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A brief history of musculoskeletal

ultrasound: From bats and ships to


babies and hips
. D. Kane, W. Grassi
1
, R. Sturrock and P. V. Balint
2

+
Author Affiliations
. Centre for Rheumatic Diseases, University Department of Medicine, Glasgow
Royal Infirmary, Glasgow, UK,
1
Department of Rheumatology, Ancona,
Italy and
2
3rd Rheumatology Department, National Institute of
Rheumatology and Physiotherapy, Budapest, Hungary.
. Correspondence to: D. Kane. E-mail: dk44a@clinmed.gla.ac.uk


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Spallanzani's bat problem
High frequency, non-audible sound waves over 20 kHz are
termed ultrasound and have existed in nature for over 1
million years. Many species including bats use ultrasound to
navigate flight and to locate food sources such as moths. The
first detailed experiments that indicated that non-audible
sound might exist were performed on bats by Lazzaro
Spallanzani (17291799) an Italian priest and physiologist [1].
Seeking to explain the ability of bats to navigate flight in
darkness, he demonstrated that blindfolded bats could
navigate but that they bumped against obstacles when their
mouths were covered. After many experiments, Spallanzani
concluded that The ear of the bat serves more efficiently (than
the eye) for seeing, or at least for measuring distances ', a
matter of scientific heresy in the 1790s. Spallanzani's bat
problem, as it was termed, remained a scientific mystery until
1938, when finally the young Harvard students, Donald R.
Griffin and Robert Galambos used a sonic detector to record
directional ultrasound noises being emitted by bats in
navigating flight [2].
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Submarines and battleships
The application of directional sound reflections being used to
detect objects and measure distancestermed echolocation
was initially developed for nautical purposes. After the sinking
of the Titanic, the Canadian Reginald A. Fessenden patented
devices using active echolocation in 1912, with the first sonar
(sound navigation and ranging) apparatus being built in 1914,
capable of detecting an iceberg 2 miles away. The threat of
German submarines to Allied shipping in World War I provided
a pressing impetus to the development of ultrasound
technology. Paul Langevin and Constantin Chilowsky
constructed an underwater sandwich sound generator using
quartz crystals and two steel plates, considered to be the
prototype of modern ultrasound devices [3]. The first recorded
detection and subsequent sinking of a German U-boat (UC-3)
using a hydrophone was on the 23 April 1916 [4], with the
technique becoming more refined and widely applied in the
protection of the North Atlantic convoys during World War II.
Between the wars, ultrasound techniques were applied to
detect flaws in metalin particular in ships and aircraftusing
machines called reflectoscopes or flaw detectors [5]. These
military and industrial applications of ultrasound were to lead
to the development of medical diagnostic ultrasound.
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Medical ultrasound imaging and the Glasgow story
The use of ultrasound as a medical diagnostic tool began in
1942 when Karl Dussik, a neurologist at the University of
Vienna, attempted to locate brain tumours and the cerebral
ventricles by measuring the transmission of ultrasound beams
through the head [6]. Later, John Julian Wild, a Cambridge
medical graduate, laid the foundations of ultrasonic tissue
diagnosis with the publication of A-mode (amplitude mode)
ultrasound investigations of surgical specimens of intestinal
and breast malignancies, the development of a linear handheld
B-mode (brightness mode) instrument and early descriptions
of endoscopic (transrectal and transvaginal) A-mode scanning
transducers in 1955 [7].
A key figure in the development of medical ultrasound in
clinical practice was Professor Ian Donald of Glasgow. Having
gained initial experience in radar and sonar techniques while
serving in the Royal Air Force during World War II, he was
enthused in medical ultrasound on meeting John Wild while he
was working at the Hammersmith in London. On becoming the
Regius Professor of Midwifery of the University of Glasgow, Ian
Donald and co-workers began a series of studies that would
establish a role for medical ultrasound, overcoming initial
clinical scepticism from his colleagues who believed that
manual abdominal and pelvic examination provided sufficient
diagnostic certainty. With the help of the engineering firm
Kelvin Hughes Ltd, Ian Donald used a flaw detector to
differentiate cystic and solid abdominal massesin one case
altering a clinical diagnosis of terminal carcinoma to simple
ovarian cystleading to the publication of their findings in the
Lancet in 1958, a major milestone in medical ultrasound [8].
With his colleagues, Donald first developed a two-dimensional
scanner and then an automatic scanner in 1960, made the first
ante-partum diagnosis of placenta previa using ultrasound,
developed the method for measuring the biparietal diameter of
the fetal head in 1962 and was the first to utilize the full
bladder to allow the detection of very early pregnancy of about
67 weeks gestation in 1963 [9].
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Musculoskeletal ultrasonography
The first report of musculoskeletal ultrasonography was
published in 1958 by K. T. Dussik who measured the acoustic
attenuation of articular and periarticular tissues including skin,
adipose tissue, muscle, tendon, articular capsule, articular
cartilage and bone [10]. This work led to the first description
of fibre anisotropy and established the effects of different
pathological processes in articular tissues on ultrasound
attenuation, laying the foundation of diagnostic
musculoskeletal ultrasound.
The first B-scan image of a human joint was published in 1972
by Daniel G. McDonald and George R Leopold in the British
Journal of Radiology [11]. They described the use of ultrasound
imaging in differentiating Baker's cysts from thrombophlebitis,
a common application in current clinical practice. Spurred by
McDonald and Leopold and with technical improvements in
ultrasonographyincluding compound linear array technology,
improved computer processing and power Dopplermany
investigators have now contributed to the ultrasound
description of the musculoskeletal system in health and
disease. Initial development of the field was led by
radiologists, especially Bruno Fornage [12] and Marnix van
Holsbeeck [13]. The demonstration of the ultrasound features
of congenital dislocation of the hip by R. Graf led to the first
widespread practical application of ultrasound in
musculoskeletal disease [14]. That ultrasonography would
become a natural adjunct to musculoskeletal examination was
a logical extension of the established practice of ultrasound in
clinical obstetrics, gynaecology and cardiology. Furthermore,
the increasing interest and practice of ultrasound among
rheumatologists would also contribute to the understanding of
the natural history of rheumatic diseases, the place of
ultrasound in the imaging armamentarium and to their
interventional clinical skills.

