Fundamentals of Skeletal Radiology 5th

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Fundamentals of
Skeletal Radiology
FIFTH EDITION

CLYDE A. HELMS, MD
Professor of Radiology and Orthopedic Surgery
Department of Radiology
Duke University School of Medicine
Durham, North Carolina
To Hideyo Minagi – the finest teacher I have ever known.
Foreword to the Second Edition
Clyde Helms, as a radiologist in training during the
mid-1970s, was, in many ways, the ideal radiology
resident. Able, perceptive, informed, and responsible,
he progressed through the various stages of residency
training in superb fashion. On the other hand, he
was different. Whereas the traditional “best resident”
always had at hand exhaustive lists of differential diag-
noses, Dr. Helms quietly ignored the trivial, the eso-
teric, and the information that was not likely to serve
him in his work as a radiologist in the “real world,”
sometimes to the discomfiture of the radiology faculty
of the University of California, San Francisco (of which
I was then a junior member). Whereas the traditional
“best resident” was suitably in awe of the faculty (many
of whom were truly awesome), Dr. Helms fearlessly
challenged what he perceived as unsupportable dogma.
Not one to sit still for pretension, he poked gentle (and
sometimes not so gentle) fun at the faculty. Occasional
pranks were perpetrated, sometimes at the expense of
members of the faculty. No one was immune, no mat-
ter how lofty his status. Dr. Helms, as the Sinatra song
goes, did it his way. Irreverent, witty, occasionally outra-
geous, and a superb radiologist, he completed his resi-
dency and went on to fulfill his military commitment.
He returned to UCSF 3 years later as a faculty mem-
ber in the skeletal radiology section. That he had not
changed was immediately apparent. Faculty meetings
were disrupted by his irreverent remarks, frequently
hilarious. Now a mentor, his teaching reflects the same
realistic, nontraditional approach he used as a resident.
He emphasizes not the exotic or esoteric but the prac-
tical, the information that is critical in the day-to-day
practice of radiology. Incorporated into his teaching
method are mnemonics, one or two of which might
not be recommended for family viewing. On the other
hand, if they work, why not use them? An increasingly
large number of young radiologists (his residents and
former residents) will attest that, indeed, they do work.
The teaching may be unorthodox, but the learning is
real and substantial.
This volume is also unorthodox. Several excellent,
superbly researched and crafted treatises on skeletal
radiology are available to the radiology resident and
practicing radiologist. This volume is not intended as an
exhaustive compendium of skeletal radiology. Rather it
is, as indicated by the title, an exposition of the basics
of skeletal radiology. In keeping with his personalized,
unusual approach to teaching, he begins with a dis-
cussion of radiologic examinations that should not be
performed. The remainder of the book deals with skel-
etal conditions that radiologists are likely to encounter
any day of the week. The reader who wishes to become
familiar with Scheie syndrome or trichorhinophalan-
geal dysplasia type II must look elsewhere.
Rather than the usual, formal language found in
other radiology texts, the reader will encounter the
vernacular used by all radiologists when they discuss
their work with other radiologists. The text is much like
Dr. Helms himself—witty, irreverent, unpretentious,
and fast-paced. The reader will find the book refresh-
ing, eminently readable, and highly informative.
The ideal condition
Would be, I admit, that men should be right by instinct;
But since we are all likely to go astray,
The reasonable thing is to learn from those who can teach.
—SOPHOCLES
Clyde Helms can teach!
Hideyo Minagi, MD
vii
ix
Preface
When I was a resident at University of California,
San Francisco (UCSF) in the 1970s, the teacher we
all tried to emulate was Hideyo Minagi. He not only
taught us radiology, he taught us how to behave, how
to treat people, and how to be professionals. He told
me that you shouldn’t tell an audience everything you
know – that was an effort to impress them; instead, you
should tell them what they need to know – that was
an effort to teach them. I hope this book follows that
advice. This book is much the same in this fifth edition
as it was 30 years ago. The fundamentals don’t change
that much. I have cleaned it up a bit and added better
illustrations here and there, but essentially it’s the same
book.
When the first edition came out, I was concerned
about what others might think of me for being some-
what irreverent and flippant in a supposedly scholarly
work. As I got older and more mature I didn’t really care
what other people thought about me. As I have gotten
even older, I now realize others were never thinking
about me at all. The hard part about condensing a huge
topic like musculoskeletal radiology into a small book
is deciding what to omit. To paraphrase Mark Twain, “I
would have written a shorter book if I had more time.”
xi
CHAPTER 1
Unnecessary Examinations
Before beginning to learn how to interpret pathologic
skeletal films, it is important to briefly consider unnec-
essary skeletal radiographic examinations. Dr. Ferris
Hall from Boston first brought to my attention the idea
that just because we could x-ray something didn’t mean
that we should. His article entitled “Overutilization of
Radiologic Examinations” in the August 1976 issue of
Radiology1 details many examples of overuse and misuse
of radiologic examinations. This article, even though it
is over 35 years old, and a similar one by Dr. Herbert
Abrams in the New England Journal of Medicine,2 should
be mandatory reading for every intern before he or she
begins to order examinations.
