Radiology in Illinois
By Franklin Alcorn, M.D.
Dr. Alcorn's history appeared in the program of the Chicago Radiological Society at the Centennial of Radiology in 1995.
The story of radiology in America is the story of the growth of the science in Illinois. There has probably never been as rapid an adoption of a new technique or device as that of Roentgen's discovery in 1895. Illinois physicians began early to experiment with its uses and assemble the apparatus with which physicians would work.
Early in 1896, Emil Grubbe, then a chemist, physicist, and physician duplicated Roentgen's experiments and, with physicians and friends, tested the new "rays" on patients. He was one of the first physicians to utilize the "Roentgen ray" in the treatment of breast cancer. As early as 1896, Dr. Nicholas Senn of the Presbyterian Hospital was utilizing radiographs probably produced at the Western x-ray Factory Laboratories, for the visualization of bones suspected of fracture. In Chicago, during the early 1900's, medical students were using bisrnuth subnitrate to obtain fluoroscopic views of the stomachs of experimental animals.
Hospitals began to acquire x-ray equipment, and many employed radiographers to assemble the equipment and expose the glass plates upon which the radiographic images were produced. Interestingly enough, lay practitioners as well as physicians were using x-rays to treat a wide variety of medical problems including skin diseases, malignancies, and other conditions. Some palliative results were obtained. A perusal of the manufacturer's catalogs of that day reveals that, as early as 1896, electrostatic generators, for use in energizing x-ray tubes and for use in electrotherapeutics, were being produced. Many manufacturers also provided devices for the electrical treatment of a host of diseases including obesity, diabetes, sedentariness, hemorrhoids, etc. Electrotherapeutic applicators were available to fit almost every orifice of the body.
As early as 1893, C.F. Samms and J.B. Wantz founded the Victor Electric Company in Mr. Wantz's basement in Chicago. By 1896, they were producing electrostatic generators and electrotherapeutic devices. They acquired electrical manufacturers, such as McAleaster and Wiggins, the Snook Roentgen Company of Philadelphia, and others. By 1913, following the advent of the Coolidge "hot-cathode" high-vacuum tube, their reputation was such that they became the sole manufacturer and distributor of the Coolidge tube in the United States. The company was eventually acquired by General Electric in 1926, and by 1930 it had become the General Electric X-ray Corporation. The Victor Company of Chicago was held in such high regard that it became the foundation upon which the now existing General Electric Medical Systems was built.
The great interest shown by the medical and surgical staff of the Presbyterian Hospital was manifested by the purchase of its first radiographic machine in 1899, for the sum of $438.33. An interested student, Joseph F. Smith, became the operator of the machine and provided radiographs during his undergraduate days and for several years thereafter. Doctor Smith left the staff in 1906, and his successor was a student at Rush Medical College, Hollis E. Potter. Mr. Potter received his bachelor's degree in 1904 from the University of Chicago, majoring in chemistry and physics. He graduated from Rush Medical College in 1908 and was promptly appointed to the staff, where he remained until his resignation in 1915. Doctor Potter, as did many other workers in the field of radiology, realized that the contrast and definition of the radiographs of that time were unsatisfactory. Only the largest and most dense objects, such as bullets, kidney stones, and dense bones could be reasonably visualized.
Ernst Pasche, in 1903, working in Germany, was the first to describe the radiographic effects of the scattering of the primary Roentgen beam by the glass envelope of the tube and by body tissues. He believed that this scattered radiation contributed significantly to poor images. He devised a moving slit and a cone to be inserted between the x-ray tube and the patient, thus lessening the scatter resulting from the impact of the primary beam on the glass envelope. Additionally, he devised a moving-slit diaphragm to be placed between the patient and the radiographic plate. These slits moved synchronously across the patient during the exposure. These devices were quite helpful in reducing the effects of scattered radiation, which led to a loss of definition and contrast.
Only small segments of the body could be radiographed in a single exposure. Studies of large, thick body parts such as the abdomen, hip, etc. could not be adequately covered. Apparently Pasche did nothing further to pursue this observation.
Doctor Gustav Bucky, a physician intensely interested in radiography, pursued this matter further. In 1912 or 1913, he published his findings describing a cross-hatched or "honey-combed" lead grid which would reduce scatter significantly over a larger area. He recognized that the presence of horizontal grid lines were felt to be unacceptable. He reported his attempts at removal of grid lines by moving the grid during an exposure. Neither an oblique nor a circular motion applied to the grid completely removed the shadows of the lead strips. He applied for, and was granted, five patents covering these observations while he was working in Germany and later the United States.
