Too often, in our enthusiasm for the positive side of diagnosis, we are apt to forget the equally important but less spectacular negative side, and because of this we may be led into considerable error. Hence, it may not be amiss to consider briefly some of the pitfalls of cranial diagnosis into which one can easily fall. The first and most frequent “pitfall” is to attempt to draw conclusions from an inadequate set of films, or from those which are the result of poor technic. We are all familiar with the fact that in about 50 to 60 per cent of adult skulls the pineal body will be calcified sufficiently to cast a shadow on the film, and most of us are aware of the methods in use for measuring its relative position. These methods are all based on proportional measurements, either mathematical or mechanical, and with either method we allow ourselves an arbitrary normal zone. If the pineal shadow falls within this normal zone, we usually feel a sense of relief and conclude that the gland is not displaced; if it is slightly out of this zone, we consider it displaced. In the vast majority of cases, these conclusions will be correct, but we cannot accept such a finding without careful consideration of each case as an entity. The reason for this lies in the fact that the pineal body may be shifted from one part of the normal zone to another without the measurements revealing such a shift. This normal zone is really too large for extreme accuracy; therefore, we must be careful to evaluate the patient as a whole before stating definitely that the pineal body is or is not displaced. Again, an innocuous anatomical variation may locate the pineal gland slightly outside the normal zone. This discussion should not lead one to conclude that the use of our present schemes for pineal measurement must be abandoned. They are the best methods we have so far been able to devise and should by all means be used, but used with the full knowledge that they are not infallible and that we cannot accept the results with as complete assurance of accuracy as we can the reading of a thermometer. The discovery of a lateral pineal shift offers no problem in good films taken either anteroposteriorly or postero-anteriorly. Another easy diagnostic pitfall is the misinterpretation of an anomalous configuration and distribution of circulatory channels. Not infrequently we will find the diploic venous channels to be larger than usual. This anomaly may be confined to the frontal, parietal, or occipital group of veins, or may involve all of them. In any case, the channels may all be large and tortuous, or some may be large and others small. When this problem confronts us, we must carefully compare both sides of the head since the condition is usually bilateral. If there seem to be more and larger venous channels on one side than on the other, it is probably of no more than passing interest, provided we are sure that the channels are venous.
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