There are many reasons why it is undesirable to
have unnecessary radiologic examinations: excess cost,
excess radiation, waste of patient’s time, waste of tech-
nician’s and radiologist’s time, false hopes and expecta-
tions based on the outcome of the examination, and,
not least of all, they indicate a breakdown in the logical
thought pattern concerning the patient’s workup.
Many examinations are ordered because of so-called
medicolegal considerations. It is believed that if a cer-
tain finding is not documented (e.g., a broken rib), the
doctor could be sued. In fact, few, if any, examples of
medicolegal “covering yourself” types of examinations
are valid. With the move toward greater consumer aware-
ness, lawsuits in the future are more likely to result from
unnecessary radiation exposure because of needless
examinations rather than from too few examinations.
EXAMPLES OF UNNECESSARY
EXAMINATIONS
Skull Series
Except for a depressed skull fracture or the presence of
intracranial metallic fragments, there is no reason to
order a skull series for trauma. This was once one of the
most abused examinations in radiology, costing millions
of dollars per year unnecessarily. Although the number
of unnecessary skull films has decreased, they remain a
costly burden in many emergency departments. There is
virtually no finding on a skull series that will alter the
next step in the patient’s workup. Presence or absence
of a fracture should not influence whether or not the
patient receives a computed tomography (CT) scan or
a magnetic resonance imaging (MRI) exam. A CT scan
or an MRI exam are obtained for other reasons: contin-
ued unconsciousness or focal neurologic signs. The plain
films only delay the eventual diagnosis, and in a patient
with a subdural or an epidural hematoma, that delay
could be fatal.3 The mortality from intracranial bleeds is
significantly increased as the time to surgical decompres-
sion is increased; therefore any delay caused by obtain-
ing unnecessary examinations (skull films) is potentially
harmful. There are no findings on a plain skull series to
indicate (or not indicate) subdural or epidural hema-
toma (Fig. 1.1). Fewer than 10% of patients with frac-
tures have subdural or epidural hematomas, and up to
60% of patients with subdural or epidural bleeds have
no fractures.4 Therefore why order the examinations?
Medicolegal reasons? On the contrary! It is well docu-
mented that delays in diagnosis in this setting can be
fatal, so ordering unnecessary examinations might in
fact be asking for a lawsuit! The American College of
Radiology has published appropriateness criteria for
when to order particular exams, and has endorsed head
CT as the initial study of choice in trauma.5
In spite of much documentation in the radiology
and emergency room literature showing the lack of util-
ity of skull films in trauma, they still are frequently rou-
tinely ordered in many emergency rooms throughout
North America. A survey performed in 1991 by Hack-
ney and published in Radiology6 showed that over 50%
of the hospitals in the study “often or always” obtained
skull films for trauma. Every hospital had CT available.
What were they thinking? Obviously they are not think-
ing about what a skull film will show them that might
affect their treatment, because it won’t change a thing,
whether it’s positive or negative.
Sinus Series
It is true that an opaque sinus and/or an air–fluid level
can be seen with sinusitis. But often the patient with
these findings is asymptomatic, and just as often in
another patient, the sinus series can be normal when
the patient has typical clinical findings of sinusitis.
Both of these patients are treated based on their clini-
cal, not radiographic, presentation, which is appropri-
ate. Therefore the information from the sinus series
is ignored. If that is the way you practice—and many
1
2 Fundamentals of Skeletal Radiology
FIG. 1.1 Skull Fracture. A thin radiolucent line char-
acteristic of a skull fracture is noted (arrow) extending
obliquely across the temporal bone. A fracture in this area
is often associated with an epidural hematoma because
the middle meningeal artery lies here. This finding by itself,
however, has little or no significance and must be corre-
lated with clinical findings.
recommend that as being proper—don’t order the
sinus series; treat the patient. Reserve the sinus series
for the patient who doesn’t respond to treatment or
has an unusual presentation. Also, if it is only sinusitis
you are concerned with, most times, a simple upright
Waters’ view (Fig. 1.2) to examine the maxillary and
frontal sinuses, rather than a full sinus series, will suf-
fice, saving money and decreasing patient exposure.7
Nasal Bone
A nasal series is often requested to see if a patient has
suffered a broken nose after trauma to the face. So
what if the nasal bone is fractured? It won’t be casted.
It won’t be reduced. In other words, no treatment will
be given regardless of what the x-ray shows. Therefore
don’t order the films in the first place. Occasionally a
nasal bone is badly enough displaced to warrant inter-
vention, but even then an acute, posttraumatic x-ray
adds nothing for the patient except expense and radia-
tion exposure. A facial series or a CT to search for addi-
tional fractures might be in order, but not a nasal series.
