Accurate diagnosis is essential for any treatment plan. For surgery, this is a must. A surgeon must have a reasonably good idea about the disease process and where is it located before inflicting any surgical incision with any real chance for success. Otherwise, the result may be more harm than help. For many centuries, physicians did not have any tools to assist them in reaching a diagnosis other than their own natural senses. Careful history and physical examination were the only available means. Smart interrogation, sharp inspection, careful palpation, detailed percussion, and sensitive auscultation were all what we had for many years.

Listening to the chest

In 1816, Rene Laennec (1781-1826) the outstanding French physician discovered the method of auscultation using wooden stethoscope. In the preface of his famous book “ De l’Auscultation Mediate” he wrote :

“In 1816 I was consulted by a young woman laboring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness. The other method just mentioned [direct auscultation] being rendered inadmissible by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, . . . the great distinctness with which we hear the scratch of a pin at one end of a piece of wood on applying our ear to the other. Immediately, on this suggestion, I rolled a quire of paper into a kind of cylinder and applied one end of it to the region of the heart and the other to my ear, and was not a little surprised and pleased to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of my ear.”
This book, De l’Auscultation Mediate, published in 1819, was a landmark in the knowledge of chest diseases. Laennec classified and discussed the terms rales, rhonchi, crepitations, and egophony. He also described many clinical findings in tuberculosis. Ironically, Laennec suffered from asthma and tuberculosis. Tuberculosis had been the cause of death of his mother when he was a child, had killed his cousin, and then lead to his own death in 1824. His nephew, Dr. Mériadec Laennec, listened to his uncle’s chest and heard the fateful sounds of tuberculosis. He had used his uncle’s stethoscope to make this diagnosis. René Laennec then wrote his will, leaving his stethoscope to his nephew, and referring to it as “the greatest legacy of my life”. Before his death, Laennec wrote:

“I know that I have risked my life, but the book I’m going to publish will be, I hope, useful enough to be of more value than the life of a man.”
Although the New England Journal of Medicine reported the invention of the stethoscope in 1821, this new method of auscultation was not readily accepted by some physicians who preferred to use direct listening to the chest with one’s ear. As late as 1885, a professor of medicine stated: “He that hath ears to hear, let him use his ears and not a stethoscope.”
The binaural stethoscope, which has two ear pieces, was invented in 1851 by Sir Arthur Leared, the Irish traveler-physician, and further improved by the American, George Camman in 1852.

Looking inside

Rigid bronchoscopy was introduced in 1895 by Gustav Killian (1860-1921) in Germany. By 1897, Killian demonstrated the first clinical application of bronchoscopy when he removed a piece of bone from the right bronchus aspirated by a farmer while drinking soup. Killian actually used a rigid esophagoscope and a long forceps to do that. However, in doing this procedure, he is considered to be the father of bronchoscopy.
Improved lighting technology, lighted suction and several instruments were introduced by the great Chevalier Jackson (1865-1958) in Philadelphia, USA. Jackson essentially invented modern esophagoscopes and bronchoscopes and many endoscopic instruments. He developed methods for removing foreign bodies from the esophagus and the airway with great safety. Prior to his inventions, mortality of foreign body aspiration or ingestion was as high as 98%. He was also the author of twelve textbooks, and over 400 medical articles. In 1907, Jackson published his standard book “Tracheobronchoscopy, Esophagoscopy and Gastroscopy”. He was also an artist who worked in decorating china and glass, and produced paintings and excellent medical illustrations. Although he was diagnosed to have tuberculosis in 1911, Jackson had a productive active life until he died on 16 August 1958 at the age of 93. His obituary from the American Medical Association described him as “one of the greatest, if not the greatest of laryngologists of all time.”
Modern flexible fiberoptic endoscopy was pioneered by the Japanese physician Shigeto Ikeda (1925-2001) who presented the first fiberoptic bronchoscope in 1966. Video-bronchoscopy was also developed under his leadership.

Electricity and the Heart

The first record of cardiac electrical activity was obtained by Alexander Muirhead (1848-1920) in Scotland. However, the first human electrocardiogram was recorded in 1872 at St. Bartholomew Hospital in London. Clinical application of electrocardiography was established in 1901 by Willem Einthoven (1860-1927) in Holland. He was born in Indonesia to Dutch parents. His father was a physician, and he studied medicine at the University of Utrecht. The first ECG machine he developed needed water cooling for the powerful electromagnets, and required 5 people to operate. The machine was huge and weighed 300 Kg. Einthoven established the terminology P, Q, R, S and T to describe ECG waves, and reported many clinical correlations with ECG changes, making it the most commonly used diagnostic tool in modern cardiology. Einthoven went on to win the Nobel Prize in 1924 for developing clinical ECG.
 

And then, there were X-rays

X-ray imaging is probably the most commonly used diagnostic tool in modern cardiology and cardiothoracic surgery, from simple chest
X-ray film to more complex CT scans, angiograms, diagnostic and interventional cardiac catheterization procedures. The first medical
X-ray film was recorded on December 22nd, 1895 by the German physics professor Wilhelm Conrad Roentgen (1845-1923) of his wife’s hand. X-rays were first generated and described in 1891 by Fernando Sanford (1854-1948) in USA. The first recorded experiment which produced X-ray type of electromagnetic radiation was reported much earlier in 1785 by the Welsh physicist William Morgan (1750-1833), and many other physicists, including the great Englishman Willam Crookes (1832-1919) investigated the effects of high voltage electric current in gases at low pressure in various glass tubes, the so called Crookes tubes and cathode rays tubes. However, the exact nature of the produced X-rays was not clearly identified, and the possible medical application of these tubes was not detected until Roentgen incidentally discovered that X-rays can identify boney structures.

