Up and Down the Stairs with Dr. Shapiro

Going Up the Stairs

One morning while reading cases with Dr. Shapiro, we came across an interesting chest radiograph (he could interpret not only neuroradiology but all types of studies); he decided that we needed to go see the patient but that riding the elevator would take too long, so we took the stairs. He was a good tennis player, so he did most of talking on our way up while I did most of the huffing and puffing. During the walk upstairs, he told me a few things about his life, which here I have complemented with material sent to me by Marc, his son, also a neuroradiologist. He told me that he was born in Philadelphia and that his father had been a tailor and his mother had stayed at home. After graduating from the University of Pennsylvania School of Medicine, he went on to serve as an intern and radiology resident at the Beth Israel Hospital in Newark, New Jersey. Immediately thereafter, he entered the US Navy Medical Corps and served in the Pacific Theater, returning to civilian life in 1946. He was a Fellow from the National Cancer Institute at the University of Minnesota under Dr. Leo Rigler. In 1948, 1 year after completing this fellowship, he published an article on pulmonary embolism in the American Journal of Roentgenology. Out of the 10 articles he published up to this time, none were in neuroradiology. How he got interested in neuroradiology is not clear to me, but all neuroradiologists need to be glad he did.

At the Top of the Stairs

Finally we made it to the top floor of Jackson Memorial Hospital only to find that the exit door was locked! Both of us were tired by now, so we rested for a few minutes before descending, and he continued telling me parts of his story. In 1950, he published his first article dealing with neuroradiology.¹ Of 75 articles he eventually published, 32 dealt with neuroradiologic topics. To understand the breadth of his practice in a community hospital, one only needs to peruse the titles of his non-neuroradiology articles. These include studies of zirconium, bromine, and cesium chloride compounds as contrast materials; experimental opacification of the pancreas; serum levels of iodine after administration of iophenoxic acid, and the effects of Teridax (an experimental cholecystography contrast) on babies, among others all published in the best journals including the New England Journal of Medicine. His interest in neuroradiology resulted in articles encompassing angiography, pneumoencephalography, myelography, head and neck disorders, and, particularly, the anatomy and development of the skull.

Far more than his articles, it was his books that resulted in international recognition. His best is simply titled Myelography (Year Book Medical Publishers, 1962). It is a classic book that I still have on my shelf and often give to my fellows to read. The first edition came out in 1962 and the fourth and last one in 1984 (Figs 1 and 2). In the British Medical Journal, a review of the first edition by Dr. James Bull stated, “This book can be recommended to all specialists interested in the subject and it has the further merit of being relatively inexpensive.”² The expanded second edition was reviewed in the Annals of Internal Medicine² as follows: “While most of the material concerns myelography, its techniques and interpretations, separate chapters devoted to discography and interosseous venography, as well as extensive description and illustration of arterial studies of the spine and spinal cord, increase the scope of the book.” Dr. Taveras said of the same edition³: “The book is a monograph on Pantopaque myelography, well documented and illustrated. As such, it is the most complete work on the subject.” Dr. Steven Kieffer called the third edition “a superb book.”⁴ Of the fourth edition of this book, the British Journal of Radiology said, “This excellent text, now in the fourth edition, has been and will probably continue to be a standard reference book on myelography for both general and neuro-radiologist” (Fig 2).⁵ I agree with these comments and believe there is still no better book on the science and art of myelography.

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Fig 1.

Cover of the first edition of Myelography published by Year Book Medical Publishers (Chicago, Illinois) in 1962.

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Fig 2.

Cover of the fourth edition of Myelography published by Year Book Medical Publishers (Chicago, Illinois) in 1984.

In 1960, he published a book called The Normal Skull: A Roentgen Study (Hoeber), which was well reviewed in Radiology.⁶ He updated this book in 1980 and changed its title to Radiology of the Normal Skull (Year Book Medical Publishers). This book was very popular with residents and is often used in emergency departments. To me, his second-best book is the little-known The Embryogenesis of the Human Skull (Harvard University Press), also published in 1980. A scholarly treatise on the development of the skull, it is replete with assembled and unassembled skulls of different ages, radiographs, transilluminated Spalteholz preparations, and histologic sections. When I visited Yale in 1987, Dr. Shapiro gave me a tour of the medical school and took me to an amazing laboratory full of fetal specimens and skulls that looked like something out of an Indiana Jones movie. It was in the same laboratory that Dr. Leon Kier did some of the best work in radiologic embryology of the time.

