Stuart Campbell, MD

:        “This is Josh Copel and I’m now going to be       interviewing Professor Stuart Campbell, the immediate past President of       the International Society of Ultrasound in Obstetrics and Gynecology.        At this point, we’re about at the halfway point of the meeting;       it’s late morning on Friday so we haven’t heard everything but I’m       wondering if you can share with us what your impressions are so far about       new and exciting things that we’ve heard about this year.”

:        “I think the thing that’s impressing me is the       development of new technologies especially three-dimensional ultrasound       and the ability to depict fetal anatomy especially in the first trimester.        What also impresses me is that prenatal diagnosis is going to move       from the classical time in gestation of 20-22 weeks to the first trimester       of around 10-14 weeks.  I’ve       just seen the most wonderful presentation by Bernard Benoit from Nice in France where he was able to show the development       of the fetal brain from six weeks right through to fourteen weeks and show       abnormalities of the brain occurring at that period of gestation.        I think this is a real pointer for the future and 3-D ultrasound       has also been invaluable in gynecology in showing congenital abnormalities       of the uterus and also in showing profusion of organs and the amount of       flow in organs in a volume scan so that you can get an overall assessment       of how much flow is going to that organ which I think is a big advance       over the classical way of picking out an individual vessel and looking at       its resistance or velocity.  So       there are many exciting developments going on and continuing to go on in       ultrasound but I do think the developments of first trimester diagnosis       are really landmark papers and will take us on well into this century.”

:        “Last night some of us heard a presentation at an ATL       event from Larry Platt in showing some of their new technology.        Do you think we need to rewrite the textbooks now in terms of what       we can see and when, and will we be pushing things that much earlier that       we need to redefine what’s normal anatomy as well?”

:        “Yes, I think so.  The important thing, of course, is that in the first       trimester this is a period of organogenesis, the brain is developing       embryologically so what you can see at that gestation might seem abnormal       in terms of the host embryonic developments.        One has to be very, very careful and truly understand the normal       developmental anatomy and that, of course, goes for other structures as       well, such as the bowel.  So       while we’re very excited at the potential for early prenatal diagnosis,       one has to be cautious and make sure that we get the embryology right.”

Articles

OBGYN.net Conference CoverageINTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY:Zagreb, Croatia

New Developments in Obstetrical Ultrasound

click             here for RealAudio version

Terry DuBose, M.S.,       RDMS, FAIUM, FSDMS:

        "We've       got Dr. Stuart Campbell here, the founding President of the International       Society of Ultrasound and Obstetrics in Gynecology here at Edinburgh. It's       a landmark meeting being in Edinburgh because it is the birthplace of       obstetrical sonography, and we're going to ask him to talk about the       organization, where it's coming from, and particularly where we're going.       Dr. Campbell?" 
       
       

       "This is an important meeting, clearly, from my perspective because       Scotland is the birthplace of obstetrical and gynecological ultrasound,       and this is my last year as President of the International Society, which       was founded in 1990. Ian Donald was the pioneer - he was the first person       to development equipment where the transducer could be placed directly       onto the abdomen, and his landmark paper was in 1958, where he first       described his contact scanner. This made ultrasound equipment very       practical, and a whole host of machines were developed - the Diasonograph       in Scotland, and the Picker machine in America, both followed after this       initial work. Of course, in those days you got static images, and you had       to sort of paint the picture on the screen by moving the transducer in a       series of movements across the abdomen. Then in early 1970, real-time       scanning came on the scene. The equipment was portable and the transducers       were easily moveable. Then the level of expertise grew throughout the       world so that in virtually all countries women were extensively scanned,       and in fact, in the majority of countries, routine scanning took place on       the fetus and the uterus. Then in the 1980's, the transvaginal probe was       developed so we could get tremendously improved information - not to study       pregnancy, but information about gynecological tumors, endometrial cancer,       fibroids, and all the gynecological usage of diagnostic ultrasounds. In       fact, the gynecological component of scanning has increased tremendously       with the improvement of information and is now an essential part of       infertility work-up and management. More recent developments were made in       the late 1980's. We got colored Doppler ultrasound, which is still       producing a tremendous amount of information, and we're still exploring       the use that. What I have essentially use colored Doppler for is to       predict many of the complications of pregnancy before they occur. For       instance, if you study the uterine artery, by finding an abnormal waveform       you can predict a deadly disease called preeclampsia, intrauterine growth,       retardation, bleeding behind the placenta, and abruptio placenta, and we       are now taking steps to manage and prevent these complications from       developing. You can see whether the fetus lacks oxygen by finding the       fetus switching blood flow to his brain, and this is now becoming the most       important means of monitoring fetal well-being. In gynecology, we can       study the blood flow patterns in the ovary, and in most cases decide       whether an ovarian tumor is a cancer or not a cancer. So colored Doppler       is playing an increasingly important role in the evaluation of pregnant       and non-pregnant women. And finally, this has been headline news for this       Congress because 3-D equipment is now becoming really quite sophisticated,       so much so that I think many centers are now purchasing this type of       equipment. Certainly from the woman's perspective, to see a baby-like face       on the ultrasound screen is a very, very exciting thing, and I can       actually see quite obviously that they're bonding with their babies much       more so than with the typical two-dimensional slice of echoes that they       normally see. I truly believe it will enhance our ability to diagnose       abnormalities earlier and earlier, and maybe even advance the prospect of       prenatal surgery. So with 3-D scanning in obstetrics - already, in fact,       in gynecology - we can get information on certain conditions that we can't       normally get, such as whether there's a congenital abnormality of the       uterus. This is instantly diagnosable by 3-D ultrasound, which can't be       done on 2-D. So overall, the technology continues to improve, and we apply       this technology to an increasing number of areas of obstetrics and       gynecology. Really, you can't be an obstetrician-gynecologist now without       ultrasound... it's an essential part of the diagnosis and management of       women."       
       