Rib Series
Fractured ribs are commonly seen in any radiologic
practice. The significance of the finding of a fractured
rib or ribs is not well appreciated by most physicians.
If the truth be known, the finding of a rib fracture after
FIG. 1.2 Waters’ View of the Sinuses. This film is
obtained with the patient’s head slightly tilted upward (as
if he were drinking water—apologies to Dr. Waters). It is an
excellent film to obtain when the maxillary sinuses need to
be seen. When done in an upright position, air–fluid levels
can be seen (arrow).
trauma has almost no clinical significance and does not
alter treatment. One must rule out a pneumothorax
and even a lung contusion, both of which are uncom-
mon and are best done on chest films, not a rib series.
In older patients with chest wall pain and rib fractures
from undetermined causes, it is extremely difficult and
often impossible to differentiate a pathologic rib frac-
ture through a metastatic focus from a posttraumatic
rib fracture. Hence, x-raying a patient with focal rib
pain to find a fracture serves little purpose other than
to find a cause for the pain. Most rib series can be elimi-
nated without changing the way the patient is treated.
Coccyx
Although not a common x-ray examination, we have
occasional requests to x-ray the coccyx to rule out a
fracture. As with the nasal bone and ribs, a fracture in
this location will not be casted or reduced. Also, this
examination has significantly more gonadal radiation
dose than a rib or nasal series. Because no treatment is
predicated on the x-ray results, don’t order the x-ray for
routine trauma to the coccyx.
Lumbar Spine
Plain films of the lumbar spine are probably the most
abused examinations in radiology. They give the high-
est gonadal radiation dose of any plain film exami-
nation, and in most cases, they offer no diagnostic
 CHAPTER 1 Unnecessary Examinations 3

information that will be acted on by the physician. A

significant number of lumbar spine films are done in
a population under the age of 40 with acute onset of
back pain after lifting or straining. There is virtually
no plain-film x-ray finding in this patient subgroup
that can be responsible for the acute problem or that
can be treated with intervention. Even the severest
spondylolisthesis cannot unequivocally be said to be
the origin of the symptoms. Disc herniation cannot
be identified. Tumors and infections are not clinical
considerations in this setting. Treatment invariably
consists of rest, nonsteroidal antiinflammatory drugs,
generally relaxing the muscle groups, and then flex-
ion and extension exercises to strengthen the mus-
cles. Radiographs have nothing to offer unless the
pain is very atypical or the clinical picture is clouded
by other considerations (such as intravenous drug
use, in which case infection must be ruled out).
The gonadal radiation dose from a lumbar spine
film is the same as that from a daily chest x-ray for FIG. 1.3 Phalanges with Subperiosteal Bone
6,8 16,9 or 98 years,10 depending on which study you Resorption. Subperiosteal bone resorption is seen as a
choose to believe. These studies were based on a three- subtle irregularity or interruption of the cortex. It is best
view lumbosacral spine series and do not include the seen on the radial aspect of the middle phalanges (arrows)
and is pathognomonic for hyperparathyroidism.
oblique views routinely obtained in many practices.
Subtle osseous changes found on oblique views are
thought by many orthopedists to be insignificant in Metastatic Bone Survey
most cases anyway. Little useful information is obtained from the majority
So when should a lumbosacral spine series be ord­ of metastatic bone surveys. Occult lesions that are not
ered? In cases of severe trauma, possible primary or meta- found on radionuclide bone scans are seldom encoun-
static tumor, and possible infection. Acute low back pain tered. Radionuclide scans are more effective at picking
with radicular signs is no indication for a spine series. An up most metastatic lesions and could be substituted for
MRI exam will show disc herniation and would be the bone surveys with less cost and better diagnostic yield.11
preferred examination over plain films, if clinically war- Many investigators believe that searching for bone
ranted. Generally a lumbar spine MRI exam is performed metastases is not warranted in every patient with a pri-
only after a failed course of conservative therapy if disc mary tumor unless finding metastatic disease will obvi-
disease is clinically suspected. ate surgery or otherwise change the patient’s therapy.
Radionuclide bone scans with x-rays of questionable
Metabolic Bone Survey or clinically suspicious areas makes more sense than a
Many institutions routinely order metabolic bone sur- complete metastatic bone survey. An exception to this is
veys in patients with hyperparathyroidism or renal in patients with multiple myeloma. Radionuclide bone
osteodystrophy to look for Looser’s fractures, brown scans are often negative in multiple myeloma even with
tumors, and subperiosteal bone resorption. Most insti- marked skeletal involvement; hence a plain film bone
tutions have replaced the bone survey with hand films, survey is warranted in these patients.
