Eur J Echocardiography (2000) 1, 811

doi:10.1053/euje.2000.0006, available online at http://www.idealibrary.com on

HISTORICAL NOTE
Seeing the Invisible:
A Short History of Cardiac Ultrasound

Address all correspondence to: J. R. T. C. Roelandt, Thoraxcenter,

Room Bd 408, Dijkzigt Hospital, Dr Molewaterplein 40,
Rotterdam 3015 GD, The Netherlands
1525-2167/00/010008+04 $35.00/0

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Cardiac ultrasound has been the most important

advance in diagnostic cardiology since the discovery
of X-rays by W. K. Rontgen[1]. Its development
closely paralleled the advances in electronic and
computer technology and is an example of interaction
and co-operative eorts of engineers, physicists and
clinicians.
The existence of ultrasound was recognized by L.
Spallanzani (17291799). He demonstrated that bats
who are blind navigate by means of echo-reflection
using inaudible sound. Spallanzani is, therefore, considered the father of ultrasound. In 1880, Jacques
and Piere Curie[2] discovered the piezo-electric eect,
a peculiar phenomenon observed in certain quartz
crystals which were the basis of the early ultrasound
systems and were later replaced by ferro-electric
materials. These were the basic ingredients, but the
technology for the ultrasound instruments was
derived from sound navigation and ranging
(SONAR) systems which were developed for the
military for ship navigation and remote submarine
detection.
The first suggestions of locating submerged objects
by echo-reflection probably came after the Titanic
disaster in 1912. During World War I, P. Langevin
(18721946) conceived in 1917 the idea to use a
piezo-electric quartz crystal as both the transmitter
and receiver, and this ultimately led to the development of sonar, which was completed with the invention of the cathode ray tube and extensively used in
World War II. Interestingly, Langevin equated mass
and energy independently of Einstein. The Austrian
K. T. Dussik was the first to apply ultrasound for
medical diagnosis in 1941[3] (Fig. 1). He tried to
outline the ventricles of the brain using echotransmission, a principle similar to X-ray imaging.
Dussik can be regarded the father of diagnostic
ultrasound. He also considered the use of echoreflection, but discontinued his idea after being
ridiculed. In 1950, the German W. D. Keidel, also

Figure 1. K. T. Dussik, the father of diagnostic ultrasound. He used an ultrasound transmission procedure to
visualize the ventricles of the brain and suggested the use
of reflected ultrasound.

using an echo-transmission technique, performed the

first cardiac examinations in an attempt to measure
cardiac output[4]. This sonocardiometric technique
was later used by R. F. Rushmer in his classic
cardiovascular experiments in awake animals.
The first experiments using ultrasonic echoreflection for examining the heart were initiated by I.
Edler and C. H. Hertz in Lund, Sweden[5] (Fig. 2).
These investigators were largely stimulated by their
surgical colleagues, who wanted a more accurate
 2000 The European Society of Cardiology

A Short History of Cardiac Ultrasound

Figure 2. I. Edler and C. H. Hertz, who in 1953 recorded

the first M-mode echocardiograms of the heart using an
industrial reflectoscope for flaw detection. The picture
was taken at the Second Symposium on Echocardiology
in 1979 in Rotterdam.

diagnosis before surgery, cardiac catherization still

being in its infancy at that time. They produced the
first echocardiograms of the heart in 1953 (Fig. 3). An
industrial pulse-echo ultrasonic flaw detector to find
cracks in metals, and which they borrowed from a
shipyard to Malmo , was used. This industrial reflectoscope was only available during weekends. Fortuitously, this instrument had the wavelength and other
physical characteristics which were appropriate for
visualizing the heart. (Quite often, the story of a
scientific discovery is based on chance rather than
design). They identified many of the structures of the
heart. C. H. Hertz also devised the ink-jet recorder to
produce a strip chart recording of the echoes originating from a selected structure (time-motion or
M-mode recording) and the simultaneous recording
of ECG. In the late 1960s the fibre-optic recorder, a