Doctor Potter, working in Chicago, published three important articles reporting his studies on the problems of scattered radiation. In 1916, in the American Journal of Roentgenology, he described his experiments on diaphragming roentgen ray beams. During experimental observations, he noted that a metallic wire could be rendered undetectable if moved across a radiographic plate at right angles to the beam during exposure. He then constructed a grid consisting of parallel slits of lead interspersed with strips of wood extending from one end of the concave cassette to the other. The radiographic plate or film was then placed behind this grid, so that they were in position to remove the scattered radiation arising from the patient. The grid was made concave so that the lead strips were parallel to the divergent primary radiation beam. These changes removed the shadow of the lead strips and improved the contrast and the definition of the radiographic image to a considerable extent. In 1920, Potter described the necessity of widening the grid to cover the entire x-ray film. It was important that the lateral-most aspects of the image would not be degraded by scattered radiation. By this time, the commercial production of the Potter grid had begun. Further refinements of the device were described in the American Journal of Roentgenology in 1922 by Wilsey.
The development of the reciprocating grid was described by workers at the University of Chicago in 1925. Before the work of Hollis Potter, there were no satisfactory radiographs of the skull, hip, or other thick parts of the body. This limitation was removed by his multileafed focused grid. We are indebted to Gustav Bucky for his recognition that the x-ray beam, when incident on the surface of the body, is scattered out of its straight line and blurs the image. It can be said that Gustav Bucky posed the problem of scattered radiation, but Hollis Potter provided the solution. His work was one of the most significant contributions to radiography after Roentgen's discovery in 1895.
Doctor Potter's life was replete with activity and achievement. He was a founding member and the first president of the Chicago Roentgen Society, (later the Chicago Radiological Society), in 1913. He was president of the American Roentgen Ray Society in 1923 and was awarded the gold medals of the Radiological Society of North America, the American Roentgen Ray Society and the American College of Radiology.
One of the leading radiologists of this early period 1900 to 1942 was James T. Case. Doctor Case attended the American Missionary College of Medicine in Chicago, which merged with the University of Illinois in 1910. Doctor Case was trained in surgery and practiced in Battle Creek, Michigan until 1929. An accomplished surgeon and clinician, he became very interested in the development of radiology as a diagnostic and therapeutic tool. Very early in his career, he traveled extensively in Europe, primarily France and Germany, acquainting himself with the development and advances in radiology, which were occurring predominantly in those countries. His talent as a surgeon and radiologist led to his appointment as the first Professor and Chairman of the Department of Radiology at Northwestern University Medical School. During various periods, he was a radiologist at Evanston Hospital, Highland Park Hospital, St. Joseph's Hospital, and St. Luke's Hospital in Chicago. He was fluent in several languages, especially German, French, and Spanish. His translations of Alban Koehler's text on "Borderlands of the Normal and Early Pathologic Skeletal Roentgenology" and the multi-volume work of Schinz, Baensch, Friedl and Uehlinger were well received.
Dr. Case was particularly interested in gastrointestinal radiology as well as osteology. In 1914, he published a four-volume work on the GI tract. He published over 100 major articles during his professional career, and he was appointed editor of the American Journal of Roentgenology in 1916. In World War 1, he was the Chief of Radiological Services in the American Expenditionary Forces in France. He traveled extensively in Central and South America, conducting teaching seminars and visiting South American radiologists. He was president of the Chicago Roentgen Society in 1915, the American Roentgen Ray Society in 1920, and the American Radium Society in 1923. He received the gold medals of the Radiological Society of North America, the American Roentgen Ray Society, and the American College of Radiology. Unquestionably, he was the most widely known and respected American radiologist of his time.
Another noted radiologist of this period was Edward L. Jenkinson. Doctor Jenkinson received his medical degree from St. Louis University in 1915. Following his internship in St. Louis, he went to Wisconsin for a brief period of general practice. He then received an appointment to the medical staff of St. Luke's Hospital in Chicago, where James Case was the Director of the Department of Radiology. Jenkinson became interested in radiology and studied with Dr. Case as his preceptor. He advanced rapidly and was Director of the Department of Radiology at St. Luke's Hospital from 1923 to 1959 and St. Joseph's Hospital from 1923 to 1939. His professional and academic career also encompassed Northwestern Medical School from 1920 until his retirement in 1959. He was Chairman of the Department of Radiology at Northwestern from 1947 until 1957.