       

 "That's       obvious and it's wonderful. I'd like to go back to historical development       because you're a key person, as far as being able to give us information       is concerned, especially since Ian Donald is gone now. Were you his       colleague?" 
       
       

       "Yes, I worked with Ian Donald, I was his junior colleague. He really       was a most remarkable man, and one of the most brilliant minds I've ever       met actually. He was a tall, charismatic figure. He worked at the Queen       Mother's Hospital in Glasgow. It was funny, though, because many junior       doctors in those days weren't particularly interested because ultrasound       was just a fuzzy picture on the screen. Many people were amused and       thought he was a bit mad. But I just liked imaging, so I sort of became       his junior doctor, or junior research fellow. There weren't such things as       research fellows in those days - you had to do your research while you       were doing the job. So on Sunday mornings, I used to have my clinic, and I       worked at ways of measuring the biparietal diameter and the abdominal       circumference of the fetus and things like that, developing growth charts.       He was very supportive and very excited that there was a young man       interested in ultrasound. Of course, now he is the most historically       important figure in the development of ultrasound, and that's why our       society has our most prestigious award, which is the Ian Donald Gold       Medal."       
       
       

       "Yes,       thank goodness for that kind of madness."       
       
       

       "Yes, that's right."       
       
       

  "It has brought us a long way,       and it's unbelievable where it's come since then, much less the A-mode       that you were using. I appreciate it. This is Terry Dubose with Dr. Stuart       Campbell, who is the founding President of the International Society of       Ultrasound in Obstetrics and Gynecology at the meeting in Edinburgh in       1998. Thank you very much."       

OBGYN.net Conference CoverageFrom 8th World Congress On Ultrasound in Obstetrics & Gynecology, Conference Date: November, 1998 - Edinburgh, Scotland

The Past, Present and Future of Ultrasound Technology

Terry DuBose, M.S., RDMS, FAIUM,       FSDMS:

       “I’m Terry Dubose, Chair of the Ultrasound section of 

,  and we have with us Professor Stuart Campbell from England who just  gave a brilliant talk on the history of ultrasound, obstetrics, and  gynecology.  He covered everybody’s work and touched on his a little bit  but we’d like to ask him a little bit about himself and fill in those  early years and how he ended up here.  So Professor, when were you born  and where?”
       
       

   “I was born in 1936 in an industrial part of Glasgow.  Shortly after  that, the German bombers started coming over when I was a young lad so  we were evacuated to the west coast of Scotland in a little town called  Inverkiething, Lothian where we were suppose to be safe.  Interestingly,  although it was very safe there, they stationed American troops there  and as a small child I saw Eisenhower and Churchill because they met  there to make their grand designs I think for D-day. We used to follow  American soldiers, ask for badges, and soldiers used to practice  shooting out of the window of our house.  I’d say it was actually quite  an eventful time for a small boy and then we went back to a town called  Paisley which is attached to the west side of Glasgow where I went to  grammar school and then to Glasgow University.”
       
       

  “What kind of a school was it, a public school or private?”
       
       

   “It was a newer fee paying school but a very, very small fee.  There  were two fee paying schools in Paisley but it wasn’t very expensive but  it was a fee paying school so I was with a selective group of pupils.”
       
       

       “Did it give you a good scientific background?”
       
       

   “It was a good education and good enough to get me into medicine.  My  mother had been a nurse and was very, very passionate about medicine.   My brother decided to do medicine so although I wasn’t passionately  dedicated to be a doctor; I thought it was probably a reasonable thing  to do.  I remember going for my interview to get into Glasgow University  and the man asked why do you want to do medicine and I said to him I  didn’t hear the voice in the night if that’s what you mean, and he  laughed so much that I just got automatic entry.”
       
       

       “That was where you started working with Ian Donald.”
       
       

   “No, I went through my education, six years, to become a doctor then I  left and went to Manchester and various other towns and then I came  back.  By this time Ian Donald started his new hospital, the Queen  Mother’s Hospital, and he had started the ultrasound research.  I went  to see him and I said I’d like to work for him.  He was a very  intimidating man, and I sat there, there was a long period of silence as  he was writing at his desk then he looked up and went -       "all right", and that was it.  So I was in and I got the job and I  started to work for him.  Funny enough, he was a great pioneer but not  many people in the hospital were actually very interested in his  research.  He had his own little team but it was hard       not to ignore because at that time the pictures were very murky.   Nobody was very excited by them, and when I joined, it was almost unique  for a junior doctor to say I’d like to work on this but I just loved  it.  I think imaging is just a natural thing for me, and I was just  really lucky in getting into something, which I just loved.  I just  loved ultrasound from the first minute I started doing it and I still  love it.  Some of my happiest time in the week is when I just sit down  and scan, that really is just a joy to me.”
       
       

       “Now which hospital are you at now, King George?”
       
       

   “No, I’m at St. George’s Hospital Medical School but I was at King’s  College Hospital for twenty years.  I just moved over for various  reasons; one was that St. George’s Hospital had a scandal, they were a  bit down, and I thought I would go right over and help them so I thought  I would do it again.”
       
       

       “You’ve really participated in some of the landmark work in this  field.  We really appreciate you giving us this interview, and we wish  you well and hope it continues.  I know it will with vascular and 3D and  everything else coming but that’s covering your other talk and we’ll  just head into that.”
       
       

  “Thank you very much.”
       
