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From a Purely Radiological Point of View

1961; Radiological Society of North America; Volume: 77; Issue: 1 Linguagem: Inglês

10.1148/77.1.126

1527-1315

Steven E. Ross,

Radiology practices and education

Shadows are but dark holes in radiant streams, twisted rifts beyond the substance, meaningless in themselves. Man—warm, lively, fleshy man—and his story are both root and key to his shadows; shadows cold, silent, and empty. John Caffey The bold, brave, boyishly boastful slogan of the United States Army Corps of Engineers, “The difficult we do immediately—the impossible takes a little longer,” may well apply to diagnostic radiologists. From visual clues often barely perceptible they extract knowledge that is safe, sound, significant, and satisfying much of the time. Pathologists, fellow students of organs altered by disease, do not regularly risk their reputations with reports resting on gross morbid changes alone, even though their pieces of evidence are polychromatic and substantial, and can be felt, smelled, weighed, and cut or caressed with a knife. What is the secret of drawing valid conclusions from shadow to substance with a frequency that is astonishing and delightful? The secret is simple though not altogether conscious; roentgen cues, like those used in crime detection, are not weighed in vacuo. Roentgenograms belong to patients and each patient has a story: age, sex (recently complicated by finesses found in the sex chromosome pattern), a health record past and recent, and a constellation of findings, the “clinical picture” or “clinical problem.” When interpreting roentgenograms, what we see we iudge in the light of what we know. Generalized loss of bone mineral (to borrow an example) may suggest hyperparathyroidism in a patient with recurrent kidney stones, deficiency of vitamin D and calcium (“osteomalacia”) if associated with chronic small-bowel disease, postmenopausal osteoporosis in a woman past her second age of blushing, or multiple myeloma if found in an elderly patient with bone pain, loss of strength, anemia, and proteinuria. Roentgen signs, like other signs in medicine, in nature, art, or human language, gain their meaning from their context. One misapprehension spread, if not sanctified, by custom deserves to be mentioned in order to be dispelled. Some doctors requesting radiologic consultation like to withhold important knowledge about their patient in order to avoid “influencing” the radiologist, even though this is not customary with other consultants. A few of us—a very few among the very best—like to look at films before they know the problem at hand. For the sake of their sanity, diagnostic radiologists must develop a taste for puzzles, and a jigsaw puzzle can be more absorbing if some of the pieces are missing. As an intellectual exercise properly practiced at meetings of radiologists, it can be entertaining and educational to consider films in isolation; suggesting the correct diagnosis on sparse evidence gives one great satisfaction.