LOGICAL ANALYSIS IN ROENTGEN DIAGNOSIS - MEMORIAL FUND LECTURE
LOGICAL ANALYSIS IN ROENTGEN DIAGNOSIS - MEMORIAL FUND LECTURE
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DOI：
10.1148/74.2.178
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发表时间：
1960-01-01
期刊：
影响因子：
19.7
通讯作者：
LUSTED, LB
中科院分区：
文献类型：
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作者：
LUSTED, LB
在我接受住院医师培训的第一年，我有机会问我的主任罗伯特·斯通医生，我如何才能确定我的X线诊断的准确性。在我们讨论的过程中，他告诉我他的前任主任霍华德·拉格尔斯医生的情况。拉格尔斯医生是一位出色的诊断专家，他在对这些片子进行简单检查后，就能做出很高的正确诊断。有时医生觉得Ruggles医生的诊断可能不太可靠，他们可能会问：“Ruggles医生，你为什么认为这个阴影是转移性病变？”对此，他也会毫不犹豫地回答：“因为它看起来像！”在某种程度上，我们所有人都是这样做诊断的，而且往往很难描述某些病变的许多可能的变化，例如，肺结核的多变表现。但是，对于那些粗心的放射科医生来说，如果他们过于随意地使用这种“看起来像”的方法，他们会遇到什么陷阱呢？图1显示了四种不同疾病的肺部表现。X线检查结果是相似的，很少有放射科医生会仅仅根据胶片就做出所有四种诊断。然而，如果我告诉你第一个病人患有胃癌，第二个病人痰中有肺炎双球菌，第三个病人患有硬皮病，第四个病人表现为急性病，有呼吸困难、咳嗽和发烧，白色血细胞计数为10，000，痰培养阴性，你就更有可能给出正确的诊断，即，对病人1来说，胃癌的淋巴扩散;例2，播散性肺炎球菌性肺炎;例3，硬皮病弥漫性纤维化;例4，病毒性弥漫性间质性肺炎。2骨病变也很难描述和识别。图2是一名因手臂疼痛而接受检查的女性右前臂的X线照片。桡骨中部三分之一处存在扩大性病变。皮质完整，无骨膜隆起，可见粗糙的骨小梁。在这种情况下，如果我告诉你，病人的左肾是因为恶性肿瘤而被切除的，你会立刻认为骨病变很可能是转移性肾功能亢进瘤。关于骨肿瘤的描述和鉴别，我稍后会有更多的论述。1950年，Sosman博士在他的Shattuck讲座《X线诊断的特异性和可靠性》（1）中提到了这些鉴别问题，他说：“我们的诊断是基于大体病理学的作为X线学家，我确信我们的准确性在很大程度上取决于给定病例或一组情况下的数学概率。”
During the firstyear of my residency training I had occasion to ask my chief, Dr. Robert Stone, how I could be sure of the accuracy of my roentgen diagnosis. In the course of our discussion he told me about his former chief, Dr. Howard Ruggles, an excellent diagnostician who was able to make a high percentage of correct diagnoses after a brief examination of the films. Sometimes physicians felt that Dr. Ruggles' ready diagnoses were perhaps not too reliable and they might ask: “Dr. Ruggles, what makes you think this shadow is a metastatic lesion?” To which his just as ready reply would be: “Because it looks like it!” All of us to some extent make diagnoses in this way, and often it is difficult to describe the many possible variations of certain lesions, as, for instance, the protean manifestations of pulmonary tuberculosis.But what about the traps set for the unwary radiologist who uses this “looks like it” method too freely? Figure 1 shows the lung manifestations of four different diseases. The roentgen findings are similar and few radiologists would make all four diagnoses correctly on the basis of the film alone. However, if I told you that the first patient had carcinoma of the stomach, the second had pneumococci in the sputum, the third had scleroderma, and the fourth appeared acutely ill with dyspnea, cough, and fever, a white blood count of 10,000, and negative sputum culture, you would be much more likely to give the correct diagnoses, namely, for patient 1, lymphatic spread of carcinoma of the stomach; patient 2, disseminated pneumococcal pneumonia; patient 3, diffuse fibrosis in scleroderma; and patient 4, diffuse interstitial pneumonitis of viral etiology.Bone lesions are also difficult to describe and identify. Figure 2 is the roentgenogram of the right forearm of a woman who was examined because of her complaint of pain in the arm. An expanding lesion is present in the middle third of the radius. The cortex is intact; there is no periosteal elevation, and a coarse trabecular pattern is present. In this case, if I told you that the patient's left kidney had been removed because of a malignant tumor, you would at once suggest that the bone lesion very likely is a metastatic hypernephroma. Later I will have more to say concerning the description and identification of bone tumors.It was to problems of identification such as these that Dr. Sosman was referring in his 1950 Shattuck Lecture onThe Specificity and Reliability of Roentgenographic Diagnosis(1) when he said, “Our diagnoses are based on gross pathology (that is, disturbed morphology) in the great majority of cases—certainly well over 90 per cent. As roentgenologists I am sure that much of our accuracy depends on mathematical probabilities in a given case or set of circumstances.”