which are preferable in regard to patient expense and
radiation dose. Subperiosteal bone resorption is seen Ankle Series
earliest and easiest on the middle phalanges and radial The most common cause for presentation to emergency
sides (Fig. 1.3) and is virtually pathognomonic for rooms in North America is an ankle sprain, with over
hyperparathyroidism. Looser’s fractures are rare and not 30,000 ankle sprains/day reported.12 Ligamentous
treated anyway. Brown tumors are uncommon and also injuries can easily be clinically differentiated from sig-
are not treated. Therefore if no treatment is based on the nificant fractures. One study showed a 50% reduction
x-ray findings, the survey only satisfies curiosity and is of ankle films with no fractures missed if the radiology
not worth the patient’s money or radiation exposure. resident would simply examine the patient.13 Another
4 Fundamentals of Skeletal Radiology
FIG. 1.4 Ankle After Trauma. Calcific densities around
the ankle that can be mistaken for avulsions are often
seen (arrow). When rounded and smoothly corticated, as
in this example, they are either accessory ossicles or old
avulsions. An acute avulsion is best diagnosed clinically
by noting point tenderness at ligament insertion sites.
Because a ligament can avulse with or without a fragment
of bone being attached, the x-ray finding will not influence
the patient’s treatment.
study revealed that if the patient were able to walk three
steps immediately after the injury or during the exami-
nation in the ER, there was almost zero chance of a frac-
ture.14 This study was one of several to utilize what has
been called the “Ottawa Rules” for when to obtain ankle
x-rays. They are so-named after the hometown of the
first authors to implement them and are in widespread
use today in the majority of emergency departments in
North America. Small bony avulsions receive the same
treatment as ligament tears, and are often difficult to dif-
ferentiate from accessory ossicles (Fig. 1.4). Therefore in
most cases, the x-ray is not a factor in determining the
patient’s treatment and should be skipped.
Lumbar Myelograms
One of the most painful radiologic examinations extant
is the lumbar myelogram, in which a spinal needle is
placed into the subarachnoid space of the lumbar spine
FIG. 1.5 Lumbar Myelogram. An iodinated contrast
material has been injected into the subarachnoid space by
way of a spinal needle. A large extradural defect is seen
that is caused by a disc protrusion. A tumor could have a
similar appearance. This examination can be quite painful,
has occasional long-lasting complications, and gives no
information that could not be obtained with an magnetic
resonance imaging (MRI) examination. In some institutions,
it requires an overnight stay in the hospital as well. For
these reasons, the standard of practice today is an MRI
exam.
and contrast material is injected (Fig. 1.5). Although this
is done for tumors, it is most commonly performed in
the workup of lumbar disc disease. Many studies show
that CT or MRI of the lumbar spine is more accurate than
myelography in diagnosing disc disease, and they empha-
size that CT or MRI should be the study of choice. Many
surgeons, however, still request myelograms in addition
to the CT or MRI study when only the CT or MRI need be
performed. In addition to being painful, the myelogram
produces side effects in some people that can be pro-
nounced and debilitating; the myelogram occasionally
necessitates overnight hospitalization; the radiation dose
from the myelogram is higher overall than with CT; and,
most important perhaps, the myelogram is not as accu-
rate and does not give as complete a picture of additional
6 Fundamentals of Skeletal Radiology
diminish exposure is to collimate the x-ray beam tighter.
One study reported that if collimation were limited just
to the size of the film, radiation dose could be reduced
by one-third.18 Exposure could be further reduced by
having proper filtration, fast screen–film combination,
and adequate gonadal shielding. Digital radiography,
which is now widely used, will further help decrease
radiation dose. Certainly, having properly trained tech-
nicians and properly functioning equipment will dimin-
ish the number of retakes. These should be high-priority
goals for all radiologists to make our specialty more cost-
effective and to provide better service to both the refer-
ring clinician and the patient. It should be part of every
radiologist’s responsibility to help educate and guide the
unknowing clinician in obtaining the appropriate imag-
ing exams while eliminating those that are unnecessary.
REFERENCES
1. Hall F. Overutilization of radiological examinations. Radi-
ology. 1976;120:443–448.
2. Abrams HL. The “overutilization” of x-rays: sounding
board. N Engl J Med. 1979;300:1213–1216.
3. Seelig JM, Becker DP, Miller JD, et al. Traumatic acute sub-
dural hematoma. N Engl J Med. 1981;304:1511–1518.
4. Masters JS, McClean PM, Arcarese JS, et al. Skull x-ray exami-
nations after head trauma. N Engl J Med. 1987;316:84–91.
5. American College of Radiology. ACR appropriateness cri-
teria head trauma. 2001. Available at: http: //www.acr.org.
6. Hackney DB. Skull radiography in the evaluation of
acute head trauma: a survey of current practice. Radiology.
1991;181:711–714.
7. Williams JJ, Roberts L, Distell B, Simel D. Diagnosing sinus-
itis by x-ray: comparing a single Waters’ view to 4-view para-
nasal sinus radiographs. J Gen Intern Med. 1992;7:481–485.
8. Webster EW, Merrill OE. Radiation hazards: II. Measure-
ments of gonadal dose in radiologic examinations. N Engl
J Med. 1957;257:811–819.
