Historical review
The history of echocardiography

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Abstract

Following a brief review of the development of medical ultrasonics from the mid-1930s to the mid-1950s, the collaboration between Edler and Hertz that began in Lund in 1953 is described. Using an industrial ultrasonic flaw detector, they obtained time-varying echoes transcutaneously from within the heart. The first clinical applications of M-mode echocardiography were concerned with the assessment of the mitral valve from the shapes of the corresponding waveforms. Subsequently, the various M-mode recordings were related to their anatomical origins. The method then became established as a diagnostic tool and was taken up by investigators outside Lund, initially in China, Germany, Japan and the USA and, subsequently, world-wide. The diffusion of echocardiography into clinical practice depended on the timely commercial availability of suitable equipment. The discovery of contrast echocardiography in the late 1960s further validated the technique and extended the range of applications. Two-dimensional echocardiography was first demonstrated in the late 1950s, with real-time mechanical systems and, in the early 1960s, with intracardiac probes. Transesophageal echocardiography followed, in the late 1960s. Stop-action two-dimensional echocardiography enjoyed a brief vogue in the early 1970s. It was, however, the demonstration by Bom in Rotterdam of real-time two-dimensional echocardiography using a linear transducer array that revolutionized and popularized the subject. Then, the phased array sector scanner, which had been demonstrated in the late 1960s by Somer in Utrecht, was applied to cardiac studies from the mid-1970s onwards. Satomura had demonstrated the use of the ultrasonic Doppler effect to detect tissue motion in Osaka in the mid-1950s and the technique was soon afterwards applied in the heart, often in combination with M-mode recording. The development of the pulsed Doppler method in the late 1960s opened up new opportunities for clinical innovation. The review ends with a mention of color Doppler echocardiography. (E-mail: [email protected]

Introduction

During the 1930s and 1940s, the application of ultrasound for medical therapeutic purposes was widespread. In Germany, Austria, France and Switzerland, it was used for a variety of diseases, especially neuralgia, myalgia, arthritis and arthrosis, for which heat was considered beneficial (Pohlmann 1951). Some doctors with an interest in technology came up with the idea to use ultrasound for medical diagnostic purposes. They were inspired by the knowledge of the use of ultrasound for echo-sounding the depth of the ocean (Behm 1921), as well as the detection of flaws in materials or constructions suggested by Sokoloff in 1929 (Sokoloff 1929), described by Sokoloff in 1935 Sokoloff 1935a, Sokoloff 1935b and solved by Sproule in England in 1944 (Wells 1969) and Firestone in the USA in 1945 (Firestone 1945).

In 1940, Gohr and Wedekind (1940) suggested the use of reflected ultrasound for the detection of tumours, exudates, abscesses and so on. They also worked practically on the problem, but never published any results.

The French physiotherapist Denier 1946a, Denier 1946b proposed that ultrasound might be used to produce images of interior body structures. His idea was as follows: a sound beam was transmitted through the body and picked up by a second quartz crystal working at the same frequency as the generator. The received signals were to be displayed on an oscilloscope wired to display Lissajous figures. In this manner he would be able to locate and estimate the shape of the heart, spleen, liver and stomach. Pathologic structures also could be identified. However, he apparently failed in the construction of the instrumentation that he envisioned.

Section snippets

The first use of reflected ultrasound as a medical diagnostic tool

The efforts of the Austrian neurologist Karl Theo Dussik (Fig. 1) were not more successful. He worked with his brother, physicist Frederick Dussik, using the transmission method for producing an image based on the differential attenuation of sound during its passage through the head (Dussik 1942). In 1947, after almost a decade of work, Dussik could produce ultrasonically generated images, “hyperphonograms,” of what he believed to be the ventricles of the brain (Dussik et al. 1947). The first

Ultrasound investigation of the thorax

In the mid 1940s, German physician Wolf-Dieter Keidel (Fig. 6), working at Physikalisch-Medizinischen Laboratorium at the University in Erlangen, Germany, studied the possibility of using ultrasound as a medical diagnostic tool. In 1950, he described a new ultrasonic method for recording the rhythmic volume variations of the heart (Keidel 1950).

The method arose as a result of earlier attempts to quantify the clinical routine method of percussion. Percussion was introduced in 1761 by the

Reflected ultrasound

Both Dussik and Keidel eliminated the possibility of using reflected ultrasound for theoretical reasons; therefore, they never performed any practical experiments with reflected ultrasound.

