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lrogers{at}ajroffice.org
It was June of 1979. He and I had just entered the narrow control area of one of the original EMI CT head units located in the Wesley Pavilion of Northwestern Memorial Hospital in Chicago. A comatose, hypertensive, elderly lady was then undergoing a head scan, and Hounsfield had been startled by the image he saw on the CT monitor. The several anxious housestaff in attendance were as startled by Hounsfield's exclamation as Hounsfield was by the image. After all, Hounsfield had invented the machine that allowed them to see this lesion so characteristic of a hypertensive bleed: a large left basal ganglia hematoma with the added feature of a layer of blood in the dilated posterior horn of the right ventricle. And yet, much to the amazement of those assembled, Hounsfield appeared to be the only one in the room who didn't know what the lesion was.
On reflection, this incident brings into sharp focus the simple, stark truth that new imaging technologies do not come with instructions as to how they are to be used. Nor do they come with instructions about how they are best applied in the care of patients. The inventor of an imaging technology does just that, invents. Admittedly, that is the heavy lifting, but it is usually left for others to determine how and when this technology is best used.
Hounsfield was an engineer, not a physician. He had worked for EMI and had played a major role in building the first mainframe computer in England. EMI recorded the Beatles and was flush with cash from selling their records. EMI had given Hounsfield free reign to pursue research of his own interests. Hounsfield believed that there was more information in an X ray than could be captured on film and thought that computers could be used to capture this information. And the rest, as they say, is history.
Some clinicians are envious of our imaging technologies, claiming that we radiologists are lucky to have such powerful tools at our disposal. True, but the power of new technologies is initially latent. The realization of the true potential of CT required clinical research. Questions addressed by that clinical research included how to use, when to use, a description of the imaging features of various diseases encountered, sensitivity and specificity for various diseases, differential diagnoses, and so forth. And we radiologists have done that clinical research very well.
The clinical research required to fully implement CT was largely unfunded. Instead, the clinical research that brought CT to its present exalted status was, in the main, underwritten by academic radiology departments with funds generated by the clinical practice of a faculty's radiologists.
Radiologists, thus supported, performed the necessary clinical research and disseminated their findings through publications in radiology journals and presentations at scientific meetings, conferences, and symposia as well as during informal discussions. Numerous textbooks devoted to CT have been published. The training of radiologists and the distribution of CT technology to all corners of the globe have been accomplished in a relatively short time, and patient care has been greatly enhanced by this effort.
CT is now so thoroughly ingrained in the practice of medicine and surgery that it has lost some of its luster. CT has become a matter of routine. And maybe it should be. But every once in a while I am reminded of how far CT has come.
Not too long ago, I was interpreting studies in the emergency department with a third-year resident and we came to a chest film of a 50-year-old woman with a history of "bleed." The resident was aware of my habit of looking at other interesting films for a case even though we might not be responsible for interpreting them.
I asked the resident, "What is this `bleed' all about?"
And the resident replied, "Oh, you don't want to waste your time looking at that case. It's just a straightforward basal ganglia hematoma in this lady with hypertension." Yes, the resident was implying that the CT was pretty simple stuff.
I replied, "Let's take a look at it just the same."
And there, except that the image was sharper and lacked the obvious pixilation we saw in 1979, was a CT scan that was for all intents and purposes an exact duplicate of the CT scan that startled Hounsfield some 24 years ago: a head CT scan with a lemon-sized hematoma in the left basal ganglia and even a layer of blood in a dilated posterior horn of the right ventricle.
CT has indeed come a long way. What was once amazing is now mundane.
This change is the fruit of many radiologists' concerted efforts in clinical research. All radiologists should take great pride in their accomplishments.
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