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Pediatric Sonography
FOURTH EDITION
Editor
Marilyn J. Siegel
Professor of Radiology and Pediatrics
The Edward Mallinckrodt Institute of Radiology
Washington University School of Medicine
St. Louis, Missouri
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Acknowledgments
riting a book is a task that requires time and commitment remain dedicated to performing high-quality examinations on
W from many people. As editor, it would not have been pos-

sible for me to complete this task without the contributions
of many other individuals, who I acknowledge below.
children.
I would also like to express my appreciation to the publish-
ing team at Lippincott Williams & Wilkins for their effort and
I offer sincere thanks to Dr. Brian Coley of Columbus Chil- professionalism in directing this project. Most particularly, I
dren’s Hospital, Dr. Ellen M. Chung, Department of Radiologic would like to thank Ryan Shaw and Brian Brown, for their ded-
Pathology, Armed Forces Institute of Pathology, and Drs. William ication and advice. Of course, I need to thank Lisa McAllister
Middleton and Nirvikar Dahiya of the Mallinckrodt Institute of who cajoled me into taking up the editorial pen once again. With-
Radiology. They graciously shared their invaluable experience out her efforts, this book would not have happened. I also
and expertise to bring depth to important chapters. express appreciation to Chris Miller, who transformed the pages
A special note of gratitude goes to my secretary, Janine into print and prepared the illustrative material. Her dedication
Wuebbles, who spent many hours acquiring references and ulti- is reflected in the high quality of the final product.
mately checking their accuracy in the proofs. Without her sup- Finally, I wish to thank one more very important person—my
port, this book could not have been finished in a timely fashion. husband, Barry A. Siegel, M.D., for his support and patience dur-
My thanks also goes to my sonographers, Deborah Reiter, Janet ing the many hours that I spent writing and editing this book. His
Hurt, Angela Heffernan, Amy Devall, and Shelly Lopez, who unconditional support made the completion of this book a reality.
viii
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Contents
Contributors v
Preface vii 10 Gastrointestinal Tract . . . . . . . . . . . . . . . 339
Acknowledgments viii Marilyn J. Siegel
1 Physical Principles and Instrumentation . . . 1 11 Urinary Tract . . . . . . . . . . . . . . . . . . . . . 384

Nirvikar Dahiya, William D. Middleton, and Marilyn J. Siegel Marilyn J. Siegel
2 Ultrasound Artifacts . . . . . . . . . . . . . . . . 21 12 Adrenal Glands, Pancreas, and Other

William D. Middleton, Marilyn J. Siegel, and Nirvikar Dahiya Retroperitoneal Structures . . . . . . . . . . . 461
Marilyn J. Siegel and Ellen M. Chung
3 Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Marilyn J. Siegel
13 Female Pelvis . . . . . . . . . . . . . . . . . . . . 509
Marilyn J. Siegel
4 Head and Neck . . . . . . . . . . . . . . . . . . . 118
Marilyn J. Siegel
14 Male Genital Tract . . . . . . . . . . . . . . . . . 554
Brian D. Coley and Marilyn J. Siegel
5 Chest . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Marilyn J. Siegel
15 Musculoskeletal System and
Vascular Imaging . . . . . . . . . . . . . . . . . . 602
6 Breast . . . . . . . . . . . . . . . . . . . . . . . . . 200 Marilyn J. Siegel
Ellen Chung and Marilyn J. Siegel
16 Spinal Ultrasonography . . . . . . . . . . . . . . 647

7 Liver . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Brian D. Coley and Marilyn J. Siegel
Marilyn J. Siegel
17 Ultrasound-Guided
8 Gallbladder and Biliary Tract . . . . . . . . . . 275 Interventional Procedures . . . . . . . . . . . . 675
Marilyn J. Siegel Brian D. Coley
Appendix 701
9 Spleen and Peritoneal Cavity . . . . . . . . . 305
Marilyn J. Siegel Index 711
ix
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CHAPTER
Physical Principles and