The first report of the practical use of this method came in 1949 from Ludwig and Struthers (1949), who attempted to detect gallstones and foreign bodies buried in the muscles of dogs. They used the principle of ultrasonic flaw detection in materials described by Firestone (1945). Very short pulses of

What was the object of receiving echoes from heart structures?

In May 1953, Inge Edler (Fig. 11a) and C. Hellmuth Hertz (Fig. 11b) met to discuss the possibilities of using ultrasound for heart investigation. The meeting was arranged by the physicist Jan Cederlund, whom Edler had asked about the possibilities of using ultrasound or radar for diagnosing mitral regurgitation. Why mitral regurgitation? The reason was that, in the early 1950s, before the introduction of left ventricular angiocardiography, there was no method for the exact diagnosis of this

The first use of ultrasound in clinical routine

In 1954, echocardiography was used in Lund as a routine clinical application for diagnosis and follow-up studies of pericardial effusion. This was the first clinical application of diagnostic ultrasound. Follow-up studies of six cases were presented at the scientific session held by The Swedish Society of Internal Medicine in Lund on 4 June 1955 (Edler 1955a; Fig. 30). As the equipment had no facilities for “time-gain-compensation,” only the anterior part of the heart was investigated in cases

Echocardiography as a diagnostic tool: 1954–1960

At the Third European Congress in Cardiology in Rome 1960, Edler, Gustafson, Karlefors and Christensson presented a scientific film describing the echocardiographic technique and the clinical application of the method (Edler et al. 1960a). The most important use of echocardiography at this time was in patients with pericardial effusion or mitral stenosis. In 1960, more than 300 patients with mitral valve disease had been investigated. In pure mitral stenosis, the anterior mitral leaflet had a

Echocardiography outside lund

Director Gellinek at the Siemens-Reiniger Werke in Erlangen was interested in introducing echocardiography in West Germany. Therefore, Hertz, during his stay in Erlangen in 1956–1957, stimulated doctors from three different centres (the medical departments in Düsseldorf, Hamburg and Würzburg) to use the method. Doctors from these three centres were sent to Lund to learn the examination technique and subsequent clinical evaluation of the results. The most successful was Doctor Sven Effert from

Introduction of echocardiography in the USA

In 1956, Rushmer et al. (1956) presented a technique for measuring left ventricular dimensions in intact dogs by using ultrasound sonocardiometry. Two small discs of barium titanate were sutured to the external surface of the cardiac wall on opposite sides of a chamber. One of the crystals served as transmitter, and short pulses, 1 μs, were transmitted. The time required for the sound wave to pass through the chamber to the receiver crystal on the opposite side is continuously monitored 1000 to

The clinical application of echocardiography during the 1960s

The main application of echocardiography during the 1960s was for the evaluation of mitral valve disease. Several groups of investigators reported a good correlation between the reduction in speed of the diastolic downstroke E-F and the degree of stenosis Buhr et al 1967, Effert 1959, Effert 1967, Edler 1961, Edler 1966, Edler 1967, Reid and Joyner 1965, Joyner and Reid 1965, Gustafson 1966, Gustafson 1967, Segal et al 1966. Effert reported his experience of 3076 patients with mitral valve

Mitral stenosis after closed commissurotomy: Echocardiographic long-term follow-up

From the beginning, echocardiography had a large impact on the diagnosis and assessment of mitral valve stenosis. As mentioned earlier, a reduced rate of anterior mitral leaflet closure (E-F slope) is the classic criterion for the echocardiographic diagnosis of mitral stenosis (Edler 1955b). The relationship between the E-F slope and mitral valve area assessed at cardiac catheterisation and surgery was described in several reports from the 1960s Edler 1967, Gustafson 1966, Joyner et al 1963a,

The first commercial equipment

In the mid 1960s, the stage was set for the commercialisation of the ideas into special purpose equipment. Up to that time, the Swedish and German groups had been forced to use industrial flaw detection devices. The Pennsylvania group was the only one with specially developed equipment. In the USA, commercialisation proceeded through a parallel effort by the Sonomedic Corporation and the Smith-Kline French Corporation. The Sonomedic Corporation was the first to produce a machine in pilot