spin-o from space technology, was introduced,

allowing the M-mode recording of all structures
along the ultrasound beam: this constituted the
definitive breakthrough in echocardiography. Today,
M-mode echocardiography remains an important
part of a complete cardiac ultrasound examination
because of its high temporal resolution, which allows
accurate analysis of fast-moving structures.
In 1968, R. Gramiak and P. M. Shah[6] described
contrast echocardiography, an accidental observation
during indocyanine green injections for cardiac output measurement. This technique was extremely helpful in further identifying and delineating the various
cardiac structures and is presently being refined for
myocardial perfusion studies.
In the 1960s, great progress was being made in
developing real-time two-dimensional (2D) echocardiography. In fact, it was the combination of
sonar technology with advanced radar circuitry which
improved ultrasonic instrument performance and
introduced the prospect of 2D echocardiography.
After the early pioneering work of J. J. Wild and
J. M. Reid[7] and D. H. Howry and W. R. Bliss[8] in
the early 1950s, both European and Japanese investigators introduced real-time 2D instruments based on
dierent principles. The practical use of these instruments, however, was limited because of the need for a
water bath contact, limited frame rates and large size
transducers. Indeed, the small precordial acoustic
windows to the heart dictate the use of a small
transducer. The large footprint of the bulky transducer was also the problem of the linear array system
developed at the Thoraxcentre, but the clinical results
with this instrument nevertheless stimulated the
interest of cardiologists[9]. In 1968, J. Somer[10] had
constructed the first electronic phased-array scanner
based on the wave-front theory formulated in the
17th century by C. Huygens and sonar technology,
but the advantages of 2D echocardiography over
M-mode echocardiography were yet to be realised. J.
Grith and W. Henry[11] introduced the mechanical
sector-scanner in 1974, in the same year that F. J.
Thurstone and O. T. von Ramm[12] constructed their
electronic phased-array scanner similar to the instrument developed by J. Somer. This instrument marked
the beginning of the revolutionary impact of ultrasound on clinical cardiology. Today, phased-array
scanners are the most widely available imaging instruments and have a greater impact on cardiac diagnosis
than electrocardiography, for which Einthoven was
awarded the Nobel prize in 1924.
The Austrian C. A. Doppler (18031853) worked
out the mathematical relationship between the frequency shift of sound and the relative motion of the
sound source and the observer, a theory tested in
Eur J Echocardiography, Vol. 1, issue 1, March 2000

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Figure 3. One of the earliest M-mode echocardiograms

of the mitral valve, recorded by I. Edler and C. H. Hertz
in December 1953. The sensitivity of the transducers
used at that time allowed the recording of echoes from
diseased valves only, and not from normal valves.

10

J. R. T. C. Roelandt

Eur J Echocardiography, Vol. 1, issue 1, March 2000

definitive clinical breakthrough of transoesophageal

echocardiography[24,25].
As early as 1960, T. Ciezynski[26] mounted a single
element transducer on a catheter to obtain intracardiac echocardiograms, and 3 years later R. Omoto[27]
obtained intracardiac 2D images with a slowly rotating, single-element transducer mounted at a cathetertip. Two years later, N. Bom et al.[28] described a
real-time intracardiac scanner using an electronically
phased circular array of 32 elements at the tip of a 9F
catheter. These developments were discontinued
because of limitations of miniaturization and the
striking improvements in precordial image quality
making intracardiac imaging unnecessary. The rapid
progress in interventional cardiology renewed the
interest in imaging devices, allowing circumferential
imaging of the arterial wall under the endothelial
surface. Both mechanical single-element and multielement electronic systems are now increasingly
used.
Since the early 1970s numerous investigators have
explored the feasibility of three-dimensional (3D)
echocardiography. New computer technologies
recently have made volume rendered data which
make the display of tissue information possible[29,30]
even in real-time[31]. In the coming years this modality
will further strengthen the diagnostic capabilities of
cardiac ultrasound.
In this short history of cardiac ultrasound, credit is
given to the pioneers of this exciting non-invasive and
cost-eective diagnostic modality. Because of its
versatility of application in a wide variety of healthcare environments, the technique will continue to
grow along with advances in digital techniques and
miniaturization.

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Investigation of blood flow velocity using Doppler
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system 1 year later. The mono- and biplane electronic
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and his multiplane probe in 1985 represented the

A Short History of Cardiac Ultrasound

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