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FIG. 1.
Comparison between sonographic images of the
metacarpophalangeal joint taken with different generations of
sonographic equipment. (A) Old prototype of 7.5 MHz probe.
Bone profile (arrowed) and joint cavity (JC) are detectable but
no other clinically relevant detail can be depicted. (B) High-
resolution sonographic picture of the second
metacarpophalangeal joint taken with a last-generation
broadband probe (816 MHz). Loss of cartilage of the
metacarpal head, bone erosion (arrowed), synovial proliferation
(S) and fluid collection (F) are clearly depicted. (C) Three-
dimensional reconstruction of a metacarpophalangeal joint in a
patient with rheumatoid arthritis. Fluid collection (F), bone
erosion (arrowed) and irregularity of the bone profile are
depicted in a completely different way compared with
conventional sonography (612 MHz)
The first demonstration of synovitis in rheumatoid arthritis was
performed in 1978 by P. L. Cooperberg, who correlated grey
scale images of synovial thickening and joint effusion in the
knee with clinical and arthrographic findings before and after
treatement with yttrium-90 injection [15]. With improvements
in ultrasound imaging definition, smaller joints and articular
structures were examined. In 1988 L. De Flaviis detailed the
features of synovitis and tenosynovitis in the rheumatoid hand,
including the first published description of ultrasound
detection of the rheumatoid erosion [16]. The first application
of power Doppler in demonstrating soft tissue hyperaemia in
musculoskeletal disease was reported in 1994 by J. S. Newman
[17] and the first report of using ultrasound to guide joint
aspiration in diagnosing a case of septic arthritis was in 1981
by B. M. Gompels [18]. As we begin the 21st century,
ultrasound is routinely used in the diagnosis and monitoring of
synovitis in rheumatology; ultrasound has been shown to be
almost 7-fold more sensitive than plain radiography in the
early diagnosis of rheumatoid erosions [19] and is of
increasing importance in the early diagnosis of rheumatoid
arthritis [20]; ultrasound has also been validated in the
diagnosis of scleroderma [21]; power Doppler is increasingly
used in diagnostic and pathophysiological joint studies [22]
and ultrasound-guided joint aspiration [23] and injection [24]
has been shown to improve both accuracy and therapeutic
outcome.
Despite the initial scepticism faced by Lazzaro Spallanzani,
Reginald Fessenden, Paul Langevin and Ian Donald, their ideas
and work have stood the test of time and have contributed to
the establishment of the field of medical ultrasonography.
Musculoskeletal ultrasound too has developed rapidly since its
inception 45 years ago by Dussik. Emerging technologies such
as power Doppler, ultrasound contrast agents and
elastography have further potential to revolutionize the ability
of ultrasound to detect joint inflammation in the near future.
The practice of musculoskeletal ultrasound in rheumatology is
now gaining increased acceptance with formal training being
offered by the British Society for Rheumatology, American
College of Rheumatology and the European Union League
Against Rheumatism. Outstanding issues of training and
reproducibility are currently being resolved, but the lesson of
the history of ultrasound is that an open and curious mind
combined with patient and scientific application to these
problems will overcome natural scepticism and see
musculoskeletal ultrasound firmly established as a routine tool
in clinical rheumatology in the near future.
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Footnotes
Heberden Historical Series/Series Editor M. Jayson
Rheumatology Vol. 43 No. 7 British Society for Rheumatology 2004; all
rights reserved
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