Author: Richard B. Gunderman
The phenomenal scope of this book on the history of medical imaging is evident in the diversity of themes it covers, from ionising radiation and X-ray crystallography to forensic art and patient experience. And at the heart of the narrative is the serendipitous discovery of X-rays, what the author referred to as a ‘revolution in the practice of medicine’, and as ‘a Promethean gift‘ that ‘can provide great benefit to mankind, but only if used wisely‘. As it chronicles the subsequent advances which led to the emergence of the specialty of radiology, the author made the consistent argument that the human qualities of the specialty must transcend its scientific framework. Although ‘contemporary radiology practice’ is largely technology-driven, the author nevertheless maintains that ‘radiology retains its artful dimension‘. To illustrate this, the book features a plethora of anecdotes which stress the importance of compassion and empathy, and which downplay the dominance of the machines and processes that define the field. In this regard, the book makes a strong case for putting medical imaging at the centre of clinical medicine, and it supports this with its focus on the humanity of ordinary people and high profile celebrities alike (pages 17-18, 29-32, 69-84 and 196).
Wilhelm Roentgen is unquestionably the most important actor in the drama that constitutes the history of medical imaging, and the book explores how he made his groundbreaking discovery of X rays, and how he immediately recognised its consequential implications. In its biographical portrait of Roentgen, the book noted that he was nearly blind in one eye from a childhood infection, but he nevertheless progressed in his career to become a professor of physics, the post he was holding when he made what the author said was ‘by far his most important discovery’. The book described how Roentgen, whilst ‘investigating the effect of passing electrical discharges through vacuum tubes‘, observed that ‘emissions from one of the tubes were causing a faint glow on a nearby screen that had been painted with barium salts‘. Speculating that this was ‘a new form of light’, the author said Roentgen named it X-ray, and used it to produce ‘the very first radiograph of a human being’. It was most inspiring when the author pointed out that Roentgen declined to patent his discovery, and magnanimously donated all of ‘the very first Nobel monetary prize in physics’ he won to his university (pages 15-16).
Just as he did for the discovery of X-rays, the author also documented an enlightening account of the advanced imaging technologies that progressively transformed the field of medical imaging. For example, in discussing computed tomography (CT), the author described it as a technology which enables clearer visualisation of individual organs by beaming X-rays ‘through the body from many different directions‘. The author also narrated the unconventional circumstances of the discovery of the technology by Godfrey Hounsfield when he was engaged in ‘a new and very unusual project‘ funded by EMI; this was the music company which developed radar during the second World War, and which had acquired ‘flush‘ profits by signing up the Beatles. Hounsfield, the author added, shared the Nobel prize for his work with Allan Cormack, the physicist who established ‘much of the theoretical mathematics for such a device’. In a similar way, the book detailed the history of magnetic resonance imaging (MRI), but the narrative in this case was dominated by the controversy and rivalry that followed the award of the Nobel prize to Paul Lauterbur and Peter Mansfield, but not to Raymond Damadian – the third pioneer of the technology. Other imaging tests the author covered ranged from the simple ultrasound, to the complex positron emission tomography (pages 85-91, 102-113, 119-122, 141-144 and 176-179).
One of the most insightful themes of the book is its discussion of the limitations of medical imaging. In this discourse, the author opined that ‘radiology is not perfect‘, illustrating with the scenarios where ‘the underlying pathology may be of such nature that the scanners cannot reveal it’, or where ‘the wrong test‘ is requested, resulting in missed diagnoses. Indeed the author pointed out that, because medical images still require ‘human interpretation‘, ‘errors are always possible’ such as when radiologists fail to detect lesions such as cancer, or when they report ‘false lesions‘ – with the ‘considerable fear and anxiety‘ these situations provoke. And with a profoundly humanitarian perspective, the author argued that medical imaging is incapable of detecting either ‘the larger web of poverty, deprivation, and despair‘ of patients, or their ‘psychological and social conditions’. Keen to stress the importance of maintaining this philosophical element of medical imaging, the author warned against allowing ‘the machine‘ to ‘dehumanize not only the patients but the technologists, nurses, and radiologists who work in it’, explaining that ‘the radiology experience can go wrong‘ when practitioners forget their humanity. To prevent this happening, the author advised radiologists to remember that ‘no matter how sophisticated it becomes’, imaging technology ‘can never substitute for the understanding and compassion of another human being’ (pages 61-63, 172, 184, 194 and 196).
As further testimony to his humanitarian outlook of radiology, the author reflected deeply upon the overarching concept of illness, and he used the experiences of a spectrum of patients as foundation for this contemplation. And one of his most enlightening explorations examined the life of painter Frida Kahlo in the contexts of her chronic and debilitating illnesses, and of how her paintings portrayed her protracted interactions with healthcare. This account particularly highlighted her longstanding disability from childhood polio, and her recurrent suffering from such conditions as chronic pain resulting from severe trauma. In describing her long periods of convalescence in hospital, the book also reviews how her artwork captured ‘her experiences as a patient’. The author also used Kahlo’s story to specifically argue that ‘suffering stems not only from the disease or injury itself, but also from the diagnostic testing, including the inability to afford tests when they are needed’. Also asserting that ‘Kahlo’s art is not meant to comfort’ but to challenge, the author said ‘it dares us as physicians and other health professionals to step outside our scientific and clinical routines and to look at the experience of illness and injury from the patient’s perspective‘ (pages 64-69).
An attractive feature of the book are the fascinating anecdotes that litter the history of medical imaging. For example, the book narrates the nerve-racking story of Werner Forssman, the physician who, against the prohibition of his superiors, self-experimented by tunnelling a catheter through a vein in his arm into the heart. By demonstrating that it was feasible and safe to do this, the author said Forssman opened the way to the development of cardiac catheterisation for the investigation and treatment of heart disorders. The author however referred to this episode as ‘both lamentable and admirable‘ because, whilst his ‘bravado‘ ‘helped to pave the way for important new uses of X-ray’, it bypassed the acceptably safer method of animal experimentation. Other interesting stories in the book are the use of X-rays in the ‘diagnosis after death’ of the mummy of Ramses II and Lindow Man, and in investigating the location of bullets in the assassination attempts of American presidents Theodore Roosevelt and Ronald Reagan (pages 19, 24, 33-37, 187-189 and 205).
This book narrates an exhaustive history of medical imaging which extends from the scientific and academic to the social and humanistic. Setting medical imaging within the wider context of total patient care, the author advocates a fresh perspective of the technology-driven specialty of radiology which encompasses the whole patient experience. The narrative not only details the chronological development of the field, it also illustrates the impact of medical imaging on people individually and collectively. The themes of the book transcend the medical to encompass the physics driving the technologies it discussed. With helpful images and striking anecdotes complementing the text, the book is both educational and entertaining – even if some of the stories were rather indulgent.
The strength of this book lies in its skilful juxtaposition of technology on one hand, and humanity on the other. Whilst the book is primarily a guide to medical imaging technology, the wider perspective it adopted helped to show how much radiology may make or mar the whole patient experience. The book turns out to be a profound social commentary that goes beyond the narrow confines of X-rays, and replete with lessons for healthcare, and I recommend it to all doctors.