HISTORY OF MEDICINE
Rachel Hajar, MD, FACC*
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In a watery world where sight is
often of little use, dolphins
explore their environment and search out their prey through echolocation.
Echolocation is a method of sensory perception by which certain animals (such as bats, porpoises, and some whales) orient themselves to their surroundings, detect obstacles, communicate with others, and find food. In echolocation, an animal emits a series of short, high-pitched sounds - pulses of ultrasonic sounds that are inaudible to humans. High frequency sounds provide better resolution of targets than low frequency sounds. These sounds travel out away from the animal and then bounce off objects and surfaces in the animal's path creating an echo. The echo returns to the animal, giving it a sense about what is in its path:
the object's size, shape, direction, distance, and motion.
During the Second World War, remote sensing tools such as radar and sonar were developed to "illuminate" and scan unseen terrain. Since radar uses electromagnetic energy and sonar acoustic energy, both systems can operate day and night. Energy returned from the terrain is detected by the system and recorded as imagery. Radar operates at much higher frequencies than does sonar and is used to image areas above sea level; the lower frequency sonar signal is transmitted through water and is used to image the seafloor.
Radar and sonar became the "eyes and ears" of warfare. It can be said that the more sophisticated remote "sense organ" developed by Britain during World War II contributed to the Allied Forces winning the war.
The discovery that ultrasound can travel through tissues paved the way for research into its potential as a diagnostic tool in medicine. Ultrasound has enabled physicians to probe the secrets of the human body painlessly.
It has been used to see the living heart over the past 50 years.
Today, together with the tremendous advances in microprocessor technology, novel methods of using ultrasound to evaluate cardiac diseases continue to evolve.
Ultrasound has truly revolutionized the way we practice medicine.
The evolution of ultrasound from a crude medical tool to a highly sophisticated non-invasive instrument is summarized in tables 1-3.
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YEAR
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FOUNDATIONS
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COUNTRY
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1793
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Lazzaro Spallanzani,
a distinguished eighteenth-century talian scientist, wrote that bats, although blind, navigate by "inaudible" sound.1 (Fig.1).
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Italy
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1822
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Daniel Colladen,
a Swiss physicist/engineer & CF Sturm, a mathematician used an underwater bell to calculate the speed of sound in the waters of Lake Geneva. They determined that the speed of sound under water was 1435 metres/second, a figure not too different from what is known today.2 (Fig.2).
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Switzerland
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1877
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Lord Rayleigh
published the famous treatise “The Theory of Sound” in which the fundamental physics of sound vibrations (waves), transmission and refraction were clearly delineated. 3
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England
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1880
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Pierre Currie
& his brother Jacques discovered the piezoelectric effect* of certain crystals.2
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France
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1883
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Galton
developed an ultrasonic whistle capable of producing vibrations as high as 25,000 cycles per second.4
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1914
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Reginald A Fessenden,
a Canadian, designed and built the first working sonar system. The Fessenden sonar could detect icebergs up to two miles away, and it was also used for signaling submarines. Between 1914 and 1918 SONAR was in great demand for the detection of German submarines in the waters. 2
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USA
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1915
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Paul Langevin,
an eminent French physicist in Paris developed a method of transmitting ultrasonic waves though water using a quartz crystal to generate the waves. He noted destruction of school of fishes in the sea and pain induced in the hand when placed in a water tank insonated with high intensity ultrasound.2
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France
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1929
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Sokolov
described an ultrasonic method of detecting flaws in metal.2
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Russia
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1942-
1945
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World war II
saw further developments in naval and military radar (using electromagnetic waves rather than ultrasound) equipments, and faster electronics, which had facilitated enormously the design of SONAR and ultrasonic detector devices in later years.2
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1942
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Firestone
was the first to use pulsed reflected ultrasound for non-military use. His work stimulated a large interest in the diagnostic uses of ultrasound in medicine.4
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USA
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Fig. 1
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Fig. 1. Bats send out sound waves using their mouth or nose and can detect insects the size of gnats and objects as fine as a human hair. |
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Fig. 2
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Fig. 2. Diagram of the underwater bell experiment to calculate the speed of sound through water. The bell was struck simultaneously with ignition of gunpowder. The flash from the ignition was observed 10 miles away and compared with the arrival of the sound from the bell underwater heard through a trumpet-like device in the water. In spite of these crude instruments, they managed to determine that the speed of sound under water was 1435 metres/second, a figure not too different from what is known today. (Photo source:
http://www.instituteformarineacoustics.org)
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YEAR
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EARLY INSTRUMENTATION
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COUNTRY
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1940s
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G. Ludwig*, RH Bolt*, HT Ballantine*, Theodore Hueter**
demonstrated that 2-dimensional images can be obtained without too much distortion, which paved the way for the subsequent development of 2-D ultrasound image formation.2
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*USA
**Germany
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John Julian Wild,
a medical graduate, pioneered ultrasonic tissue diagnosis. Together with Donald Neal, an engineer, they published the use of uni-directional A-mode ultrasound to diagnose intestinal and breast malignancies, where they concluded that the A-mode spike patterns of various tissues were different.2
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USA
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1953
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Uchida
built Japan’s first ultrasonic scanner operating in the A-mode.2
John Reid & Wild built a linear hand-held B-mode instrument to visualize tumors by sweeping from side to side through breast lumps. They produced real-time images at 15 megahertz of a 7mm cancerous growth of the breast. They had also coined their method 'echography' and 'echometry' suggesting the quantitative nature of the investigation.2
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Japan
USA
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1954
1957
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Douglas Howry, William Roderic Bliss & Gerald J Posakony
develop the Immersion tank ultrasound system, the first 2-dimensional B-mode linear compound scanner, and later-on the motorized "Somascope", (Fig. 3) a compound circumferential scanner. The transducer of the somascope was mounted around the rim of a large metal immersion tank filled with water. The machine was able to make compound scans
of an intra-abdominal organ from different angles to produce a more readable picture. The sonographic images were referred to as
"somagrams."2
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The "Pan-scanner"
(Fig.4) where the transducer rotated in a semicircular arc around the patient, was developed. The patient sat on a modified dental chair strapped against a plastic window of a semicircular pan filled with saline solution, while the transducer rotated through the solution in a semicircular arc.