       

Would you like to comment on this       interview? Send your comments to the 

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OBGYN.net Conference CoverageFIGO 2000 INTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS: Washington DC, USA

Professor Stuart Campbell: His Formative Years

   “Welcome to this the fourth in a series of luncheon historical  lectures, without the luncheon I might add.  I’m Tom Basket from  Dalhousie University in Halifax in Canada.  The topic is the History of  Ultrasound in Obstetrics and Gynecology.  Now without a doubt,  ultrasound has probably had one of the most profound impacts on our  specialty in the last half century.  I think the only other thing that I  would put in the same league would be the oral contraceptive pill. 

       We’re very lucky today to have as our lecturer Professor Stuart  Campbell who is one of the pioneers in its development.  Stuart Campbell  has been Professor and Head in the Department of Obstetrics and  Gynaecology at St. George’s Hospital Medical School in London since  1996, and for twenty years before that he was Professor at King’s  College Hospital in London.  But for today’s purposes, that’s beside the  point.  The relevant part of his history is his early years, following  graduation from the University of Glasgow in 1961, he served between  1965-1968 as a Research Registrar with Ian Donald at the Queen Mother’s  Hospital in Glasgow, and that’s really where the story begins.  We’re  very fortunate to have someone rather like we did on Monday with  Professor Edwards who was actually involved with the evolution of one of  the most important aspects of the history of our specialty.  Stuart.”



 I  have always avoided lecturing on the history of the development of  ultrasound in obstetrics and gynaecology, because I was part of the  history, and I have actually got to place myself in historical context,  which is a difficult thing to do.  However, I will try even if it means  accusations of being biased and immodest!  It is often difficult to know  when many subjects actually begin.  They sort of evolve, but ultrasound  in obstetrics and gynaecology had a very definite beginning.  In 1958,  the classic paper by Donald, McVicar, and Brown in the Lancet, which I  will elaborate on later, was the very precise beginning; no two ways  about it.  Nobody had applied ultrasound to obstetrical and  gynaecological diagnosis before, but of course ultrasound had been used  medically before that, and I am going to discuss that a little bit  later.  I will show you some of the early problems, and I will take you  right through to the present time.  In thirty minutes that’s an almost  impossible task, so if I speak fast and I get my words mixed up, please  forgive me. 

       This is a picture of Ian Donald (1911 – 1987).  He was a most  charismatic man.  I worked for him for several years, and he was not  always easy to live with, because he would fire questions at you all the  time, and if you didn’t know the answer then you really got a roasting.   He was impulsive; if he was scanning a patient and her bladder was too  full, then you got a terrible rollicking. His temper was quick and  sometimes quite frightening, but then just as quickly it would subside.   He was actually a most generous man.  For example, if you did research,  you got the credit.  When I wrote my first paper on cephalometry, he  did not ask to have his name on it, even though I was working for him.   There was no “droit de Seigneur”, as you might say.  So Donald was a  generous and a cultured man; he played the piano, he painted, he wrote  poems and made furniture.  He was a workaholic; he worked so hard and he  was very courageous because he had rheumatic heart disease and he  needed valve replacement operations on at least three occasions, but he  never wasted a second of time; for instance, he never took a lift - he  always climbed the stairs, even though his chest was heaving at the top.   He wouldn’t waste any time to go to the barbers; he used to cut his  own hair and sometime the results weren’t all that good.  So Donald was a  most extraordinary man, and it was a privilege to work with him. 

       But let me go to the beginning and, of course, none of this would  have happened if we hadn’t had Christian Doppler giving his theories on  the Doppler Effect, Lord Rayleigh and his classic Theory of Ultrasound  describing the transmission, reflection, and defraction of ultrasound,  Pierre Curie describing the Piezo-electric Effect by which ultrasound is  generated and Paul Langevin who described the hydrophone by which  submarines could be detected by surface vessels.  These were the  physicists who described the basic theories on which all technical  developments were based.  Then we had the technical developments in  medical imaging.  In 1949, the A-scan with Ludwig (gallstones) at the  Massachusetts Institute of Technology and J. J. Wild (breast) in  Minneapolis, but I’m not going to waste time talking about A-scan.  In  terms of medical diagnosis, A-scan was extremely limited. It is with 2D  scanning that the history of medical ultrasound imaging begins and the  credit for the first 2D scanning images goes to Wild and Reid from  Minneapolis, who published 2D images of breast anatomy in 1952.  J.J.  Wild was an English surgeon who escaped to America shortly after the  Second World War and settled in Minneapolis.  He gave up surgery and  started doing ultrasound research with the Honeywell Corporation.  Six  months after his seminal paper, Howry and Bliss from Denver published  their paper and 2D scanning was born.  Both groups published impressive  pictures of anatomy, though the patient was usually immersed in water to  achieve satisfactory images.  The ever-inventive J.J. Wild, however,  did produce transrectal and transvaginal probes, which were rather  gruesome looking, but these never became popular in these early days.   In 1958, contact scanning was first described by Donald and Brown in  their classic Lancet paper.  They described in detail a compound  scanning technique with the transducer in contact with the abdomen  through a layer of olive oil and that was the real revolution in  ultrasound imaging.  It was this paper that transformed ultrasound into a  technique that could be easily applied to all patients and all parts of  the anatomy.  Donald, McVicar and Brown were also the first researchers  to apply ultrasound to obstetrics and gynaecology.  Their equipment was  the first to be commercially produced for export to other research  centres.  Then in 1969 there was the development of grey scale by means  of the scan converter by George Kossoff and his team in Sydney,  Australia. This made 
       a tremendous impact on the quality and interpretation of ultrasound images. 