Roentgen was experimenting with cathode rays that were projected through a glass tube. One night, he noticed a faint green light against the wall. The light traveled through several materials, such as books, paper and wood. He started to put various objects in front of the tube. As he was doing that, he noticed the outline of the bones of his hand projected on the wall. One time, he saw a picture of his wife’s hand recorded on a photographic plate. This hand X-ray photo of his wife, Anna, was the first ever photograph of a human body part using X-ray. On Dec. 28, 1895 he published his paper: “On a new kind of ray: A preliminary communication” in which he referred to the produced rays as “X” to indicate that it was an unknown type of radiation. The first Nobel Prize in Physics was awarded to Roentgen in 1901 for his discovery.

Loosing hands and arms

Clarence Madison Dally lost both of his arms and died of cancer in 1903 while working on X-ray tubes at Thomas Edison’s Lab. John Hall-Edwards used X-rays in 1908 for radiation therapy, and lost his left arm to severe radiation dermatitis. Biological hazards of radiation were not well known at the time, despite early warning about that in 1897 by the great physicist and engineer Nikola Tesla (1856-1943).
Computed tomography was initially developed at EMI (Electric and Musical Industries), the English music production company that made a fortune with the music of the Beatles. EMI was involved in radar, guided missiles, television, early computers and EMI scanners (CT scan). In 1972, Godfrey Hounsfield (1919-2004) in England, and Allen McLeod Cormack (1924-1998) in USA, developed the early CT scanners. By 1979, they were awarded together the Nobel Prize for Physiology or Medicine for developing the CT scan.

The Hertz family
 

Although George Ludwig (1922-1973) of USA was the first to demonstrate possible medical application of ultrasonic waves in 1940’s, the credit of establishing echocardiography goes to the Swedish cardiologist Inge Edler (1911-2001) and the physicist Carl Hellmuth Hertz (1920-1990). Together they produced the first M-mode echocardiogram on October 29th, 1953. Carl Hertz was the son of Gustav Ludwig Hertz (1887-1975), who received the Nobel Prize in Physics in 1925, and the nephew of Heinrich Rudolf Hertz (1857-1894) the famous German physicist for whom the wave frequency unit “hertz” is named in honor of his early studies of electromagnetic waves. Heinrich Hertz was multitalented in science and languages, and he learned Arabic and Sanskrit. His studies of waves were the basis for the development of radio, television, radar, and wireless communication. However, when asked about the potential use of his discoveries, Hertz replied: “Nothing, I guess”, “it is of no use whatsoever … We just have these mysterious electromagnetic waves that we can not see with the naked eye. But they are there”.
Carl Hellmoth Hertz wanted to develop the technology for 2-dimensional echocardiography and for using the Doppler effect to measure the rate of blood flow. However, he was given no support in the form of grants from the Swedish Board of Technical Development, because the Board’s advisors believed that the method lacked “medical” and “commercial” interest. Disappointed, he left the field of cardiac ultrasound and directed his attention to the development of inkjet printing.
Johann Christian Doppler (1803-1853) was the famous Austrian mathematician and physicist who, in 1842, described the apparent change of frequency and wavelength as perceived by an observer when there is a relative movement between the observer and the source of the wave. This change was later called “Doppler effect”, and was applied on sound and light waves with valuable applications in astronomy. While teaching at the University of Vienna, Doppler was influential on Gregor Mendel (1822-1884), who later became the founding father of Genetics.
Echocardiography was further developed to detect the direction and velocity of blood flow, study cardiac valves function, measure gradients and shunts, and use the trans-esophageal approach, vastly expanding the use of this diagnostic tool. The great potential clinical application of echocardiography was not well appreciated in its early years. Edler had the opportunity to present the technique to André F. Cournand (1895-1988) after receiving the Nobel Prize in Physiology or Medicine for his early work in heart catheterization. “He will definitely understand” thought Edler. However, Dr. Cournand showed no interest in this noninvasive technique. Due to his sensitivity about the lack of interest in his work within the scientific community, Edler delayed his PhD thesis presentation in echocardiography till 1961.

To open the heart

The limits of our senses were vastly expanded by the fine work and the great sacrifices of dedicated pioneers, not only in medicine, but also in physics, mathematics, and engineering. By the second half of the 20th Century, cardiologists and cardiothoracic surgeons had several great diagnostic tools that expanded their abilities to examine the chest, and to look inside the heart. These devices enabled physicians to reach precise diagnosis and to produce excellent treatment plans for complex diseases previously considered helplessly lethal. Using improved diagnostic tools, and better anesthesia, pioneer physicians, similar to their great fellow mathematicians, physicists and engineers, did come up with superb solutions to defeat dreadful diseases, and opened up a new frontier in medicine, the heart.¨

References:

1. Naef A.P. The mid-Century revolution in thoracic and cardiovascular surgery: Part I. Interac Cardiocasc Thorac Surg 2003;2:219-226
2. Litwak R.S. The growth of cardiac surgery: Historical notes. Cardiovasc Clin 1971;3:5-50.
3. Meade R. “History of Thoracic Surgery”; 1961.
4. Leon Morgenstern. Endoscopist and artist: Chevalier Jackson, MD. Surgical innovation 2007;14:149-152.
5. Siddharth Singh and Abha Goyal. The Origin of Echocardiography. A tribute to Inge Edler. Tex Heart Inst J 2007;34:431-438.