9. Antoku S, Russell WJ. Dose to the active bone marrow,
gonads, and skin from roentgenography and fluoroscopy.
Radiology. 1957;101:669–678.
10. Andron GM, Crooks HE. Gonad radiation dose from di-
agnostic procedures. Br J Radiol. 1957;30:295–297.
11. Mall JC, Bekerman C, Hoffer PB, et al. A unified radio-
logical approach to the detection of skeletal metastases.
Radiology. 1976;118:323–329.
12. Cheung Y, Rosenberg ZS. MR imaging of ligamentous
abnormalities of the ankle and foot. Magn Reson Imaging
Clin N Am. 2001;9:507–531.
13. Auletta A, Conway W, Hayes C, Guisto D, Gervin A. In-
dications for radiography in patients with acute ankle in-
juries: role of the physical examination. Am J Roentgenol.
1991;157:789–791.
14. Stiell I, Greenberg G, McKnight R, et al. Decision rules
for the use of radiography in acute ankle injuries. JAMA.
1993;269:1127–1132.
15. Jarvik JJ, Hollingworth W, Hoagerty P, Haynor DR, Deyo
RA. The Longitudinal Assessment of Imaging and Disabil-
ity of the Back (LAIDBACK) study: baseline data. Spine.
2001;26:1158–1166.
16. Mirvis S, Diaconis J, Chirico P, Reiner B, Joslyn J, Militello P.
Protocol-driven radiologic evaluation of suspected cervi-
cal spine injury: efficacy study. Radiology. 1989;170:831–
834.
17. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker
MI. Validity of a set of clinical criteria to rule out injury to
the cervical spine in patients with blunt trauma. N Engl J
Med. 2000;343:94–99.
18. Morgan RH, Hearings before the Committee on Com-
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sion; 1977:241–266.
Another random document with
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 C’est une des caractéristiques du génie de Henri Poincaré qu’il
réunit un prodigieux esprit d’invention à un esprit critique
extrêmement aiguisé. Sa critique semble même aller parfois
jusqu’au scepticisme; il contemplait sans tristesse les ruines des
théories. Alors que d’autres constatent avec regret que certaines
idées ne s’accommodent plus aux faits, et commencent par penser
que ceux-ci ont été mal vus ou mal interprétés, Poincaré a plutôt une
tendance contraire, bien qu’elle se soit peut-être atténuée dans les
dernières années. Ainsi un jeune physicien ayant cru jadis pouvoir
s’inscrire contre la célèbre expérience de Rowland, d’après laquelle
une charge électrique en mouvement produit un champ magnétique
conformément à la théorie de Maxwell, cette annonce ne parut pas
étonner Poincaré. Nul n’eut moins que lui la notion statique d’une
science se reposant sur quelques conquêtes définitives, et c’est ce
qui explique que plusieurs se soient crus autorisés à tirer de certains
de ses écrits, où il poussait sa tendance critique presque jusqu’au
paradoxe, des conclusions sur la vanité de la Science contre
lesquelles il dut protester.
Quelques Préfaces des Leçons de Poincaré ont vivement attiré
l’attention. Dans l’Introduction du Livre Électricité et Optique, il
discute ce qu’on doit entendre par «interprétation mécanique d’un
phénomène». Cette interprétation est ramenée d’après lui à la
possibilité de la formation d’un système d’équations de Lagrange
avec un certain nombre de paramètres que
l’expérience atteint directement et permet de mesurer. Dans ces
équations figurent l’énergie cinétique et une fonction des forces
. Cette possibilité étant supposée, on pourra toujours déterminer
masses (masses visibles ou cachées) et leurs coordonnées (
) fonctions des (en prenant assez grand), de manière
que la force vive de ce système de masses soit égale à l’énergie
cinétique figurant dans les équations de Lagrange.
L’indétermination est ici très grande, et c’est précisément là qu’en
veut venir Poincaré, dont la conclusion est que, s’il y a une
explication mécanique, il y en a une infinité. Il faut avouer, dirons-
nous, que cette indétermination est même trop grande, car on perd
complètement de vue les corps en présence. Ainsi, suivant les
formes qu’auront l’ensemble des masses partiellement
indéterminées , on n’aura pas nécessairement dans la suite les
mêmes mouvements; il pourra, par exemple, y avoir ou non des
chocs. Que devient aussi la répartition des forces réelles dans les
systèmes en partie fictifs auxquels on est ainsi conduit?
Dans la Préface de sa Thermodynamique, Poincaré, voulant
descendre en quelque sorte jusqu’au fond du principe de la
conservation de l’énergie, conclut que «la loi de Meyer est une forme
assez souple pour qu’on puisse y faire rentrer presque tout ce qu’on
veut». Il semble à la vérité un peu effrayé de sa conclusion, car il
ajoute plus loin qu’il ne faut pas «pousser jusqu’à l’absolu». Nous
retrouverons cet esprit hypercritique, si j’ose le dire, clans certains
écrits philosophiques de Poincaré.
