic attachment to an X-ray table which he described in April 1937 (Twining BJR 1937; 10(112): 332-347).
The techniques of neuroradiology developed as the 1930s progressed. MH Jupe reviewed ventriculography in a paper appearing in March 1936 (Jupe BJR 1936; 9(99): 147-160). He described ventriculography and encephalography. Full encephalography was a major procedure and was not to be undertaken without proper indications. In May 1938 there was an important paper by Eric Lysholm from Stockholm describing ventriculography in full (Lysholm BJR 1938; 11(125): 273-288). Eric Lysholm was a master of the technique. The Neuroradiology Department at the National Hospital in Queen Square was named in his honour. In November 1938 T Garratt Hardman described a radiographic position to demonstrate the fourth ventricle in ventriculography (Hardman BJR 1938; 11(131): 726-735). EW Twining from Manchester gave a masterly Hunterian Lecture in 1936 on the radiology of the third and fourth ventricles and in July 1939 an expanded article based on the lecture was published (Twining BJR 1939; 12(139): 385-418). The article reproduced the Twining’s mercury model used to show the problems of filling the third ventricle. Part two appeared in October 1939 (Twining BJR 1939; 12(142): 569-598).
In December 1937 Hugh Davies from the National Hospital in Queen Square described cerebral angiography (Davies BJR 1937; 10(120): 871-881). For the technique he used a colloidal suspension of dioxide of Thorium (Thorotrast) injected directly into the carotid artery. Thorotrast gave beautiful images which were illustrated however it had the disadvantage of not being excreted from the body and being radioactive resulting in an incidence of radiation induced malignancy. The risks of Thorotrast were assessed by J Rundo from Harwell in November 1955 (Rundo BJR 1955; 28(335): 615-619) and radiation dosage was assessed.
In the spine the oily contrast Lipiodol could be used to locate tumours as demonstrated by HM Worth (Worth BJR 1938; 11(124): 211-226) in April 1938.
These complex techniques were difficult and considerable time was spent examining the plain skull radiograph in suspected intracranial diseases as described by MH Jupe in March 1938 (Jupe BJR 1938; 11(123): 146-164) and looking at skull reactions to internal pathology.
Image source: Jupe BJR 1938; 11(123): 146-164