Launching a new journal page: Clinical Vistas

You cannot experience your own interior by closing your eyes and concentrating on it. In order to discover your own contents you have to investigate the inside of someone else.

— Jonathan Miller1

Human beings have always speculated about their physical contents; the difficulty has been in obtaining an adequate interior view. Although human dissection (of criminals, whether dead or alive) was permitted in Alexandria in 300 BC, Galen, 5 centuries later, still had to extrapolate human structures from animal parts.2 Impeded by law, moral scruples and dogma, the study of the human anatomy progressed by fits and starts, always in tandem with the artistic representation, on paper, in woodcut, engraving or wax model, of what was seen at times with questionable objectivity. With the 19th century came new technologies that offered not only new ways to record, but new ways to see.

Roentgen's discovery of x-rays in 1895 offered views of anatomy and pathology that would otherwise not be felt, seen or heard in a living person. Now we have even more wondrous means of peering into the human frame. With fibreoptic scopes we look down throats, and into knees, stomachs, bowels and bladders from new angles. Computed tomography and magnetic resonance imagery give us virtual “slices” of life. We inject nuclear isotopes and scan bones, glands, brains, hearts and lungs for defects. Diseased tissues declare themselves through special dyes and tags under microscopes that are increasingly powerful. With ultrasonography we record echoes of our present, and promises of the future. We can identify currents, chemicals and chromosomes, and we can even track a sperm and egg intermingling at the start of something big. Although we will always rely on our patients to describe that domain of self that is personal (felt), a host of technologies have now expanded what can become public (seen).

Every day, physicians are presented with clinical situations that can be dramatic, poignant, fascinating, beautiful, classic or rare. In the words of physician and Pulitzer Prize–winning poet William Carlos Williams “whole lives are spent in the tremendous affairs of daily events without even approaching the great sights that I see every day”.3 Aspects of these sights are often captured in photographs, radiographs, micrographs and scans. Medical imaging usually has practical intentions; “it is meant to be evidential, not interpretative. One takes photographs of a case (as distinct from a person) to act as teaching aids, as demonstration of a diagnosis, as a record of the progress of treatment or the process of disease, as legal record, as forensic evidence. The clinical photograph is perhaps the furthest that photography can get from art.”4 It is easy to lose the perspective that the images that we encounter every day are remarkable, not to mention beautiful.

From the earliest days of medical school, we learn to put aside personal and societal taboos about probing into the bodies and the stories of others. Paradoxically, the very technology that is meant to allow us to see deeper into human beings than ever before allows us to keep our distance, both physically and emotionally. Just as Laennec's stethoscope allowed a physical and metaphorical remoteness to evolve between physician and patient,5 sophisticated technologies allow us to diagnose at a distance, sometimes without ever having seen the patient. Focusing on the clinical details, it is easy to lose a sense of wonder about the particular aspect of the human condition that medical images reflect.

At CMAJ, we are proposing a new journal page to start in 2002 that will use visual cues for review and reflection. We plan to combine 2 or 3 interesting images on related themes, with figure legends that briefly explain what is seen or the cases involved. Surrounding the images will be snippets of text written by our editorial staff that summarize some interesting aspects of the recent literature about the topic raised in the images.

Our main goal is to allow physicians to share with one another some of the views of “the human condition” that they have captured in clinical images. A secondary goal is to help physicians to close the gap between themselves and their patients, and to rekindle the sense of wonder and fascination that may have inspired them the first time they saw such images. We will consider nearly any sort of image — photograph, scan, radiograph or micrograph, whether common, classic or rare — that is in some way visually interesting. A big, bright red eardrum may prove as stunning as a high-resolution MRI of a rare fascinoma. The images need not be from a conventional clinical setting; an outreach worker's photo of a heroin addict injecting into a vein may find itself in the journal next to a chest radiograph of Pneumocystis carinii pneumonia. A photo of the stooped posture of a patient with parkinsonism, snapped during a home visit with all the collateral visual context, could prove more meaningful than a similar photo posed in front of a white screen in an office.

A few firm requirements exist. First, like all other submissions to CMAJ, the material must be original. Second, consent for the image to be published in the print and online versions of the journal must be obtained from the patient and documented. Third, the image must be sharp, with clearly visible details. Fourth, the image must come from a clinical encounter, even if the encounter is in a nontraditional setting. Images can be sent to us by post (Editorial Fellow, CMAJ, 1867 Alta Vista Dr., Ottawa ON K1G 3Y6) and inquiries about possible submissions may be directed via post or email ([email protected]).

The word “vista” can mean both a “long narrow view as between rows of trees” and “a prospect or panorama.”6 In our Clinical Vistas page we hope to foster a double focus: examining detail, but embracing context.

Figure. “Abdominal Muscles” by Jacopo Berengario da Carpi (1521): anatomical depictions such as this print from a woodcut are subject to obvious artistic interpretation. Although modern imaging techniques are arguably more objective, they capture fascinating, but imperfect, views of sickness and health. Photo by: National Library of Medicine

Figure. MRI: a remarkable slice of life.

Figure. Arthroscopic view of a torn meniscus: such glimpses inside a joint are among the most common orthopedic procedures, and yet are foreign to many physicians in other medical fields.

Photo by: Courtesy of Dr. Bill Smyth