Edward L. Jenkinson was probably best known as one of the founding members of the American Board of Radiology, and he was a member of the first Board of Trustees, serving over a period of 27 years. He was president of the Board from 1946 until 1951. He also served as president of the Chicago Roentgen Society from 1923-1926 and of the American Roentgen Ray Society in 1956.
Benjamin Orndorff was another luminary among the radiologists of his day. He received his M.D. degree in 1906. He became interested in radiology while still a medical student at the Chicago College of Medicine and Surgery. He was the founder of the Department of Radiology of the Stritch School of Medicine of Loyola University and remained Chairman of the Department for 52 years, until his retirement in 1968. His scientific writings included "The Description of Techniques and the Values of Pneumoperitoneum and Peritoneoscopy Procedures," a field in which he was accomplished. He published several papers in 1930 on the effects of the hormone cholecystokinin on the human gall bladder. He was an associate editor of the Journal of Roentgenology, which was the predecessor of Radiology. He was active in the Western Roentgen Society, later to become the Radiological Society of North America, and he was one of the founders of the American College of Radiology. He was a supporter of international organizations, and, in 1937 hosted the 5th International Congress of Radiology in Chicago. In recognition of his accomplishments, he was awarded the gold medals of the American College of Radiology and the Radiological Society of North America.
In 1927, Paul C. Hodges, M.D., Ph.D., was appointed Professor and Chairman of the Section of Radiology in the Department of Medicine at the University of Chicago. This extraordinary individual was uniquely prepared to accept the opportunities and challenges of that position. He had been involved in radiology since the age of 14, when he prepared chemical solutions for x-ray development at a local hospital in Wisconsin. He studied physiology and medicine at the University of Wisconsin and was awarded his medical degree by Washington University in St. Louis in 1918. During World War 1, he was stationed at the army x-ray school at Camp Greenleaf, Georgia. The University of Wisconsin later granted him a Bachelor of Science degree in 1919 and a doctorate degree in physiology in 1924.
Doctor Hodges created a research-oriented department at the University of Chicago. Three main areas of concentration were selected: the improvement of x-ray systems for subspecialty applications, the improvement of film development facilities, and the development of new ancillary hardware. In order to accomplish his goals, he established a machine shop in the department. From this facility, and under Dr. Hodges' direction, equipment dedicated to skull, chest, upper gastrointestinal, colon, and kidney examinations was designed and built.
Doctor Russell Morgan, a radiologist in the department with a substantial engineering background who worked with Dr. Hodges, developed an exposure meter, the photo timer, a spot filming device for fluoroscopy, as well as automatic collimation.
Clinical research was not overlooked at the University of Chicago. A classic loose-leaf text on the pathologic correlation of the diagnosis of diseases of bones and joints was published under Dr. Hodges' authorship. Templeton's text on gastrointestinal radiology was also prepared in the department.
Doctor Hodges was instrumental in the creation of the Association of University Radiologists in 1953. Doctor Russell Morgan was elected the first president. Many honors came to Dr. Hodges as a result of his long and extraordinarily productive career. He delivered the Caldwell lecture and was awarded the gold medal of the American Roentgen Ray Society in 1953. He was president of that society in 1955. He was awarded the Order of the Brilliant Star of the Republic of China in 1963 for his early missionary work in China, and the gold medal of the Association of University Radiologists in 1978. The Radiological Society of North America dedicated its 1992 Scientific Session to Dr. Hodges.
As a result of his long career devoted to research and education, Dr. Hodges had a significant influence on radiologic education in the United States. We place him among the truly outstanding radiologist in this country, and in the entire world. He is a titan among radiologists.
In 1881 under the aegis of the United Hebrew Relief Association, Michael Reese Hospital was opened for patient care for all people. The original hospital was destroyed in the great Chicago fire of 1871. The first radiology department was established in 1910. In 1913 the Sarah Morris Children's Hospital opened. The fledgeling x-ray department was called upon to provide services for the infants and children at Sarah Morris. This hospital provided the first neonatal care facility in the Midwest. Robert A. Arens was Director of the Department of Radiology and Radiotherapy from 1916 through his retirement in 1954. In 1937, Dr. Eric Uhlmann founded the first separate department of oncologic therapy then called The Tumor Clinic. It included not only teletherapy but radium therapy as well. Although not a university hospital, close associations were formed with Northwestern University Medical School, the Chicago Medical School, the University of Chicago School of Medicine, and the University of Illinois College of Medicine. These affiliations provided the stimulus for teaching and research as well as the obligation to deliver excellent patient care. Gynecography, a combination of hysterosalpingography and pelvic pnuemography, was developed to outline the pelvic visera. This enabled Doctors Erich Stein and Michael Leventhal to discover a major cause of infertility, congenital polycystic ovaries(the Stein-Leventhal Syndrome). Techniques were also developed for treating head and neck cancers with a four gram radium pack. Later these facilities were replaced by high energy radiation therapy.