       The development of real-time scanning occurred at much the same  time and came in the form of the Vidoson from the company Siemens.  In  1968 this machine was produced and officially is the first real-time  scanning machine.  However, it had a cumbersome probe and a flickering  image and, although the equipment was popular in Germany, it had severe  limitations in terms of image quality.  It was the development of the  Phased Array Scanner in the early 1970’s with Jan Somers in the  Netherlands and the Linear Array Scanner with Nicholaas Bom, again, in  the Netherlands that paved the way for the real-time revolution. In 1975  the ADR Linear Array Scanner was produced by Martin Wilcox in America,  which was the first practical real-time machine in obstetrics.  I cannot  underestimate the impact that real-time scanning had on obstetric  ultrasound.  No longer was it necessary for a machine to have a large  gantry suspending the probe, so machines were cheaper, lighter and  smaller (and therefore could be moved to the patient); more importantly,  scanning was technically easier and, therefore, the training time  shorter.  Technicians and radiographers , who has perhaps struggled with  the larger equipment were amazed at how quickly they could achieve  reproducible fetal measurements with a good quality Linear Array  Scanner.  Fetal movements could be followed and quantified and invasive  procedures could be monitored in real-time.

       Continuous wave Doppler began in the early 1970’s in Japan with  Satomura, which led to the development of the fetal heart detector.   Duplex Doppler equipment was produced in the early 1980’s from Angelsen  in Sweden, and then colour Doppler from Namekawa from Japan who, working  with Aloka, produced the first colour Doppler machine in the mid  1980’s.  The first 3D scanner was produced in 1974 in Glasgow by Tom  Brown, i.e. the engineer who worked with Ian Donald, but it was not  computerized and without computer storage of the images it foundered  very seriously and the project lost millions of pounds.  But Karl Kretz,  Kazunore Baba, and Thomas Nelson much about the same time in the late  1980’s started to use computerized modeling of ultrasound images, and we  are now reaping the fruits of that research in beautiful 3D images,  which I will discuss later on. 

       So let’s show some of the pictures of the early pioneers, their  equipment and images. This is a picture of J. J. Wild, the English  surgeon who lives in Minneapolis.  I phoned him the other day, he’s  eighty-three and just as sprightly as ever.  In his interview for the  Wellcome Trust, he said, “Donald, at my last meeting with him, said I  was 40 years ahead of my time.  I corrected him and said, no, I’m 40  years ahead of your time”.  So you can see he’s not exactly a modest  man, but the trouble with J.J. Wild’s research is illustrated in this  first 2D image of the breast.  He was looking at tissue  characterization, not organ structure.  In other words, he felt he could  tell the difference between cancer and non-cancer by their reflected  echoes.  Even today, tissue characterization by ultrasound is at a  fairly primitive stage of development, so to be quite honest, although  he is undoubtedly the pioneer of 2D scanning, the particular path he was  beating I believe was going up a blind alley

       This next image is of Douglas Howry, a very able physicist who  worked in Denver, Colorado, and here is a typical machine that he  created.  He believed that optimal imaging was by water delay scanning  and here you can see a man immersed in a water chamber.  You will notice  the rather inelegant toilet seat that he’s sitting on, and that’s a  thing that you’ve got to realize that these were people cobbling  together bits of equipment.  They did not have massive funding, and they  usually published in relatively obscure journals.  Howry was actually  beginning to produce good images; here is a picture of a gall bladder  and with his compound B technique, he began to get very nice  circumferential views of structures, such as the adult neck and here you  can see the thyroid in front.  At the time that Ian Donald was just  beginning, Douglas Howry in Denver, Colorado was getting impressive 2D  images, by using the technique of immersing a patient in a bath of  degassed water.  This would not have been suitable for pregnancy  scanning. 

       Now we come to Ian Donald, this charismatic figure I was telling  you about.  Here is a picture of him at his famous Diasonograph, which  was the first commercial machine to be produced.  This is the Queen  Mother’s Hospital, which he persuaded the government to build for him.   He was such a dominating personality; he just persuaded the government  to build a hospital just for him!  It couldn’t happen now, but this was  built in 1965. 

       This is a picture of Tom Brown, the brilliant engineer, and you  can see the rather primitive equipment that they cobbled together at the  beginning.  He has hitched the pulley and the transducer to the bed  table, so, very simple equipment to begin with.  This is a slide of  Donald’s famous paper in 1958, and what a paper it was.  I mean nowadays  we would probably stretch this to about five publications, certainly I  would!  It began with the physics of ultrasound scanning techniques,  safety experiments, ultrasound imaging of pregnancy, ultrasound images  of gynecology, and a really detailed description of the strengths and  weaknesses of this new technique.  It was a seminal work.  Here are some  of the images he obtained in the early years; a fetal head,  polyhydramnios, malignant ascites, hydatidiform mole, which he described  in 1962, and here is an early pregnancy seen through a full bladder.   He was the one to develop the full bladder technique to visualize early  pregnancy.  Now it’s interesting, because Donald never quite grasped the  importance of transvaginal sonography, which was really propagated in  Vienna by Alfred       Kratochwil.

       On the next two slides, I summarise the main schools in the 1960’s  during the early development of ultrasound diagnosis.  These schools  were in Glasgow, Denver, Sydney, Vienna, Copenhagen, Lund and Tokyo.  I  have highlighted the engineers in yellow, because they were the key  factor in these days, for each centre needed a top class engineer, for  they were developing new models all the time.  Furthermore, although  commercial ultrasound companies were appearing, they had a limited  ability to maintain the machines that they produced.  So the progress of  development in each of these centres was very much reliant on the  quality of the engineer.        