Poincaré, sans cesse curieux de nouvelles théories et de
nouveaux problèmes, ne pouvait manquer d’être attiré par
l’Électromagnétisme qui tient une si grande place dans la Science de
notre époque. On ne saurait trop admirer avec quelle sûreté et
quelle maîtrise il repense les diverses théories, les faisant ainsi
siennes. Il leur donne parfois une forme saisissante, comme quand,
dans l’exposition de la théorie de Lorentz, il distingue entre les
observateurs ayant les sens subtils et les observateurs ayant les
sens grossiers. La considération, bien personnelle à Poincaré, de ce
qu’il appelle «la quantité de mouvement électromagnétique», la
localisation de celle-ci dans l’éther et sa propagation avec une
perturbation électromagnétique sont venues rétablir d’importantes
analogies. Le Mémoire sur la dynamique de l’électron, écrit en 1905,
restera dans l’histoire du principe de la relativité; le groupe des
transformations de Lorentz, qui n’altèrent pas les équations d'un
milieu électromagnétique, y apparaît comme la clef de voûte dans la
discussion des conditions auxquelles doivent satisfaire les forces
dans la nouvelle dynamique. La nécessité de l’introduction dans
l’électron de forces supplémentaires, en dehors des forces de liaison
est établie, ces forces supplémentaires pouvant être assimilées à
une pression qui régnerait à l’extérieur de l’électron. Poincaré
montre encore quelles hypothèses on peut faire sur la gravitation
pour que le champ grafivique soit affecté par une transformation de
Lorentz de la même manière que le champ électromagnétique.
 On sait l’importance qu’a prise aujourd’hui le principe de la
relativité, dont le point de départ est l’impossibilité, proclamée sur la
foi de quelques expériences négatives, de mettre en évidence le
mouvement de translation uniforme d’un système au moyen
d’expériences d’optique ou d’électricité faites à l’intérieur de ce
système. En admettant, d’autre part, que les idées de Lorentz et ses
équations électromagnétiques sont inattaquables, on a été conduit à
regarder comme nécessaire le changement de nos idées sur
l’espace et sur le temps; espace et temps ( ) n’ont plus
leurs transformations séparées et entrent simultanément dans le
groupe de Lorentz. La simultanéité de deux phénomènes devient
une notion toute relative; un phénomène peut être antérieur à un
autre pour un premier observateur, tandis qu’il lui est postérieur pour
un second. Les mathématiciens, intéressés par un groupe de
transformations qui transforment en elle-même la forme quadratique
( = vitesse de la lumière) se sont livrés à
d’élégantes dissertations sur ce sujet et ont sans doute contribué à
la popularité du principe de relativité. A d’autres époques, on eût
peut-être, avant de rejeter les idées traditionnelles de l’humanité sur
l’espace et le temps, passé au crible d’une critique extrêmement
sévère les conceptions sur l’éther et la formation des équations de
l’électromagnétisme; mais le désir du nouveau ne connaît pas de
bornes aujourd’hui. Les objections ne manquent pas cependant, et
d’illustres physiciens, comme Lord Kelvin et Ritz, sans parler des
vivants, ont émis des doutes très motivés. La Science assurément
ne connaît point de dogmes, et il se peut que des expériences
positives précises nous forcent un jour à modifier certaines idées
devenues notions de sens commun; mais le moment en est-il déjà
venu?
Poincaré voyait le danger de ces engouements, et, dans une
conférence sur la dynamique nouvelle, il adjurait les professeurs de
ne pas jeter le discrédit sur la vieille Mécanique qui a fait ses
preuves. Et puis, il a vécu assez pourvoir les principaux
protagonistes des idées nouvelles ruiner partiellement au moins leur
œuvre. Dans tout ce relativisme, il reste un absolu, à savoir la
vitesse de la lumière dans le vide, indépendante de l’état de repos
ou de mouvement de la source lumineuse. Cet absolu va
probablement disparaître, les équations de Lorentz ne représentant
plus qu’une première approximation. Les plus grandes difficultés
viennent de la gravitation, au point que certains théoriciens de la
Physique croient ne pouvoir les lever qu’en attribuant de l’inertie et
un poids à l’énergie, d’où en particulier la pesanteur de la lumière. Si
Poincaré avait vécu, il eût sans doute été conduit à rapprocher des
vues actuelles son essai de 1905 sur la gravitation. Au milieu des
incertitudes qui se présentent aujourd’hui en électro-optique, son
esprit lumineux va nous manquer singulièrement. Il faut avouer que
dans tout cela les bases expérimentales sont fragiles, et peut-être
Poincaré eût-il suggéré des expériences apportant un peu de
lumière dans cette obscurité.