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1955
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Newer piezoceramics, barium titanate and lead zirconate- titanate
allowed production of smaller and better transducers which led to the development of less cumbersome ultrasound equipments, which were more efficient and sensitive. Lighter versions of these systems, particularly with water-bags or transducers directly in contact and movable on the body surface of patients were however, imminently required. 2
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USA
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Fig. 3
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Fig. 3. Howry’s “Somascope”. The picture shows the system and operation. The transducer was a focused transducer made of lithium sulfate. It had a fairly narrow beam and a broad bandwidth signal response. The transducer head could be in moved linearly back and forth or it could oscillate back in a polar rotation over about 120 degree angle or it could do both. This latter consideration allowed seeing biological structures that were in the field of view of the sound beam. The kidney can be seen on the oscilloscope screen. (Excerpted from Historical Notes from Mr. Gerald Posakony at
http://www.ob-ultrasound.net/posakony_notes.html) |
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YEAR
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COUNTRY
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Keidel
was one of the first investigators to use ultrasound to examine the heart to determine cardiac volumes. He transmitted ultrasonic waves through the heart and recorded the effect of the ultrasound on the other side of the chest.4
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1950s
1960s
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Hertz and Inge Edler*
used an industrial pulse-echo flaw detector to examine the heart in May 1953. In 1954, they published a paper describing their equipment and their anatomical experiments with isolated hearts. They presented their first time position recordings (Fig. 1) (now called M-mode echocardiograms).1 The technique, which they called "ultrasound cardiography" was used initially to detect mitral stenosis.4 Edler et al presented a scientific film at the 3rd European Congress of Cardiology in Rome in 1960 and in 1961 published a large review of the technique for the diagnosis mitral stenosis, left atrial tumors, aortic stenosis, and anterior pericardial effusion. 4
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Sweden
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Effert
duplicated work by Edler and reported on detection of left atrial tumor using ultrasound. 4
Schmitt and Braun
introduces the technique in Germany, duplicating the work of Edler.4
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Germany
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Wild and Reid
introduced ultrasonic visualization of the heart in the USA and published a report in 1957 using ultrasound to visualize the excised human heart.4
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Germany
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Reid and Joyner in 1964
assembled equipment themselves and used a camera with a moving photographic film to record their traces.1
Edler in 1961,
irritated at having to wait for films to be developed, began to record his cardiac ultrasound tracings on an ink-jet recorder with a time-to-voltage analogue converter. This technique recorded only1
Gramiak et al in 1968
introduced contrast echocardiography using indocyanine green dye and saline solution. Using this technique, it became possible to identify many cardiac structures and provided experimental proof for many of the current echocardiographic techniques.5
*The term echocardiography was formulated by the American Institute of Ultasound Medicine to indicate the ultrasonic technique of evaluating the heart. This term was universally accepted.
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USA
USA
USA
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YEAR
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COUNTRY
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1967
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Asberg
constructed a mechanical scanner with water-bath coupling and made images of the living heart at seven frames per second.1
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Bom
a Dutch engineer, developed the multi-element cardiac scanner, which generated great interest in real-time cross- sectional echocardiography.4 Bom and colleagues in Rotterdam are credited for realizing and exploring the potential of real-time echocardiography.