Instrumentation
1
NIRVIKAR DAHIYA, WILLIAM D. MIDDLETON, AND MARILYN J. SIEGEL
Acoustics Real-Time Imaging Doppler Sonography

Wavelength and Frequency Mechanical Transducers Continuous-wave Doppler
Propagation of Sound Multiple-element Array Transducers Pulsed Doppler
Transducer Selection Color Doppler
Instrumentation
Power Mode Doppler
Transmitter Harmonic Imaging
Transducers Elastography
Extended-Field-of-View Imaging
Receiver
Contrast Agents
Image Display Real-Time Compounding
Image Storage Three-Dimentional Ultrasound Imaging
ltrasonography has been a valuable method for dis- degrades the ultrasonographic image. For a given sono-
U playing normal and abnormal anatomy for many years.

There are many reasons why it is an especially attrac-
tive imaging technique in the pediatric age group. One of
graphic unit and a given type of transducer, higher trans-
mitted frequencies provide better image resolution, but
poorer penetration. These conflicting characteristics of
the most important features of sonography is its lack of ion- transducer frequency force a compromise in adults, in
izing radiation. An important goal in imaging the pediatric whom lower frequencies must be used to obtain adequate
patient is to obtain diagnostic information with the least depth of penetration at the expense of image resolution.
amount of radiation exposure. Sonography can provide However, the need for greater depth of penetration is less
clinically useful information without apparent biologic ef- in children than it is in adults, reflecting the differences
fects on the patient or the operator. in body habitus. Therefore, higher-frequency, higher-res-
A second appealing aspect of sonography is the real- olution transducers can be used routinely in pediatric
time nature of the examination. This makes it easier to examinations.
examine patients who cannot suspend respiration, are The ability to perform the examination using portable
uncooperative, or are crying, all common problems among equipment is another advantage that sonography has over
pediatric patients. In addition, the real-time nature of the other cross-sectional modalities, such as computed tomog-
examination allows evaluation of rapidly moving struc- raphy (CT) and magnetic resonance imaging (MRI). This
tures, such as the heart. is obviously important in evaluating patients who cannot
A third advantage of sonography is its multiplanar be transported to the radiology department because of
imaging capability. Newer real-time equipment enables their underlying condition or because of their dependence
great flexibility in the selection of imaging planes and the on monitoring devices.
ease of altering these planes. This capability is especially Finally, in the era of medical cost containment, the rel-
helpful in determining the origin of pathologic masses ative inexpensiveness of ultrasonography, compared with
and in analyzing spatial relationships of various struc- CT or MRI, makes it an attractive imaging study for many
tures. These advantages have been expanded even fur- clinical problems. The issue of cost makes ultrasonography
ther with the advent of three-dimensional (3D) ultra- especially appealing in situations in which multiple
sound. sequential examinations are necessary or when screening
Another advantage of sonography in the pediatric age of large patient populations is desired.
group is its excellent resolution, which is related to the All of these factors make ultrasonography an extremely
size of the patient and the smaller amounts of body fat. valuable tool in the investigation of pediatric disorders.
The lack of significant body wall and intra-abdominal fat Therefore, any radiologist who performs diagnostic ultra-
in most small children is a great advantage in the exami- sonography on pediatric patients must have an under-
nation of pediatric patients because fat generally standing of the physical principles of this technique and
1
2 P E D I AT R I C S O N O G R A P H Y
the instrumentation available for detecting and displaying through the interface. Refraction is important because it is
the acoustic information. This information has been one of the causes of misregistration of a structure on an
described in detail in several comprehensive textbooks, ultrasound image. Refraction and its resultant artifacts are
chapters, and review articles (1–6). This chapter will be discussed in more detail in Chapter 2.
limited to the basic physical principles and the instrumen- Scattering refers to the redirection of sound in many
tation that are most relevant to the practice of diagnostic different directions. This phenomenon occurs when the
ultrasound. sound pulse encounters an acoustic interface that is not
smooth. Scattering can also occur in solid tissues and
organs as a result of the heterogeneity (i.e., multiple small
ACOUSTICS interfaces) of biologic tissues.
Wavelength and Frequency Absorption refers to the loss of sound energy secondary
to its conversion to thermal energy. Absorption is greater
Sound is the result of mechanical energy traveling
in soft tissues than in fluid, and it is greater in bone than
through matter in the form of a wave with alternating
in soft tissues. Sound absorption is the major cause of
compression and rarefaction of the conducting medium.
acoustic shadowing.
Human hearing encompasses a range from 20 to 20,000
The combined effects of reflection, scattering, and
Hz. Ultrasound differs from audible sound only in its
absorption are a decrease in the intensity of the sound
higher frequency. The term “ultrasound” refers to sound
pulse as it travels through matter. This decrease in inten-
above the audible range (i.e., 20 kHz). Diagnostic
sity is termed attenuation. As a result of attenuation, an
sonography generally operates at frequencies of 1 to
acoustic interface in the deeper tissues produces a
20 MHz.
weaker reflection than an identical interface in the super-
ficial tissues. To compensate for this degradation in
Propagation of Sound sound intensity, echoes returning from the deeper por-
Most diagnostic ultrasound examinations use brief bursts tions of the image are electronically amplified. This is
of energy that are transmitted into the body, where they referred to as distance gain compensation or time gain
travel through tissue. In tissue and fluid, sound is propa- compensation.
gated along the direction of the particles being displaced.
The resistance of the tissues being compressed largely
determines the speed at which the sound wave travels. The INSTRUMENTATION
velocity of propagation is constant for a given tissue and is The essential components of all scanners are a transmitter
not affected by the frequency or wavelength of the sound to energize the transducer; the transducer, which is the
wave. In soft tissues, the assumed average propagation source of the sound pulses; a receiver to detect the reflected
velocity is 1540 meters/sec. Fluid and fat have slightly signals; a display that presents the data for viewing; and,
slower propagation velocities. finally, a storage module.
After the sound pulse is generated and transmitted
into the body, it can be reflected, refracted, scattered, or Transmitter
absorbed (7). Reflection or backscatter occurs whenever
The transmitter activates the transducer, which causes it to