Ian Donald, of course, had Tom Brown and his clinical  researchers were John McVicar, who did studies on hydatidiform mole,  James Willocks, who did early studies on cephalometry, Usama Abdullah  who did studies on placentography and safety, myself (and I will indulge  myself by discussing my contribution later), Hugh Robinson, who  pioneered early studies on the first trimester embryo and Joachim  Hackeloer, who was visiting  Glasgow from Germany and did early studies  on follicular development.  The leader of the rival group in Denver was  Joe Holmes, backed up by Douglas Howry, the famous early pioneer of 2D  scanning.  His clinical researchers were Horace Thompson, who did first  studies on measuring the chest circumference, Ken Gottesfeld, who  produced the first paper on placental location, much to Ian Donald’s  frustration, and Stewart Taylor.  The clinical leader of the Australian  group was Bill Garrett and supporting him was George Kossoff, the  pioneer of grey scaling, who unfortunately decided that water delay  scanning was still the best method of obtaining obstetric images and  rejected the concept of contact scanning.  In Vienna we had Alfred  Kratochwil backed up by his engineer Paul Kretz, perhaps one of the most  inventive of all ultrasound engineers. Kretz built equipment for  Kratochwil suitable for transvaginal scanning and Kratochwil was the  lonely advocate for this approach until the development of the real-time  transvaginal scanners in the 1980’s made this the optimal method for  gynaecological scanning.  Kretz founded the company Kretztechnik, which  pioneered many innovative ideas including 3D scanning.  In Copenhagen,  the leader of obstetrical and gynaecological research was Jens Bang  backed up by a brilliant engineer called Hans Henrik Holm, who developed  the Smith Kline instruments.  In Lund, the major figure was Edler, who  started off the clinical science of echocardiography.  He had the  support of a brilliant engineer called Hellmuth Hertz. Working in this  department was Bertil Sunden, who was the first person to buy one of Ian  Donald’s Diasonographs and did some very interesting early work on  obstetric and gynaecological imaging with this equipment.  Finally in  Tokyo we had Hisaya Takeuchi and an engineer called Uchida, who may  actually have been the first to do clinical A-scan studies. So these  were the groups in the 1960’s. 

       I will now show you some slides of these early days.  This is  James Willocks demonstrating his A-scan method of fetal head  measurement.  This technique had problems, because it was impossible to  be certain that the echoes were derived from the parietal eminences and  so inaccuracies inevitably occurred.  The following year I developed the  combined A and B-scan technique, which is illustrated in the next  slide.  This technique demanded that the midline echo was demonstrated  on B-scan before the A-scan measurements were taken.  With hindsight,  nowadays, I think I should have just taken the measurements on the  Polaroid, but in general, the A-scan measurements were more precise.   Because the Diasonograph had a strong gantry (also rather heavy!) in  those days,  it was easy to line up the fetal head in the precise plane  for an accurate measurement.  The following slide shows the sort of  pictures that were being obtained from Denver in those days.  You can  see that there are no midline structures in the Denver picture and there  is a very thick outline to the head, so I had a tremendous advantage in  having a machine that could do the business.

       This is a picture of Bertil Sunden, who as I explained before used  one of Ian Donald’s original Diasonographs and was the first to  recognize a fetal abnormality by ultrasound.  This was a case of  anencephaly in the third trimester, associated with polyhydramnios.   Sunden produced some excellent papers, both on obstetric scanning and in  assessing gynaecological tumours. 

       This is an picture of Alfred Kratochwil, who introduced  transvaginal scanning in the late 1960’s.  He was the first person to  recognize, for instance, an ovarian follicle transvaginally. 

       I will now show a few more slides from my own collection.  When I  had completed growth charts of the biparietal diameter, I went down to  London to Queen Charlotte’s Hospital and with the Diasonograph I started  a programme of diagnosing early fetal abnormalities with this brilliant  machine.  On the left you will see a picture of the first early  diagnosis of anencephaly (at 18 weeks), which I described in 1972 and  the other slide shows a picture of the early diagnosis of a spina bifida  which I diagnosed in 1975.  So the early diagnosis of fetal  abnormalities was now a reality.  After I left Glasgow, Hugh Robinson,  who is shown in the next slide, took my place and concentrated his  efforts on first trimester diagnosis.  Hugh was the first to chart the  growth of the crown-rump length in the first trimester and did some  seminal work on the early fetal heart rate.  Hugh did these studies  abdominally with the full bladder technique and, although we can say  first trimester began in the early 1970’s, the major development  occurred in the 1980’s when the real-time transvaginal probe became  available.

       The next slide shows this extraordinary man, George Kossoff, who  worked away in the Commonwealth Acoustic Laboratories in Sydney,  Australia in the 1970’s.  George had visited Howry in the old days and  still believed that water delay scanning was the way to do it, and he  built this huge tank on top of which the patient lay.  Here he is with  David Robinson and Bill Garrett, who was the obstetrician who worked  with him, and they built this tank, which held 50 gallons of water.  I  understand that one day the water leaked out and spilled on the floor  and they thought at first that the patient had ruptured her membranes.  I  guess a 50 gallon leak would suggest polyhydramnios.  The next slide  shows the typical image they got in the early 1970’s and although they  were impressive, the outlines were rather thick and did not concern me  too much.  However, suddenly like a bombshell in the mid-1970’s they  produced beautiful grey scale images like this.  This was because  Kossoff had invented the scan converter, which allowed the demonstration  of small back-scattered echoes to give the appearance of tissue  texture.  In other words, grey scale.  To show you the impact of this,  the next slide shows a typical abdomen circumference, which I was  measuring at this time, and the one on the right is their picture of an  abdominal circumference. You can see how beautiful the gray tones are of  the Garrett/Kossoff image.  So the scan converter was the breakthrough  in showing subtle small-reflected echoes. Here is another comparative  slide showing my picture of a fetal chest and heart on the left, but the  Garrett/Kossoff image is so much better and you can even see  calcification in the placenta.  I remember going to a lecture by George  Kossoff in the Royal Marsden in London and I just couldn’t believe the  quality of these images. Eventually, of course, the scan converter was  incorporated into all our contact scanning machines, and the water delay  scanner fell out of existence. 