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Netherlands
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King
used ECG gating of a conventional static scanner to obtain two dimensional images of the heart at different phases of the cardiac cycle.1
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USA
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Thurston and von Ramm
first demonstrated the potential of phased array in echocardiography.1
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USA
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YEAR
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COUNTRY
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1842
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Christian Doppler,
an Austrian mathematician, is known for the Doppler Effect. He thought that the frequency of sound waves would change if either the source or the observer were moving. If they were approaching, the frequency would be higher; if they were diverging, the frequency could be lower.7
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1957
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Satomura
first applied Doppler in the assessment of blood flow velocity in peripheral vessels.8
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Japan
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1961
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Kaneko et al
showed that the Doppler shift in the frequency of ultrasound backscattered from flowing blood was detectable.1
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Japan
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1964
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Callaghan
proved the usefulness of the Doppler effect in the detection of fetal heart motion.1
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USA
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1969
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Lindstrom and Edler
studied the direct application of Doppler flow based on continuous wave Doppler instrumentation.8
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1969
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Baker* and Peronneaux**
independently demonstrated the feasibility of range-gated pulsed Doppler analysis of blood flow.8
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*USA,
**France
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1970s
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Pulsed Doppler instrumentation
was introduced and developed simultaneously in several echocardiographic laboratories through the work of numerous investigators. Consequently, the technique became available in commercial ultrasound equipments. 8
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1977
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Hatle and Angelson
studied in detail the Doppler spectralpattern of the intracardiac blood flow under normal physiologic conditions according to different approaches and
echocardiographic views and also in the presence of diverse
cardiac pathology. Their work laid the basis for routine clinical
application of the Doppler method.7
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Norway
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1980
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Philips et al
develop simultaneous two-dimensional imaging with Doppler beam to identify anatomical location of Doppler signals.1
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USA
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YEAR
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COUNTRY
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1981
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Marco Brandestini
et al described color flow mapping system operating at an image frame rate of four per second. It was too slow for cardiac investigation.1
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1985
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Kasai et al
described results of their work about the feasibility of carrying out real time color flow. Kasai was an industry engineer while his collaborators included a cardiac surgeon.1
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Japan
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YEAR
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COUNTRY
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1968
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Side and Gosling
carried out the first cardiac investigations with ultrasound via the esophagus using a gastroscope with steerable tip. They used a dual-element construction mounted on a standard gastroscope to obtain continuous wave Doppler information about the velocity of cardiac blood flow.
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1975
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Duck et al and Daigle et al
described pulsed-wave Doppler interrogation from within the esophagus.
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1976
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Frazin et al
initially introduced TEE in an embryonic form. They and others recorded m-mode echocardiograms of the left ventricle and used the changes in its dimensions to monitor its function.
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1977
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Hisanaga et al
first reported real-time cross sectional imaging. They constructed a scanning device that consisted of a rotating single element in an oil-filled balloon mounted at the tip of a gastroscope.
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Japan
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1984
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Bertini et al
described a similar system as Hisanaga.
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Hisanaga et al
described a linear mechanical sector scanner suitable for TEE studies. A single element was moved parallel to the long axis of the gastroscope, and 8 to 20 images were obtained.
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Japan
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Souquet et al
introduced the phased-array transducer (3.5 MHz). This marked the definitive breakthrough for the TEE approach. Technological improvements evolved which greatly improved image quality leading to integration of TEE in the clinical evaluation of cardiac diseases.
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Germany
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Hanrath et al
introduced the first biplane probe.
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Omoto et al
published an extensive clinical evaluation of the biplane approach.
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Japan
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Harui and Souquet
first proposed multiplane imaging, which would provide an infinite number of planes over a full 180- degree rotation of a single-phased array transducer.
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Brommersma et al
developed a prototype multiplane transducer at the Thoraxcentre with publication of clinical experience.
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Netherlands
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Omoto et al
introduced “variomatrix” probe, which combines the rotating capabilities of the multiplane probe and the biplane phased-array matrix probe.
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Japan
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3-DE photos: Courtesy: Jos Roelandt, MD
1. Wells PNT. History and development. In: Roelandt JRTC,
Sutherland GR,
Iliceto S, Linker DT, eds. Cardiac Ultrasound. London: Churchill
Livingstone,
Longman Group UK Limited, 1993:3-7.
2. About_com http—www_ob-ultrasound_net-history.htm
3. Strutt JW (Third Baron Rayleigh) 1877 vol 1; 1878 vol
2.
The theory of sound. MacMillan, London.
4. Feigenbaum H. Echocardiography. Philadelphia:Lea
& Febige r, 1976:
1-4.
5. Gramiak R, PM Shah, DH Kramer. Ultrasoundcardiography:
contrast studies in anatomy and function. Radiology. 1969;92:929
6. http://www.ob-ultrasound.net/therapy.html
7. Hatle L, Angelsen B. Doppler ultrasound in
cardiology.Philadelphia:1985:1-7.
8. Garcia-Fernandez MA, Zamorano J, Azevedo J.
Doppler
Tissue Imaging Echocardiography. Spain: McGraw-Hill,1998:1-3.
9. Roelandt JRTC, History and development. In:
Roelandt JRTC, Pandian NG,
eds. Multiplane TransesophagealEchocardiography.
New York:Churchill Livingstone,
1996:1-10.
Director, Non-Invasive Cardiac Laboratory, Cardiology & Cardiovascular
Surgery Department, Hamad Medical Corporation
Doha, Qatar, Email:rachel@hmc.org.qa
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CARDIOVASCULAR
