Seminars in Roentgenology

VOL. XIX, NO. 1 JANUARY 1984

Letter From the Editor

W e have dealt with brain tumors in previous Seminars, but neuroradiology has ad-

vanced so spectacularly in the past few years that updating is not only desirable but essential. As I reviewed these outdated articles, my thoughts drifted back to my early years in radiology when 1 had to do neuroradiology. There were only a few bona fide neuroradiologists in the US, all self-trained (the best kind), so by default much of the brain work became the brainwork of neurologists and neurosurgeons. Ours admitted that they needed help, so in addition to my other duties, I was delegated to be their helper. My ten thumbs prevented me from actually performing the procedures, mostly pneumography, so the neurosurgeon did them and I reported them.

In those days we spent a lot of time on plain films. John Camp and Merrill Sosman, among others, were my mentors. We looked carefully for the calcified pineal, and measured it for displace- ment not only in the frontal view but also in the lateral. 1’11 bet you didn’t know that you can accurately determine pineal displacement on a rotated PA or AP film. Accidental rotation up to 12” doesn’t alter the midline position of the normal pineal calcification significantly. We had a number of ways of determining displacement of the calcified pineal in the lateral view, including an angled template as well as a rubberband method that was quick and easy and (I think) reliable. You stretched the rubberband between the internal tables of the skull, front and back, and the normal pineal fell between two dots you preset on the rubberband as instructed in an article by the “inventor.” 1 often wondered whether all rubberbands had the same stretch.

I have a great conversation opener with my Negro colleagues: “‘Do you know that the pineal gland is less commonly calcified in Negroes than in Caucasians?” 1 once coauthored a paper with a Nigerian neurosurgeon on this momentous subject.

Seminars ,n Roentgenology, Vol. XIX, No. 1 (January). 1984

We looked for and sometimes found eighth nerve tumors with plain films and conventional tomography; we even learned how to diagnose glomus jugulare tumor. We also made some pretty fancy diagnoses (for those times) from the plain films: lipoma of the corpus callosum, tu- berous sclerosis, neurofibromatosis, and pseudo- pseudohypoparathyroidism.

Hyperostosis frontalis interna was considered a sign of endocrine disturbance by Morgagni. Sherwood Moore spent much of his academic career writing papers about it. Today it is consid- ered a nonentity, along with its eponymic desig- nation. But the next time you see a good example of internal frontal hyperostosis, 1 challenge you to go see the patient. You will likely find a fat woman with menstrual problems.

We made beautiful stereoscopic skull films, and it was amazing how often they enabled us to detect such details as faint calcium in a brain tumor. We still have a stereoscope somewhere in our radiology department, but nobody could find it this morning. 1 try to teach residents to stereo without a stereoscope, but it’s a headache. both figuratively and literally. 1 once saw a one-eyed medical student using the stereoscope. He claimed he could see the shadows in 3-D, and my tests seemed to bear him out. And why not‘? After all, stereoscopy is an optical illusion. Eli Gordon invented a mirrored prism for one eye that permitted stereoscopic viewing by a two- eyed radiologist.

Pneumoencephalography and ventriculogra- phy were our sophisticated diagnostic tools. Books by Leo Davidoff and Cornelius Dyke, by DavidotT and Bernard Epstein, and by Henry Pancoast, Eugene Pendergrass, and Philip Hodes, along with articles and lectures by Arthur Childe, were Talmud and Bible to us, and we pored over them.

Then came angiography. In the early days some people used Thorotrast as a contrast

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2 BENJAMIN FELSON

medium. It was a fine agent for cerebral angi- ography except for the million year half-life radiation that remained in the patient for life. Extravasation of Thorotrast caused boardlike fibrosis of the neck in a few years. I was worried more about visceral cancer, which turned out to be a rare complication. Fortunately, we never used the stuff except in animal experiments. Half-life, full life, or dog’s life, it was widely used in some circles.

At first we did single film cerebral arteriogra- phy, but later we constructed a hand operated tunnel cassette changer with built-in grid. The Fairchild camera, an automatic airplane camera used for spotting the enemy in World War II, was adapted for cerebral angiography, but the films were of disappointing quality. The first cassette changer to work well for cerebral angi- ography was the hand operated Sanchez-Perez machine. As I recall, Jesus Sanchez-Perez, a neurologist, designed and manufactured it. He gave up medicine to sell the contraption, only to have another company, using his brainchild, cor- ner the market.

One of my neuroheroes is B. G. Ziedses des Plantes, pioneer in conventional tomography, and the man who invented the subtraction con- cept. American recognition of the contributions

of this imaginative innovator has only recently been forthcoming.

When something new comes along, something old often goes. So it was with angiography and polytomography, which bankrupted cerebral pneumography, and so it is with CT and DSA, which are now putting cerebral angiography into receivership. Although many of my colleagues don’t agree, I strongly suspect that NMR will before long put CT out of business so far as the brain is concerned. So don’t take a header in CT.

I owe Dr. Bernard P. Adelman and his tech- nologist, Mrs. Diane Tharp, apologies. Somehow I forgot to credit them with providing me with two of the animals in my “Zoo,” published in the July 1983 Seminar: Brown Nose Duck and Japa- nese Masseuse. I feel like a loser, defined as a masseur who rubs people the wrong way.

1 also must point out an error in the title of the article by K. J. W. Taylor and T. S. Richman in the April 1983 Seminar. It should have read: Sonography of Tumors of the Liver.

Benjamin Felson Editor