       Real-time scanning began in 1969 with the development of the  Vidoson by Siemens, and the great practitioner of this equipment was Dr.  Manfred Hansmann in Bonn.  Manfred Hansmann used this machine to do  intraperitoneal transfusions under direct ultrasound control and I think  he was the first person to do that.  You can see it had a large water  bag in which the transducer was placed, so it was a very large probe  that you placed on the abdomen and angling this to get fetal planes was  difficult.  Furthermore, because the beam was swept mechanically with a  parabolic mirror, it was a very flickery picture, and I was personally  unimpressed with the quality of the images.  Actually, I remember in the  early 1970’s being asked to go to Singapore to train the doctors there  in ultrasound scanning.  When I arrived there, I found I had to use the  Vidoson and was a bit shattered because I found it difficult to obtain  planes of the biparietal diameter and abdominal circumference, which I  was used to getting.  However, Manfred Hansmann did brilliant work with  this machine.  As I said, he pioneered invasive needling procedures  under real-time control with this equipment, but when the ADR came into  existence in 1975, then everyone was able to get beautiful real-time  images with a small manoeuvrable probe, so ultrasound guided invasive  procedures quickly became the norm.  This is a typical ADR picture in  1975.  You can see that the image looks a bit stripey, because at this  time they had not learnt to interpolate scanning lines, but really the  quality was actually quite good.  I remember I first saw the ADR when I  was in Canada visiting Fred Winsberg, and I was totally bowled over by  the images he was obtaining.  I picked up the phone in his laboratory  and phoned up the Chief Executive of my hospital and said, ‘I’m buying  this machine, and I expect you to pay for it.’  You could do things like  that in those days. 

       How about routine ultrasound scanning in pregnancy?  I would like  to claim that I was the first person who drew the attention of people  that routine ultrasound was a desirable thing.  This is a statement I  made in 1969 in the British Journal of Obstetrics and Gynaecology  (called then Journal of Obstetrics and Gynaecology of the British  Commonwealth ): “It may be that a routine ultrasonic measurement of the  biparietal diameter in the second trimester in all antenatal patients,  would reduce the number of inductions of labour and that more attention  could be paid to cases of true post maturity.  Certainly in those  maternity hospitals, where ultrasonic equipment is available, routine  assessment of the fetal biparietal diameter would be practically  feasible, as the method is safe, causes no discomfort to the patient and  rarely takes more than 10 minutes”.  It is strange to think that it  could take up to 10 minutes to measure a biparietal diameter in those  days, when now we would expect to do all fetal biometry in the same  period of time.  Anyway,  this is one prediction which has come to pass,  because it has been demonstrated that routine second trimester biometry  will reduce the number of unnecessary inductions of labour, as is  demonstrated in the meta-analysis of 8 trials of routine versus  selective ultrasound in pregnancy, where one of the significant  advantages of routine ultrasound is reduction in the numbers of  inductions for post-term pregnancies.  However,  Persson and Grennert  from the Malmo group were the first researchers to publish a study on  routine ultrasound in pregnancy.  You can see that they started in 1974  and published in 1978.  The first national programme for routine  ultrasound scanning was in the Federal Republic of Germany and I think  there is no doubt they were influenced by the persuasive powers of  Manfred Hansmann; they recommended two routine scans for all women.  The  Royal College of Obstetricians and Gynaecologists in Britain       belatedly in 1984 recommended that women in the United Kingdom  should be offered a routine scan between 16 and  18 weeks’ gestation,  but in the same year, the NIH in the U.S.A. did not support routine  scanning.  They did produce a list of seventeen indications for an  antenatal scan, which could allow for liberal interpretation, but still  basically in the United States you do not believe in routine scanning,  which I have to say with current knowledge on the benefits of routine  scanning is difficult to understand.  I am putting this in very  diplomatic language.

       The schools in the 1970’s and 1980’s did not require a physicist  to support their work; they all had the availability of the very latest  equipment produced by commercial companies, such as Acuson, ATL, Aloka,  Toshiba, etc.  In the next two slides,       I outline some of the key researchers and schools of the 1970’s  and 80’s.  All of these researchers and centres made singular  contributions to the development of the ultrasound scanning techniques  and the various applications to which ultrasound is put today. 



       In the following slides I will go through some of the seminal  papers on the various applications of ultrasound in obstetrics and  gynaecology, which have shaped the way in which ultrasound is practiced  today.





       I will begin with my 1971 paper on biparietal diameter growth  charts, which were very detailed and not only had cross sectional data,  but velocity graphs according to weeks’ gestation and biparietal  diameter size as well.  I had earlier in 1969 produced the first BPD  growth curve, but the 1971 paper, I think, had a seminal influence on  the construction of growth charts.  After this, there was a large number  of such charts from all parts of the world, but the next seminal paper  must be Hugh Robinson’s crown-rump length graph in 1973, which set the  stage for first trimester biometry.  In 1975, the Campbell and Wilkin  paper on measurement of abdominal circumference was  an important  milestone because this remains the most important parameter in the  assessment of fetal weight and nutrition.  I place Steve Warsof’s 1977  paper on fetal weight prediction next on the list, for this was the  first to use multiparameter equations for the prediction of fetal  weight.  Finally, I would place Hadlock’s series of papers on fetal  biometry and weight estimation produced between 1981-1984 on my list of  seminal papers, because these are the most frequently used graphs  worldwide, even today.