Un des derniers travaux de Poincaré a été une discussion
approfondie de la théorie des quanta, édifiée par Planck, d’après
laquelle l’énergie des radiateurs lumineux varierait d’une manière
discontinue. De ce point de vue «les phénomènes physiques, dit
Poincaré, cesseraient d’obéir à des lois exprimables par des
équations différentielles, et ce serait là sans aucun doute la plus
grande révolution et la plus profonde que la philosophie naturelle ait
subie depuis Newton». Quelque grande, en effet, que doive être
cette révolution, il est permis toutefois de remarquer que des
circonstances plus ou moins analogues se sont déjà présentées.
Ainsi, dans un gaz à la pression ordinaire, ou peut parler de pression
et l’on peut appliquer les équations différentielles de la dynamique
des fluides; il n’en est plus de même dans un gaz raréfié, où il n’est
plus possible de parler de pression. Il faudra peut-être nous résigner
à faire usage, suivant les limites entre lesquelles nous étudions une
catégorie de phénomènes, de représentations analytiques
différentes, si pénible que puisse être cette sorte de pluralisme pour
ceux qui rêvent d’unité. Mais c’est là encore le secret de l’avenir, et il
serait imprudent d’affirmer qu’on ne trouvera pas quelque biais
permettant de rétablir dans nos calculs la continuité.
 V.
Les nombreux écrits de Poincaré, sur ce qu’on appelle la
philosophie des sciences, ont fait connaître son nom à un public très
étendu. Nous entrons ici dans un autre domaine que celui des
recherches proprement scientifiques, et je n’ai pas l’intention
d’étudier à fond cette partie de son œuvre. Il y est tout d’abord
singulièrement difficile de se rendre compte de l’originalité de telle
ou telle étude; ainsi, dans ses écrits sur l’hypothèse dans la Science,
Poincaré s’est rencontré plus d’une fois avec divers auteurs, mais
l’illustration de son nom, consacrée par tant de découvertes
mathématiques, donnait à ses opinions une autorité particulière. La
forme en ces questions est aussi de grande importance. La phrase
concise de Poincaré, allant droit au but, parfois avec une légère
pointe de paradoxe, produit une singulière impression; on est un
moment subjugué, même quand on sent qu’on n’est pas d’accord
avec l’auteur. Mainte page de Poincaré a produit sur plus d’un
lecteur un vif sentiment d’admiration en même temps qu’une sorte
d’effroi et d’agacement devant tant de critique.
On a parlé quelquefois de la philosophie de Poincaré. En fait,
penseur indépendant, étranger à toute école, Poincaré ne chercha
jamais à édifier un système philosophique, comme un Renouvier, un
Bergson ou même un William James. Il a écrit des livres de
«Pensées», où savants et philosophes trouvent ample matière à
réflexions. Il n’est esclave d’aucune opinion, pas même de celle qu’il
a émise antérieurement, et il sera un jour intéressant de suivre
certaines variations de la sa pensée, où l’on voit quelque peu
s’atténuer ce qu’on a appelé son nominalisme. Il fut ainsi conduit à
expliquer certaines affirmations qui, prises trop à la lettre, avaient été
mal comprises et utilisées dans un dessein dont il n’avait aucun
souci.
 Si l’on voulait toutefois caractériser d’un mot les idées de
Poincaré, on pourrait dire que sa philosophie est la philosophie de la
commodité. Dans quelques unes de ses pages, le mot commode
revient constamment et constitue le terme de son explication.
D’aucuns pensent qu’il faudrait donner les raisons de cette
commodité, et, parmi eux, les plus pressants sont les biologistes
toujours guidés par l’idée d’évolution. La commodité résultera pour
eux d’une longue adaptation, et, ainsi approfondie, deviendra un
témoignage de réalité et de vérité. A l’opposé des évolutionnistes,
d’autres ne voient que l’esprit humain tout formé et sa fonction la
pensée. A certaines heures au moins, Poincaré fut de ces derniers,
et cet idéalisme lui a inspiré des pages d’une admirable poésie qui
resteront dans la littérature française; telle cette dernière page de
son Livre sur la valeur de la Science, qui débute par ces mots «Tout
ce qui n’est pas pensée est le pur néant». Entre des doctrines si
différentes toute communication est impossible, et l’on arrive à se
demander si l’on peut discuter de l’origine des plus simples notions
scientifiques, sans avoir à l’avance une foi philosophique à la
formation de laquelle auront d’ailleurs concouru d’autres éléments
que des éléments proprement scientifiques.
