“You Still Have to Work for It”

During the last fifteen years, fluoroscopic equipment has changed fundamentally, primarily because of the introduction of the screen intensifier. The intensifier has not only tremendously improved the fluoroscopic image but has also resulted in further technical developments, such as cinefluorography, television monitoring, tape recording of the fluoroscopic image, and remote-control fluoroscopy. The day is not too far away when young radiologists will no longer have any knowledge of old-fashioned pre-intensifier fluoroscopy. They will be proud of their equipment which they will consider ever so much better than that of the previous generation. Are they correct? Is the examination with the intensifier and its various adjuncts that much better? Is it even possible that the use of the intensifier results in a poorer examination? An appraisal appears necessary in order to keep the new generation from growing up in an atmosphere of unjustified self-assurance. Such an appraisal is a somewhat unpopular, but—I believe—necessary task. I undertake it as one who for decades has been interested in fluoroscopy and has, I hasten to state, completely switched to fluoroscopy with screen intensifiers. What are the advantages of the intensifier? The greatest is of course the increase in light intensity. This permits the use of smaller amounts of radiation. The advantage is at times diminished by the fact that the examination may be more cumbersome and therefore prolonged. The intensifier permits examination in a partially lighted room, which is obviously desirable. Fluoroscopy can be performed without dark adaptation when the intensifier is used. Not only does this save time, but, more important, it permits the procedure at a moment's notice outside the usual fluoroscopic schedule. This has permitted its use, for example, during intravenous pyelography and in certain fractures—demonstrating the fracture plane in questionable cases or showing depression in skull fractures. It has also made possible the fluoroscopic study of any equivocal chest lesion without delay at the time of the initial film check. The greatest gain, however, lies in the fact that the examiner is able to use light-adapted vision, i.e., cone rather than rod vision, resulting in considerably increased visual acuity. What are the disadvantages of intensification compared to such an impressive array of gains? The new equipment is more awkward than the old. This not only leads to a prolongation of the examination but also tires the examiner and decreases his ability to concentrate on the findings. (This objection is overcome when the remote-control equipment is employed.) The clumsiness of the apparatus has been reduced by some of the newer 6-in. amplifiers. Palpation of the patient is considerably poorer when one uses the intensifier and all its modalities rather than the oldfashioned fluoroscope. Some explanatory words are needed here. It is often thought that palpation and compression are synonymous.