From reading his letters, I have the impression that Dr. Shapiro became restless at the start of the 1960s. Dr. Rigler had left Minnesota to become director of the Cedars Sinai Hospital in Los Angeles, and he attempted to recruit Dr. Shapiro as Chief of Neuroradiology, also mentioning that a similar position was open at the University of California in San Francisco. Dr. Rigler extolled the wonderful California weather, the very good billing system, and the generous state monies available to the hospitals, but in the end, Dr. Shapiro took the Chair position at Beth Israel Hospital in Boston. In the hospital newsletter (November 1962), Dr. George Berry, then Dean of Harvard Medical School, praised Dr. Shapiro's “astute clinical acumen and knowledge of chemistry” and considered him an important addition to the community. The New Haven Register lamented that he was leaving that town.⁷ One year later, he went back to Saint Raphael and Yale, where he stayed until age 67, when he moved to Miami.

Other activities of his are worth mentioning here. He founded the Ezra Academy in Woodridge, Connecticut, a school for Jewish children that is still functioning (http://www.ezraacademy.net). He was a devoted worshipper who seldom missed Shabbat services, and his Hebrew was admired by all congregation members. In radiology, he trained individuals such as Dr. John Doppman, who became Chief of Radiology and Chief of the Health Clinical Center at the National Institutes of Health; Dr. Diego Nunez, who is now Chair of Radiology at Saint Raphael; and Dr. Harold Blatt, a Professor of Radiology at the University of Miami, among others (including myself). Add to this the fact that he was a very good tennis player, had 4 children and a successful marriage and you end up with very well-rounded individual who lead a full and fulfilling life.

Going Down the Stairs

Going down 6 flights of stairs was treacherous and slow as I remember that Dr. Shapiro was recovering from a foot injury. Although he blamed it on sports, retrospectively I wonder if it was an early manifestation of the myeloma that took his life in 1992. Two years after arriving in Miami, the Board of Trustees of the Hospital of Saint Raphael named its radiology department the Robert Shapiro Department of Radiology and a nice oil painting of him hangs there (Fig 3). In a letter dated September 10, 1984, the Archbishop of Hartford thanked him for 36 years of dedicated service. Saint Raphael also has an annual lectureship in his honor (the other is in Miami, vide supra), and I also had the honor to give it in 2003.

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Fig 3.

Oil painting of Dr. Shapiro hanging in the Robert Shapiro Department of Radiology at the Hospital of Saint Raphael in New Haven, Connecticut. Courtesy of Dr. Diego Nuñez, New Haven, Connecticut.

From 1986 to 1990, Dr. Shapiro wrote 5 articles about ancient Talmudic descriptions of anatomic structures and lesions of the central nervous system, including the cauda equina, head injuries, number of vertebrae, and Luz, the bone of resurrection. In this last intriguing one, he mentions that the coccyx was considered the bone of resurrection in antiquity probably due to the fact that teratomas (which may have fetal-like components) arise, not uncommonly, from it.

To give a balanced view of this man, I asked several individuals who were his residents what they thought of him. Many answered that he loved teaching and was very concerned about them as people and that he was very keen on patient care and became emotional when things were not correctly done. To me, this last observation is not surprising. Individuals who set a high bar for themselves and who deeply care for their patients are often this way. To understand how deeply he cared about patients, I offer the last part of my anecdote:

Once we made it back to the hospital lobby, I told Dr. Shapiro that maybe it was better to return to the reading room and catch up with work. He returned a look as if I had gone crazy. We then took the elevator up to the top floor, talked to the patient, and listened to his lungs. All was going well until he handed me the electrocardiogram strip and asked me to interpret it. When a dumb look crept into my face, he snatched it from me, told me that this time he would excuse my ignorance, and proceeded to give me a lecture on the basics of its interpretation. Dr. Shapiro was the only neuroradiologist whom I have known to be able do this.