Teaching was also a significant commitment of the department. For many years, the radiology department provided an award winning school of x-ray technology. Additionally, the Tuesday night film reading sessions for radiologists were instituted by Dr. Arens. At that time no other hospital in the city held teaching sessions available to radiologists and trainees at a time convenient for them to attend.
After 114 years of service to the community, the radiology department retains its deserved reputation of excellence as a clinical, research, and teaching medical center, unique in a non-university setting.
The advances and contributions of Illinois radiologists to the field of diagnostic radiology are well known. Most of the earlier radiologists were also involved in radiation therapy. Doctors Potter, Orndorff, Case, Jenkinson, Hodges, and others were primarily general radiologists providing both diagnostic and therapeutic services to their patients. By the 1950's, advances in radiation therapy had reached the point at which separate disciplines had become necessary.
In the early 1950's, Hines Veterans Administration Hospital was experiencing a peak of activity, caring for the service personnel of two world wars. Virtually all veterans with cancer in the Chicago area who required radiation therapy were treated there. Based on their experience at Hines, pioneer therapists Max Cutler and Franz Buschke published a book on cancer. It was at this time that the therapy group headed by Cutler brought Henri Coutard and Juan del Regato to Chicago to participate in forming what was to be an institution not unlike the Memorial Hospital in New York City, the Chicago Tumor Institute.
The Radiation Therapy Club that had existed informally for many years in Chicago evolved into a national organization, The American Society of Therapeutic Radiation Oncologists (ASTRO), in 1966.
In the 1960's, there were about 25 radiation therapy residents in training per year in the United States. By 1994, there were 526 residents in 84 programs throughout the United States . Five of these programs are in Chicago, offering 30 residency positions. The radiation oncology departments in our city have participated in the various protocols of the Radiation Therapy Oncology Group (RTOG).
In September 1976, the Neutron Therapy Facility was established at Fermilab in Batavia by Lionel Cohen of the University of Chicago and Michael Reese Hospital and by Frank R. Hendrickson of the Rush Presbyterian St. Luke's Hospital as principal investigators. Edwin J. Liebrier, at the University of Illinois, obtained the first Oldelft simulator and tomographic units for radiation treatment planning in 1981. In 1979, Dr. William N. Brand and his colleagues at Northwestern University College of Medicine cosponsored the American College of Radiology Radiation Oncology Self Assessment Program. Doctor Geoffrey L. Smoron has recently been chairman of this program.
In 1942, at Stagg Field of the University of Chicago, the atomic age was born in a scientific event that rivaled the significance of Roentgen's discovery almost 50 years earlier. This event was the development of the nuclear chain reaction under the direction of Professor Enrico Fermi. A new age in radiology had arrived. This was made evident by the increase in the utilization of supervoltage radiation therapy and nuclear medicine. The growth of Illinois radiology was reflected in the Atomic Energy Commission's decision to locate the Argonne National Laboratory near Chicago, and to build the Argonne Cancer Research Hospital at the University of Chicago to explore medical uses of radiation sources. An accompanying increase in the need for medical physicists, radiation oncologists, and nuclear medicine physicians became evident. In 1946, collaborative work between the Tumor Clinic of Michael Reese Hospital and the Physics Department of the University of Illinois, by Drs. Lester S. Skaggs and Lawrence H. Lanzl, led to the development of a free beam of electrons from the 22 MeV betatron at the University of Illinois at Urbana.
In 1948 the physicists at the Carle Clinic and the University of Illinois in Urbana, adapted the 22 MeV betatron x-ray beam for the treatment of cancer. Doctors Henry Quastler, Eric Uhlmann, Lanzl, Laughlin, Skaggs, and others collaborated in this work. The first betatron dedicated to full time patient use was installed in the early 1950's at the University of Illinois Research and Education Hospital in Chicago.