       Again I begin with one of my papers in 1972, which was the early  diagnosis of anencephaly followed by termination of pregnancy.  This was  in effect the beginning of early prenatal diagnosis by ultrasound and I  followed this up a few years later with the early diagnosis of spina  bifida.  However, the second paper I would put on my list is Hobbin’s  classic paper in the American Journal of Obstetrics and Gynecology in  1979, which described the prenatal diagnosis of a variety of congenital  abnormalities including skeletal anomalies.  The seminal paper on  echocardiography was produced by Lindsey Allan in 1980.  This was a  really important development and her paper was an absolute classic,  where she described the systematic planes of the heart to make the  diagnosis of fetal abnormalities.  It really was the beginning of fetal  echocardiography.  Finally, I would put on my list of seminal papers,  Nicolaides paper on the intracranial signs (lemon and banana) for spina  bifida.  This is a classic paper because it introduced the concept of  screening for a major abnormality with a very simple screening  technique, so it actually had a tremendous influence on our ability to  diagnose spina bifida. 





       The seminal paper on identification of fetuses at high risk of  chromosome abnormalities in the second trimester, by looking for  anatomical markers, was Benacerraf’s 1987 paper in the New England  Journal of Medicine.  It was she who focused the world’s attention on  nuchal fold thickness, short femur, renal pelvic dilatation and other  markers, which soon became an important part of the routine second  trimester scan.  I include in this section Timor-Tritsch’s important  1988 paper in the American Journal of Obstetrics and Gynaecology on  sonoembryology, because the majority of defects in the first trimester  are associated with chromosome abnormalities and he, more than anyone,  focused attention on early prenatal diagnosis.  The breakthrough in  terms of using a fetal marker to screen for Down’s syndrome came with  Nicolaides’s seminal paper in 1992 in the British Medical Journal, where  he used the measurement of fetal nuchal translucency between 11 and 14  weeks to screen for Down’s syndrome.  The establishment for likelihood  ratios for a particular nuchal translucency measurement meant that for  the first time ultrasound could be demonstrated to be superior to  biochemical methods in screening for karyotype abnormalities.  Now I  know that nuchal translucency screening is not popular in the United  States yet, but surely you will have to fall in line with the rest of  the world, because this is now becoming the standard test for screening  for Down’s syndrome in the first trimester, although in the future  nuchal translucency will probably be combined with biochemistry, such as  PAPP A and free  hCG.  At the present time, with combined nuchal  translucency and biochemistry, we can now detect about 90% of Down’s  babies with a 5% invasive testing rate so this is quite clearly the way  to go. 





       Ultrasound guided procedures were developed even before the advent  of real-time scanning.  The classic early paper by Bang and Northved in  1972 from Copenhagan described the use of a specially developed  transducer with a central hole for the needle in order to reduce the  risks of amniocentesis.  Hobbins and Mahoney first described the use of  ultrasound guided fetoscopy in 1974.  Hobbins used this technique not  just to examine fetal anatomy, but also obtain red blood cells from the  surface of the placenta for the prenatal diagnosis of thalassaemia. Then  in 1979, Charles Rodeck and myself described pure blood sampling from  the cord insertion; it was the first time pure blood had ever been  achieved and this paved the way for biochemical studies on the fetus.   Then in 1983, Daffos in Paris first described a technique to obtain pure  fetal blood without the use of the fetoscope by directing the tip of  the needle under ultrasound control directly into the cord insertion.   Daffos actually had a sonographer identifying the cord insertion, while  he inserted the needle, but Nicolaides described the two-handed  technique of cordocentesis, where the operator performed both scanning  and needle insertion.  Finally, of course the procedure of chorion  villus sampling would not have become so wide spread and indeed the most  important method of determining the fetal karyotype, were it not for  the classic paper by Hahnemann in 1984, where he described the  transabdominal technique, which has pretty well confined the  transcervical method to the dustbin of history. 



Ultrasound Guided Therapeutic Procedures:



       Although Hansmann, I believe, ultrasound guided intraperitoneal  transfusion, I have put on my list of seminal papers the 1976 paper by  Hobbins, as this was hugely influential in persuading people to abandon  the old Xray method pioneered by Lilley.  Charles Rodeck in 1981 first  described fetoscopic intravascular transfusion, which overcame problems  associated with absorption of fetal cells from the fetal peritoneal  cavity.  Nicolaides and Berkowitz separately described intravascular  transfusion by cordocentesis very shortly after that. 

       Golbus, in San Francisco, and Berkowitz in New York were the first  to describe the insertion of a vesico-amniotic amniotic shunt to  relieve bladder obstruction due to posterior urethral valves.  Although  shunting procedures have subsequently been performed for this and many  other indications, there is little proof that these are life saving  procedures.  I have also included Ville’s 1995 paper, where he described  laser surgery to the placenta.  Although I have jumped to the 1990’s,  which is unfair, I just wanted to point out that although the fetoscope  was abandoned following the development of cordocentesis, it is  gradually being rediscovered and this is a very important application  for the fetoscope.





       We must begin with the first Doppler ultrasound paper on  continuous wave assessment of umbilical artery flow, which was published  in 1977 in the British Medical Journal by Fitzgerald and Drumm from  Dublin.  This really was a seminal paper from a city with no big  ultrasound tradition  In 1980, Sturla Eik-Nes, who was working in Mlmo,  showed that fetal aortic velocimetry could be carried out using a  duplex scanner, i.e. an imaging transducer linked to a pulsed Doppler  transducer.  With the same system, I first described in 1983 in the  Lancet, the assessment of the utero-placental circulation and that high  resistance waveforms were obtained in pre-eclampsia.  Subsequently these  studies were done with colour Doppler and in many centres this has  become an important screening technique to predict women at risk of  pre-eclampsia.  With the use of colour Doppler, Wladimiroff pioneered  the study of the middle cerebral artery in 1987 and the use of the  middle cerebral to umbilical artery PI ratio to demonstrate  centralisation of the fetal circulation.  In 1991 Kiserud completed the  Doppler story by describing waveforms in the ductus venosus, which is  now recognised as a key examination to predict right heart failure in  the hypoxic fetus and the most important indicator of imminent fetal  demise. 