the sound pulse encounters an interface between tissues
vibrate and create a pulse of sound that can be transmitted
that have different acoustic impedances. Acoustic
impedance is equal to the tissue density times the speed into the body. This is done by the application of short,
of sound propagation in that tissue. The amount of high-amplitude voltage pulses. The maximum voltage that
sound that is reflected at an interface varies with the dif- may be applied to the transducer and, hence, the acoustic
ference in acoustic impedance between the tissues and output of diagnostic scanners is limited by federal regula-
the angle of incidence of the sound beam. The greater tions.
the acoustic impedance mismatch is, the greater the
backscatter or sound reflection. Reflection does not Transducers
occur in a homogeneous medium that has no interfaces The transducer converts electric energy generated by the
to reflect sound and, consequently, the medium appears transmitter into acoustic pulses, which are transmitted into
anechoic or cystic. the patient. It also receives the reflected echoes, converting
Refraction refers to a change in the direction of the pressure changes back into electric signals. Because the
sound as it passes from one tissue into another. Refraction crystal element converts electric energy into pressure waves
occurs when sound encounters an interface between two and vice versa, it is referred to as a piezoelectric crystal
tissues that transmit sound at different speeds. Because the (i.e., pressure electric).
sound frequency remains constant, the sound wavelength The sound pulses used for diagnostic sonography are
must change to accommodate the difference in the speed of generated by ceramic crystal elements housed within the
sound in the two tissues. The result of this change in wave- ultrasonic transducer. These ceramic crystals deform
length is a redirection of the sound pulse as it passes when the transducer is electrically stimulated, resulting
Chapter 1 • P H Y S I C A L P R I N C I P L E S A N D I N S T R U M E N TAT I O N 3
in a band of frequencies. The range of frequencies pro- together to produce a two-dimensional image. With static
duced by a given transducer is referred to as the band- B-mode imaging it was possible to view large organs, such
width. The preferential frequency produced by a trans- as the liver, in one cross-sectional image. The major dis-
ducer is equal to the resonant frequency of the crystal advantage of static B-mode imaging was its lack of real-
element, which in turn is dependent on the thickness of time capabilities. Because of this limitation, static articulated-
the crystal. arm B-mode devices have now been replaced by real-time
The ultrasound pulses produced by the transducer units.
must travel through tissue to generate diagnostic infor-
mation. The transfer of energy from the transducer to Image Storage
tissue requires the use of a coupling gel. After entering Permanent storage of images for analysis and archiving
the body, the ultrasound pulses may be propagated, was originally done in the form of transparencies printed
reflected, refracted, scattered, or absorbed as discussed on hard-copy radiographic film. However, computers
previously. The small pressure changes from reflections and digital storage are now used for reviewing images and
that return to the transducer distort the crystal element archiving the sonographic data. Digital Imaging and
and stimulate the transducer. This distortion once again Communications in Medicine (DICOM) standards are in
generates an electric pulse that can then be processed place to sustain image compatibility between different
into an image. ultrasound systems and transfer and storage of these
images.
Receiver
The returning echoes hit the transducer face, producing
voltage differences across the piezoelectric crystal. The REAL-TIME IMAGING
receiver detects, amplifies, and processes the voltage Real-time imaging permits investigation of both anatomy
changes that return to it. The time gain compensation con- and motion. The effect of motion is achieved when images
trol amplifies the weaker signals from deeper structures, are displayed at rates of several frames per second. Thus,
thus compensating for tissue attenuation. The receiver also the information is regarded as being viewed in real time.
compresses and remaps the backscattered signals. This Several transducers are available for real-time imaging.
changes the brightness of different echo levels in the image,
which in turn affects image contrast.
Mechanical Transducers
The earliest and simplest transducer design was the
Image Display mechanical sector transducer, which used a single large
A- AND B-MODE IMAGING piezoelectric element to generate and receive the ultra-
Ultrasound images have been displayed in A-mode and B- sound pulses. Beam steering was accomplished by an oscil-
mode formats. The A (amplitude)-mode format was the lating or rotating motion of the crystal element itself or by
earliest format for displaying sound signals returning to reflection of the sound pulse off an oscillating acoustic mir-
the transducer. With this format, the reflections arising ror. Beam focusing was done by using different-shaped
from tissue interfaces were displayed in graphic form with crystal elements or by attaching an acoustic lens to the
time on the horizontal axis and echo amplitude on the ver- transducer. The disadvantage of the mechanical sector
tical axis. transducer was the absence of variable focusing. The only
The B (brightness) mode displays the returning way to vary the focus distance was to switch to a com-
sound signal two-dimensional (2D) image with higher- pletely different transducer. Because of their lack of flexi-
amplitude echoes appearing brighter than lower-amplitude bility, mechanical sector transducers have been almost
echoes. In both A- and B-mode sonography, the distance entirely replaced by multiple-element electronic transduc-
of the reflector from the transducer is obtained by con- ers, commonly called arrays.
verting the time taken for the echo to return to the trans-
ducer to a distance. This is based on the speed of sound Multiple-element Array Transducers
in soft tissues, which is equal to 1540 meters/sec. In gen-
The array transducers contain groups of small crystal ele-
eral, the range of brightness should be as wide as possi-
ments that can steer and focus the ultrasound beam elec-
ble in order to differentiate small differences in echo
tronically (8). The basic types of arrays are the phased
intensity.
array and the linear array.
In the early two-dimensional units, the B-mode trans-
ducer was attached to an articulated arm that was capa-
ble of determining the exact location and orientation of PHASED ARRAY SECTOR TRANSDUCER
the transducer in space. This allowed the origin of the With the phased array transducer, each sound pulse is cre-
returning echoes to be localized in two dimensions. Then, ated by the composite of multiple pulses generated by each
by sweeping the transducer across the patient’s body, a element in the array. By varying the time and sequence in
series of B-mode lines of information could be added which the individual elements are fired, the composite
A C
Phased array viewed from the side. In this illustration, there