These early efforts on the part of Illinois physicists and radiation oncologists made electron beam therapy available for the treatment of malignancy. Today, almost all radiation oncology departments nationwide have high energy electron beams available for cancer treatment.
During the 1950's, Michael Reese Hospital and the Argonne Cancer Research Hospital of the University of Chicago acquired a linear accelerator for the treatment of cancer by electron beams. The unit at Michael Reese had a range of electron energies of 5 to 35 MeV. The University of Chicago unit had a range of 5 to 50 MeV. The University of Chicago unit had a unique scanning beam device for controlling field size and shape. Much of the developmental work of the University of Chicago unit was carried out by physicists Skaggs, Lanzl, and Martin Rozenfeld. The unit at the University of Chicago was in service for 34 years.
In the middle 1950's, a master's degree program in medical physics was initiated by Professors L.S. Skaggs and L.H. Lanzl through the Department of Radiology, University of Chicago. This was the first degree program of its kind in the United States. The program was expanded in the 1960's to include a Ph.D. degree in medical physics.
In 1956, a group of medical physicists organized the Radiation and Medical Physics Society of Chicago, and in two years the organization had grown to such an extent that the name was changed to The Radiation Medical Physics Society of Illinois. This organization later became the Midwest Chapter of the American Association of Physicists in Medicine (AAPM). The William D. Coolidge Award for Distinguished Contributions to Medical Physics was awarded to Dr. Lanzl in 1978 by the AAPM.
Nuclear medicine was in its infancy in the early 1960's, limited primarily to the evaluation of thyroid disease. During the decade that followed, dramatic growth occurred. By the end of the mid 1970's, radioisotopic procedures were as commonplace in clinical medicine as was plain-film radiography. The foundation of modern isotope imaging was established at the University of Chicago by pioneering work in nuclear physics. The first commercially available gamma camera in the world was manufactured by the Nuclear Chicago Corporation. Doctors Paul Harper and Catherine Lathrop at the University of Chicago should be credited as the first researchers to recognize the unique characteristics of technetium 99-m as an isotope for nuclear imaging studies in man. Technetium chemistry is probably the single most important factor in the success of isotope imaging today. James L. Quinn headed the first nuclear medicine department at Northwestern University and was one of the first to employ radioactive iodinated serum albumin for pulmonary perftision studies in suspected cases of pulmonary embolism.
Although mammography was popularized in the early 1960's by Robert L. Egan, it was not until the mid-1980's that a substantial number of mammographic studies were performed. This resulted from a national interest in breast screening for the detection of early lesions, following the encouraging reports of the results of the Breast Cancer Detection Demonstration Project (BCDDP). In 1984, a unique breast cancer screening project was sponsored jointly by the Illinois Division of the American Cancer Society and WBBM-TV. Doctor Harold J. Lasky, as chairman of the Illinois Radiological Society Mammography Committee, participated in the project as radiologic consultant. At the conclusion of the project, it became apparent that, in many cases, the quality of the mammograms was poor. In an effort to improve the diagnostic value of the studies, quality assurance was developed. The diagnostic quality of the films were evaluated by use of a phantom devised by Dr. Lasky, and the diagnostic acumen of the radiologists was ascertained by the development of a questionnaire. With the encouragement and guidance of Dr. Lasky, the entire complex of image and reader evaluation studies was adopted on a national basis under the aegis of the American College of Radiology. In 1988, 511 mammography facilities were accredited, and by March 1991, 5571 facilities had been accredited. This approach to a national quality assurance program resulted in the Mammography Quality Standardization Act [MQSA] which was passed in 1994. Today, the Food and Drug Administration is responsible for the certification of all facilities performing mammography. The American College of Radiology Accreditation Program has been adopted for this purpose. Members of the Illinois Radiological Society played a pivotal role in developing this program. It is the first program of its kind in which a federal regulatory agency has recognized the importance of evaluating and certifying a diagnostic radiographic facility.
In 1922, the radiologists of Illinois had organized themselves into two separate divisions: the Chicago Roentgen Society and the Central Illinois Radiological Society. In 1967, after the institution of the chapter system by the American College of Radiology, it became evident that the time had arrived for the radiologists of Illinois to be represented by one state organization, the Illinois Chapter of the American College of Radiology. This was accomplished under the leadership of Dr. Frederic Lake. The Chicago Roentgen Society then became known as the Chicago Radiological Society. The annual meeting of the American College of Radiology thereafter was attended by councilors and the alternate councilors from each division of the chapter, chosen on the basis of proportional representation. The presidency and officership of the Illinois Radiological Society (IRS) were then held alternately by members elected from the Chicago Radiological Society and the Central Illinois Radiological Society.