       The first fetal activity to be studied was fetal micturition by  Campbell and Wladimiroff in 1973 and they subsequently demonstrated that  in IUGR fetuses, fetal urinary production was reduced.  With the advent  of real-time scanning, detailed studies of fetal activity were  produced.  The group of Patrick in London, Ontario, was one of the first  to document the incidence of fetal breathing movements over a 24 hour  period.  More detailed studies of fetal behaviour were given a stimulus  by the 1981 paper of Birnholz on fetal eye movements.  Perhaps the most  seminal paper produced on this subject was in 1980 when Manning and  Platt described the biophysical score, which for 20 years has remained  the most important method of assessing fetal wellbeing, certainly in the  United States.





       Even before the advent of transvaginal sonography, which has now  become the standard method of evaluating the pelvis to diagnose  gynaecological conditions Kadar et al in 1981 had produced their seminal  paper on the early diagnosis of ectopic pregnancy, describing the  discriminatory zone of  hCG, above which an intrauterine gestation sac  should be visible. Cacciatore’s classic paper in 1984 established that  transvaginal sonography was the most accurate method of diagnosing  ectopic pregnancy.  Campbell et al in 1989 were the first to publish on a  large scale 5 year screening project for ovarian cancer.  Subsequent to  this DePriest et al in Denver published similar encouraging reports on  screening for ovarian cancer by transvaginal sonography.  Morphological  scoring systems to improve the diagnosis of ovarian cancer in masses  detected by ultrasound was carried out by several workers, but the paper  of Sassone and Timor-Tritsch in 1991 remains the classic.  Finally,  Bourne and Kurjak both published papers advocating the use of colour  Doppler in refining the prediction of ovarian cancer in ovarian masses.   Granberg was the pioneer in using the measurement of endometrial  thickness to predict endometrial cancer and the use of a 5 mm limit is  used widely to exclude this disease.






       Even before the advent of transvaginal sonography, Hackeloer  working in Glasgow, described the growth of the ovarian follicle and  correlated growth rates with oestrodial values.  The 1984 paper by Susan  Lenz in the Lancet was a seminal work, because for the first time it  was demonstrated that eggs could be obtained from ovarian follicles  directly under ultrasound control. Susan Lenz described a transvesical  approach and I have to say it made a profound impression on me.  I  remember reading the paper and I said to my Lecturer, John Parsons,   “Fantastic, this is the way we are going to obtain eggs from now on -  throw away the laparoscope!”, so I think we probably had the first truly  outpatient system for IVF anywhere in the world. Then Dellenbach in  1988 described transvaginal egg collection by guiding a needle along a  transvaginal probe and this has become the standard method for egg  collection.  The use of Doppler in reproductive medicine was pioneered  by Steer when he correlated impedance in the uterine arteries to  successful implantation and Bourne for his studies on peri-follicular  blood flow and oocyte maturity.  Finally we must give credit to Deichert  in Germany for his seminal paper in 1990, where he described evaluation  of the Fallopian tubes with a positive contrast agent (HyCoSy).  This I  believe will turn out to be the standard method of tubal evaluation,  especially as now we can look at the tubes by this method in  three-dimensions.  Talking about 3D scanning, this must be the big  development of the new century.  If this lecture is given in ten years’  time, then researchers like Eberard Merz in Germany, Bernard Benoit in  France and Davor Jurkovic in London will undoubtedly be featured  strongly.  This is a 3D picture I took of a 12 week fetus just three  days ago.  This is not just a pretty picture.  The fine detail you can  see of the spinal column is a huge advance on what we can do with 2D  scanning.  I believe that three dimensional scanning will transform  sonoembryology.

       A final point about education.  Although each of us in our units  ran training courses for people wanting to learn new techniques, it was  Asim Kurjak with the Ian Donald School in Dubrovnik, who was the first  person to set up a large international school for teaching and training  in ultrasound.  It was he, who during one of these meetings in Dubrovnik  proposed that we should have an International Society of Ultrasound in  Obstetrics and Gynecology and I was delegated to set up such a society  and run the first World Congress in London, which was held in 1991.  I  also have to acknowledge the huge contribution to training of Kypros  Nicolaides, who runs several international courses each year through his  Fetal Medicine Foundation.  But to return to the International Society  of Ultrasound in Obstetrics and Gynecology; it runs annual world  congresses each year in different parts of the world.  It has an  Executive Committee, a Board of Directors, a Secretariat, a Scientific  Committee, and a Education Committee.  It is totally committed to  education in ultrasound and it publishes a monthly journal, which now  has an impact rating even higher than the Green Journal, which is very  exciting indeed.  I believe the International Society and the White  Journal, as it is called, are setting standards and making ultrasound in  obstetrics and gynaecology a well respected subspecialty. 

       Finally, I end up with a slide of the Ian Donald Gold Medal,  because the International Society gives annually this medal to people  who have contributed enormously to the development of ultrasound.  I  have mentioned many of them today and some of the people I have  mentioned today will receive it in the future, but showing this slide is  a fitting way to end a lecture on the history of ultrasound in  obstetrics and gynaecology, for it is to Ian Donald that we must pay  homage as the ultimate pioneer of this subspecialty.  Thank you all very  much indeed.”

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