Fig. 1.1
are 16 elements in the array. All of the elements are acti-
vated to generate each individual composite sound pulse. A: By firing
the elements on the right side of the array first, a composite pulse is
created that is steered to the left. B: By firing all of the elements simul-
taneously, the composite pulse is steered straight down. C: By firing
the left elements first, the pulse is steered to the right. D: The resulting
image has a sector format. Because all the elements are used for each
sound pulse, the center axis of the beam always arises from the cen-
D ter of the probe. Therefore, the apex of the sector comes to a point.
sound beam can be steered in different directions (Fig. 1.1) poor near-field focusing capabilities. The focusing capabil-
and can be focused at different depths (Fig. 1.2). Because ities in the periphery of the image are also limited, because
the sound beams are generated at varying angles from one the center axis of the beam arises from the center of the
side of the transducer to the other, a sector image format is transducer (Fig. 1.4).
produced (Fig. 1.3). The focal zone can be adjusted by the
operator, depending on the location of the structure of LINEAR ARRAY OR LINEAR SEQUENCED ARRAY TRANSDUCERS
interest. Another capability of phased array sector trans- Unlike phased arrays, in which all individual crystal ele-
ducers is the ability to focus at multiple levels simultane- ments are used to generate the sound pulse, linear arrays
ously, although this is accomplished at the expense of a activate a group of adjacent elements to generate each
decreased frame rate. Compared with the other electronic pulse. The individual elements of this transducer are
array transducers (discussed later), the phased array type is arranged in a linear fashion. By firing groups of transducer
smaller and has a larger deep field of view. However, elements in succession, a series of sound pulses is produced
phased arrays have a small superficial field of view and along the face of the transducer and thus has the same effect
Focusing of array transducers. Sixteen-element phased