The continuing development of echocardiography in the USA

William L. Winters Jr. of the Division of Cardiology, Temple Medical School in Philadelphia, was invited in 1962 by Claude Joyner to see the work performed at his laboratory. Winters was very impressed, and shortly thereafter he obtained a Sperry ultrasound machine and an early Smith-Kline ultrasound machine. In 1963, Winters began working with ultrasound together with Jose Gimenez of the Department of Radiology, Temple Medical School. They began using the ultrasound equipment as a clinical

Contrast echocardiography

The echocardiography anatomy described by Edler and associates Edler 1961, Edler 1965, Edler et al 1960b was confirmed and completed by Gramiak and coworkers in 1968–1972. On 28 April 1967, a young man was being studied for aortic regurgitation in the cardiac catheterisation laboratory. An echocardiogram performed during left ventricular injection of indocyanine-green revealed dense contrast filling the cavity, with a defect in the pattern produced by noncontrast blood through the mitral

Two-dimensional echocardiography

Before 1965, the interest in echocardiography was very slight, even though, according to Feigenbaum (1976), the M-mode technique had the capability of displaying cardiac motion in a method not available by almost any other diagnostic procedure including angiocardiography. The main reason for this was that most doctors were not able to understand the M-mode records. They could not relate the records to anatomical stuctures of the heart because they did not have the faculty of seeing in three

The lund real-time cardiac scanners

In the late 1950s, Hertz and Edler often discussed the possibility of producing two-dimensional images of the heart. In the previously developed two-dimensional cross-sectional imaging, the transducer was moved at a slow rate in the area over the organ to be visualised (Baum and Greenwood 1958, Donald and Brown 1961, Donald et al 1958, Holmes and Howry 1954, Howry and Bliss 1952, Howry et al 1954; Wild and Reid 1952). This method is impossible to use for heart investigations, since the

Early Japanese investigations in two-dimensional echocardiography

Inspired by the investigations with two-dimensional ultrasound images of soft tissues reported by Wild and Reid and Howry and Bliss, the Japanese investigators Kikuchi, Wagai and coworkers started using ultrasound and presented similar two-dimensional pictures of the brain, abdomen and breast tumours. They used plan-position indication (PPI), B-scope indication and time-position indication (TPI). A barium titanate transducer working at a frequency of 1 MHz was used. Kikuchi and coworkers named

The stop-action images

The stop-action technique for cardiac ultrasonography was described by Donald L. King in 1970 (King 1972). He became interested in ultrasound when, as a resident in radiology, he saw in a popular magazine an article about the work of Howry and Holmes at Colorado University, Denver, CO, USA. The article showed the famous “cross-section of the neck,” visualising the carotid artery, jugular vein and vagus nerve (Fig. 102). For King, it was immediately obvious from those images that this new

Linear array system

In 1971, Nicolaas Bom in The Netherlands presented the first real-time linear array used to obtain moving cardiac images. After finishing high school, Bom was not sure what to study, and he flipped a coin to decide between medical study and study for electronic engineering. Fate decided that he went to the University of Technology at Delft. After his examination, he served duty as a naval officer for 2 years. He was active in a sonar laboratory and subsequently moved to a NATO sonar laboratory

Ultrasound in paediatric and congenital heart disease

The first attempt to use ultrasound for diagnosing congenital heart disease was made by Gässler in Hamburg, Germany. Together with Jacobi and Samlert in 1958, she published a report of 40 patients with left-to-right shunts investigated using reflected ultrasound (Jacobi et al. 1958). In 17 of 18 patients with atrial septal defect, they considered the movement pattern of the anterior mitral leaflet to be abnormal. However, this “abnormality” was due to tachycardia. The A-waves started

The Doppler effect: Theory and experimental verification

In May 25 1842, at a meeting of the Royal Bohemian Society of Sciences in Prague, Christian Doppler presented his paper, “Über das farbige Licht der Doppelsterne und einiger anderer Gestirne des Himmels” (“On the coloured light of double stars and some other stars on the heaven”). This paper was published the following year in Abhandlungen der Königlichen Böhmischen Gesellschaft der Wissenschaften (Doppler 1843). A copy of the title page is shown in Fig. 136. Changes in wavelength of light

Dr. Inge Edler died on 7 March 2001, ten days short of his ninetieth birthday.

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    Dr. Inge Edler died on 7 March 2001, ten days short of his ninetieth birthday.

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