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
Next Section 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]. Previous Section Next Section 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. Previous Section Next Section 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]. Previous Section Next Section 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.
View larger version: In this page In a new window Download as PowerPoint Slide 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. Previous Section Next Section Footnotes Heberden Historical Series/Series Editor M. Jayson Rheumatology Vol. 43 No. 7 British Society for Rheumatology 2004; all rights reserved Previous Section
References 1. ! Eisenberg R. Radiology: an illustrated history. St. Louis: Mosby, 1992. 2. ! Griffin DR, Galambos R. The sensory basis of obstacle avoidance by flying bats. J Exp Zool 1941;86:481506. CrossRefWeb of Science 3. ! Hill CR. Medical ultrasonics: an historical review. Br J Radiol 1973;46:899905. Abstract/FREE Full Text 4. ! Woo J. A short history of the developments of ultrasound in obstetrics and gynecology. http://www.ob- ultrasound.net/hydrophone.html 1999. 5. ! Firestone FA. The supersonic reflectoscope, an instrument of inspecting the interior of solid parts by means of sound waves. J Acoust Soc Am 1945;17:28799. CrossRef 6. ! Dussik KT. On the possibility of using ultrasound waves as a diagnostic aid. Z Neurol Psychiatr 1942;174:15368. CrossRef 7. ! Shampo MA, Kyle RA. John Julian Wildpioneer in ultrasonography. Mayo Clin Proc 1997;72:234. CrossRefMedline 8. ! Donald I, MacVicar J, Brown TG. Investigation of abdominal masses by pulsed ultrasound. Lancet 1958;i:118895. 9. ! Kurjak A. Ultrasound scanningProf. Ian Donald (19101987). Eur J Obstet Gynecol Reprod Biol 2000;90:1879. Medline 10. ! Dussik KT, Fritch DJ, Kyriazidou M, Sear RS. Measurements of articular tissues with ultrasound. Am J Phys Med 1958;37:1605. Medline 11. ! McDonald DG, Leopold GR. Ultrasound B-scanning in the differentiation of Baker's cyst and thrombophlebitis. Br J Radiol 1972;45:72932. Abstract/FREE Full Text 12. ! Fornage BD. Musculoskeletal ultrasound. New York: Churchill Livingstone, 1995. 13. ! van Holsbeeck M, Introcaso JH. Musculoskeletal ultrasound. St. Louis: Mosby, 1991. 14. ! Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic Combound treatment. Arch Orthop Trauma Surg 1980;97:11733. CrossRefMedlineWeb of Science 15. ! Cooperberg PL, Tsang I, Truelove L, Knickerbocker WJ. Gray scale ultrasound in the evaluation of rheumatoid arthritis of the knee. Radiology 1978;126:75963. CrossRefMedlineWeb of Science 16. ! De Flaviis L, Scaglione P, Nessi R, Ventura R, Calori G. Ultrasonography of the hand in rheumatoid arthritis. Acta Radiol 1988;29:45760. CrossRefMedlineWeb of Science 17. ! Newman JS, Adler RS, Bude RO, Rubin JM. Detection of soft-tissue hyperemia: value of power Doppler sonography. Am J Roentgenol 1994;163:3859. CrossRefMedlineWeb of Science 18. ! Gompels BM, Darlington LG. Septic arthritis in rheumatoid disease causing bilateral shoulder dislocation: diagnosis and treatment assisted by grey scale ultrasonography. Ann Rheum Dis 1981;40:60911. Abstract/FREE Full Text 19. ! Wakefield RJ, Gibbon WW, Conaghan PG et al. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. Arthritis Rheum 2000;43:276270. CrossRefMedlineWeb of Science 20. ! Schmidt WA. Value of sonography in diagnosis of rheumatoid arthritis. Lancet 2001;357:10567. CrossRefMedlineWeb of Science 21. ! Cosnes A, Anglade MC, Revuz J, Radier C. Thirteen-megahertz ultrasound probe: its role in diagnosing localized scleroderma. Br J Dermatol 2003;148:7249. CrossRefMedlineWeb of Science 22. ! Wakefield RJ, Brown AK, OConnor PJ, Emery P. Power Doppler sonography: improving disease activity assessment in inflammatory musculoskeletal disease. Arthritis Rheum 2003;48: 2858. CrossRefMedlineWeb of Science 23. ! Balint PV, Kane D, Hunter J, McInnes IB, Field M, Sturrock RD. Ultrasound guided versus conventional joint and soft tissue fluid aspiration in rheumatology practice: a pilot study. J Rheumatol 2002;29:220913. Abstract/FREE Full Text ! Naredo E, Cabero F, Mondejar B et al. A randomized comparative study of short-term response to blind injection versus sonographic-guided injection of local corticosteroid in patients with painful shoulder. Arthritis Rheum 2002; 46(Suppl. 1):S550.
Fatty Acids As Biocompounds: Their Role in Human Metabolism, Health and Disease - A Review. Part 1: Classification, Dietarysources and Biological Functions