Early in 1982, Dr. Harold Lasky proposed the formation of a Resident Physician Section (RPS) to the Executive Committee of the Chicago Radiological Society. Resident physician sections had been functioning successfully as an integral part of the American Medical Association, Illinois State Medical Society, and several specialty societies for a number of years. These sections introduced residents to the purposes of organized medicine by providing an opportunity for direct participation in the deliberations of the society, a vote on proposed resolutions, and regularly scheduled informational sessions.
Dr. Franklin Alcorn urged the acceptance of this concept by the Executive Committee of the Chicago Radiological Society, and he encouraged the program directors and their residents to participate. These efforts were successful, and a Resident Physician Section of the Chicago Radiological Society was formed. In addition, in 1984, a resolution to this effect was forwarded to the American College of Radiology by the Illinois Radiological Society and was accepted. The Resident Physician Section of the Illinois Chapter of the American College of Radiology became a functional reality. Other chapters encouraged by the American College of Radiology soon formed their Resident Physician Sections.
Today all of the chapters in states with active teaching programs have formed Resident Physician Sections. The Illinois Radiological Society was the first chapter to form a Resident Physician Section. All RPS have representatives attending the annual meeting of the ACR. They consider the same resolutions as the councilors. Their section is allotted one vote on each resolution considered by council.
A talented member of the Central Illinois Radiological Society, Cesare Gianturco is an unusually creative generalist. While at the Carle Clinic at Urbana, he developed an automatic transport system to carry exposed cassettes from the angiographic suite to the dark room. He also developed a compression device for abdominal studies, especially upper G.I. examinations. He and his colleague, George Miller, performed most of the arteriography, and they performed proctoscopy on all of the patients referred for lower GI series. He is probably best known for his work in the development of the Gianturco coil spring for arterial occlusion. For his creativity and long years of service to his patients, Dr. Gianturco was awarded the Radiological Society of North America Gold Medal in 1970, and the Gold Medal of the American College of Radiology in 1994.
The evolution of modern radiology has occurred largely during the last 45-50 years. The specialty today has become widely diversified. Spectacular technical advances have always received the greatest attention in the scientific literature and the lay press. The ultimate value of these advances, however, lies in the extent to which they are able to provide clinically useful information concerning the patient. Imaging has become increasingly important in virtually all fields of modern medicine. It plays a key role in both the diagnosis of disease and the treatment of patients. Many members of the IRS have played pivotal roles in the development and encouragement of widespread application of the disciplines mentioned above. Their value is recognized by the esteem in which these outstanding individuals are held by their colleagues both locally and nationally. Our members have also provided quality leadership in the fields of public service and organized medicine. Through the years, a number of our members have served as presidents and members of the Board of Trustees of the Illinois State Medical Society and the Chicago Medical Society. Many of our members have received local and national recognition. Since the the early days of radiology, 8 members have been president of the American College of Radiology, 10 members have been presidents of the Radiological Society of North America, 7 members have been president of the American Roentgen Ray Society and 10 members have received the Gold Medal of the American College of Radiology. Fourteen members have received the Gold Medal of the Radiological Society of North America, and 4 members have delivered the Caldwell lecture and received the Gold Medal of the American Roentgen Ray Society. Three members have served as president of the American Board of Radiology.
It has been the good fortune of the current members of the IRS to have practiced during a period in which radiology has experienced an extraordinary degree of scientific advancement, technical sophistication, and acceptance as a major influence in medicine by both our clinical colleagues and our patients.
Physicians practicing radiology during the first 45 or 50 years of this century were to a large extent generalists. This was true not only in Illinois, but also in the remainder of the country. The diversity of and increase in the number of patients, as well as the complexity of the studies and treatments offered, have made subspecialization in diagnostic and therapeutic radiology a necessity. This fact, accompanied by increasing regulation of our activities by both state and national governments promises to create a more difficult atmosphere in which to practice. The danger of increasing loyalty on the part of radiologists to their subspecialty societies, rather than the parent radiologic organizations, poses a significant danger of fragmentation. Let us hope that we will be able to speak as a single group of specialists when called upon to confront those problems which will inevitably arise in the future.