Pour ne pas rester uniquement dans les généralités, arrêtons-
nous un moment sur les principes de la Géométrie. Poincaré part
d’un esprit humain, dans lequel l’idée de groupe préexiste et
s’impose comme forme de notre entendement. L’esprit, après un
travail d’abstraction aboutissant aux premiers concepts de la
Géométrie (point, droite, etc.), cherche à exprimer les rapports de
position des corps; il le fait au moyen de l’idée de groupe, prenant le
groupe le plus commode et le plus simple qui est le groupe de la
géométrie dite euclidienne. Les propriétés géométriques ne
correspondent, pour Poincaré, à aucune réalité; elles forment un
ensemble de conventions que l’expérience a pu suggérer à l’esprit,
mais qu’elle ne lui a pas imposées. L’évolutionniste dont je parlais
plus haut voit là de grandes difficultés, non pas seulement pour la
raison banale que la dualité ainsi posée entre l’esprit et le milieu
extérieur est contraire à sa doctrine, mais parce que, cherchant à
retracer la genèse des origines de la Géométrie dans l’espèce
humaine, il lui paraît impossible de séparer l’acquisition des notions
géométriques et celles des notions physiques les plus simples, la
Géométrie ayant dans des temps très anciens fait partie de la
Physique. Sans changer l’ensemble de ces notions, on ne peut,
semble-t-il, remplacer le groupe euclidien par un autre, et les
exemples cités de transport d’un homme dans un autre milieu (où
cet homme commencerait par mourir) sont plus pittoresques que
probants. On retombe ainsi, sous un autre point de vue, sur les
idées de Gauss qui considérait comme un fait expérimental que la
courbure de notre espace est nulle, et regardait, contrairement à
Poincaré, que la géométrie euclidienne est plus vraie que les
géométries non euclidiennes. Il y a sans doute bien des hypothèses,
ne disons pas des conventions, en Géométrie. C’en est une par
exemple, oubliée quelquefois, que notre espace est simplement
connexe. Peu importe quelle est la connexité de l’espace, quand on
se borne à envisager une partie assez petite, celle-ci s’étendît-elle
jusqu’aux lointaines nébuleuses, mais il pourrait en être autrement
quand on considère l’espace dans son ensemble.
Tous les esprits élevés trouveront, dans l’œuvre philosophique et
littéraire de Poincaré, matière à longues réflexions, soit qu’ils se
laissent convaincre par sa dialectique, soit qu’ils cherchent des
arguments contraires. Certaines pages sont d’une austère grandeur,
comme celle où la pensée est qualifiée d’«éclair au milieu d’une
longue nuit». Non moins suggestive est la parenthèse ouverte un
peu avant «étrange contradiction pour ceux qui croient au temps»,
où l’on est presque tenté de voir un demi-aveu. Les inquiétudes
qu’on peut concevoir au sujet de la notion même de loi furent-elles
jamais exprimées avec plus de profondeur que dans l’étude sur
l’évolution des lois? J’ai déjà fait allusion au prétendu scepticisme de
Poincaré. Non, Poincaré ne fut pas un sceptique; à certaines heures,
il fut pris, comme d’autres, d’angoisse métaphysique, et il sut
éloquemment l’exprimer. Mais tournons le feuillet, et le savant,
confiant dans l’effort de l’esprit humain pour atteindre le vrai, nous
apparaît dans des pages admirables sur le rôle et la grandeur de la
Science. Les plus belles peut-être forment cet hymne à l’Astronomie
qu’il faudrait faire lire aux jeunes gens à une époque où tend à
dominer le souci exclusif de l’utile. Aucune des préoccupations de
notre temps ne fut d’ailleurs étrangère au noble esprit de Poincaré;
c’est ce dont témoigne une de ses dernières études sur la morale et
la science, où l’argumentation est irréprochable, si par morale on
entend la morale impérative de Kant.
On ne ferme pas sans tristesse ces volumes d’un contenu si riche
et dont quelques parties auraient été l’objet de nouveaux
développements, si la plume n’était tombée des mains de leur
auteur. Tous ceux qui ont le culte de la Science pure et
désintéressée ont été douloureusement émus par sa mort
prématurée, mais ce sont surtout les sciences mathématiques qui
sont cruellement frappées par cette disparition. Poincaré fut, avant
tout, un profond mathématicien, qui, pour la puissance d’invention,
est l’égal des plus grands. L’heure n’est pas venue de porter un
jugement définitif sur son œuvre que le temps grandira encore, ni de
le comparer aux plus célèbres géomètres du siècle dernier: peut-être
Henri Poincaré fût-il encore supérieur à son œuvre?
[1] On sait qu’un savant Finlandais M. Sundmann vient de donner
une solution complète du problème des trois corps. Il serait injuste
de ne pas reconnaître que les travaux antérieurs de Poincaré ont
eu une grande influence sur les recherches de l’astronome
d’Helsingfors. J’ai fait une étude des Mémoires de M. Sundmann
dans un article récent de la Revue générale des Sciences (15
octobre 1913) et dans le Bulletin des Sciences Mathématiques
(octobre 1913).
[2] C’est en approfondissant cette idée, et en ne craignant pas de
comprendre dans son analyse le cas des chocs que M.
Sundmann est arrivé à une solution du problème de trois corps
(voir la note ci-dessus).

53717 Paris,—Imprimerie Gauthier-Villars, 55, quai des Grands-

Augustins.

AU LECTEUR
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corrigées.
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 *** END OF THE PROJECT GUTENBERG EBOOK L'ŒUVRE DE
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