In this era of so many amazing scientific advances, we can accept almost anything conceivable as achievable and attainable.
The ability to transplant organs, to operate on motionless hearts, to successfully treat certain forms of cancer, and to dissect chromosomes and transplant genes - these are but a very few of the almost impossible dreams of yesterday that have become realities today.
This second issue of PEDIATRIC ANNALS on deep-tissue diagnosis continues to present to pediatricians new developments in an area in which startling new concepts are aiding greatly in medical discernment and judgment.
The methods of diagnosis to be further discussed in this issue include ultrasound and computed tomography.
What can we, as practicing pediatricians, expect from these new methods of diagnosis, and are they generally available? Can ultrasound be used in the pediatrician's office much as we formerly used the fluoroscope?
To answer the last question first, we know that many obstetricians throughout the United States already have ultrasound equipment in their offices. Many of them, I have heard, use it on every pregnant patient primarily as an extra source of income. One can visualize the position of the infant in the uterus by means of ultrasound. Generally, I do not believe that this is necessary. Any welltrained medical-school graduate should be able to locate the fetus correctly in the later months of pregnancy by palpating the head, buttocks, and legs. The primary value of sonography in obstetrics is to determine the infant's position as a safety precaution before attempting amniocentesis.
As far as the office practice of pediatrics is concerned, the use of ultrasound cannot yet be recommended. Those of you who read the February issue of PEDlATRiC ANNALS, devoted to deep-tissue diagnosis, realize that there are already different types of ultrasonography - A-mode, B-mode, realtime, and T-M (time-motion) imaging. The use of ultrasound, at least at the present time, should be in the hands of those skilled in its use and skilled in the interpretation of its readings. Improvements in technology are constantly being made, and, as suggested by Dr. Herman Grossman in his introduction , the time will come for computerized ultrasonography similar to computerized tomography.
We asked above what the pediatrician may expect from sonography. Since it is safe (at least insofar as we now know), noninvasive, and painless, it is an ideal diagnostic tool for use in pediatrics. It is especially useful when one desires to avoid radiation, as in lowerabdominal diagnosis, when one wants to prevent absorption by the ovaries and testes, or in the upper mediastinal area, in order to avoid radiation of the thyroid gland.
Ultrasound is not all-inclusive, however, and radiography, computed tomography, and srintigraphy all are of the greatest additional value in deep-tissue diagnosis. The advantages and shortcomings of each of these methods will become self-evident through the papers presented in this second part of the symposium.
The first article is "Sonography of the Female Child's Reproductive System" and was written by Dr. Morton Schneider, Associate Professor of Radiology at the New York Hospital-Cornell Medical Center in New York City, and Dr. Herman Grossman, the guest editor of these two issues on deep-tissue diagnosis, who is Professor of Radiology and Pediatrics at Duke University Medical Center, Durham N. C. Their article clearly outlines the indications for pelvic sonography and notes what diagnostic findings might be expected.
After reading this article I could not help recalling a number of instances during the past when this safe, painless diagnostic procedure would have been helpful had it been available then. I remember especially the child with precocious puberty who developed breasts at nine months and menstruated at two years of age. Then there were several cases of ovarian cysts in which diagnosis was made by surgical intervention. And there was a girl with amenorrhea and obesity who had an unsuspected pregnancy despite her strong protestations to the contrary when questioned about the possibility. Add one patient with hematocolpos who came in with a history of amenorrhea and abdominal pain and was found to have an imperforate, bulging hymen. I could continue with many similar cases from my own practice in which sonography of the female child's reproductive organs would have been very helpful had it been available.
The second contribution continues with the subject of sonography, with emphasis on its diagnostic use in chest problems of children. Its author is Dr. Jack O. Haller, director of pediatrie imaging at the State University of New York Downstate Medical Center in Brooklyn. Dr. Haller, incidentally, is coauthor with Dr. Morton Schneider of the book Pediatrie Ultrasound, which has just been published by the Year Book Medical Publishers.
Ultrasound has not had widespread use in pediatrie pulmonology, Dr. Haller notes at the outset, because the ultrasound beam is poorly transmitted both by the aerated lung and by bone. There are conditions, however, in which ultrasound can be of great assistance in diagnosing diseases or trauma in the chest - for example, a disorder that completely or partly opacifies the hemithorax or an area of the lung. Consolidation can be differentiated from pleural effusion, for example. Dr. Haller presents a group of cases - wellillustrated - in which sonography was of considerable help in establishing the diagnosis.
The two following articles continue the discussion of computed tomography in pediatrics that began in our February issue with the publication of the article by Drs. Donald R. Kirks and C. F. Harwood-Nash on computed tomography in pediatrie neuroradiology. In this issue Dr. Kirks, who is Associate Professor of Radiology and Pediatrics at Duke University School of Medicine, covers computed tomography of the chest in infants and children. His coauthor is Dr. Melvyn Korobkin, Professor of Radiology at Duke. This article is followed by "Computed Tomographie Imaging of Abdominal Abnormalities in Infancy," by Dr. Jerald P. Kühn, chief of radiology, and Dr. Paul E. Berger, attending radiologist, at the Children's Hospital, Buffalo.
These are two very exciting presentations, for with a scan of only a few seconds one can, for instance, obtain 1-cm. sections from the thoracic inlet to the subdiaphragmatic region. Furthermore, where studies of different tissue densities are concerned, one can, if desired, use separate displays of the same reconstructed-image data - for example, for lung parenchyma, mediastinum, and bony thorax. Drs. Kirks and Korobkin explain how this is done and note that CT can distinguish separate densities with 100 times the ability of conventional radiography.
Naturally, the pediatrician is greatly interested in the risk to the child of CT radiation. As to the chest diagnosis, the authors note that there is a skin dose equal to that of an upper-gastrointestinal series or an intravenous pyelogram. Drs. Kühn and Berger, in their article on abdominal CT, state that a "CT scan of the abdomen will require more radiation to the skin but less to the gonads than a barium enema."
The same authors take pains to inform the reader when they feel that ultrasound should be used before attempting computed tomography and also when they feel that a gallium scan is indicated.
Both articles are beautifully illustrated by clear cross-sections of areas where pathology exists.
Thomas Carlyle said that "the age of miracles is forever here." Computed tomography is another proof of this axiom.