Fig. 1.2
array viewed from the side. A: By slightly delaying the firing
of the center elements, the composite pulse is focused in the far field.
B: By increasing the delay in firing of the central elements, the com-
A B posite pulse is focused in the near field.
Longitudinal view of the right kidney (RK) and liver (L) obtained with a 3-MHz electronic phased array transducer. The multiple focal zone
Fig. 1.3
indicators to the right of the image reflect the ability of phased array transducers to focus at variable and multiple depths.
Focusing capabilities of phased array transducers. View of an ultrasound phantom shows a number of identical metal pins that are
Fig. 1.4
imaged in cross section. Note that the pins at the edge of the image (open arrows) are displayed as larger reflectors than the pins in the
center of the image (solid arrow). This is secondary to the poorer focusing capabilities of phased array transducers in the periphery of the image.
A B C D E
F
Trapezoidal array viewed from the side. In this eight-
Fig. 1.7
element array the beam is sequentially steered and moved
from the left to the right (A–E) by varying the timing of activation of four
adjacent elements. This mechanism borrows the steering action of a
B
phased array, but like a linear array, only uses a limited number of ele-
Linear array transducer viewed from the side. In this illustra- ments to form each sound pulse. F: The image format is a sector.
Fig. 1.5
tion there are 40 individual elements. A: Each composite Because each pulse arises from a different segment of the transducer,
pulse is created by the activation of three adjacent elements. The first the apex is flat instead of pointed.
pulse is created by activation of elements one through three, the second
pulse by elements two through four, the third pulse by elements three
through five, and so on. B: The resulting image format is rectangular.
A B
Transverse view of the scrotum using a 10-MHz linear array transducer. A: Using the standard rectangular format, the two testes are par-
Fig. 1.6
tially imaged. The limited field of view excludes the lateral aspect of both testes. B: Using the trapezoidal format, the field of view is larger
and both testes are seen in their entirety. As with the phased array transducer, the linear array can focus at multiple and variable depths. It also
provides excellent resolution in the superficial field of view.
Fig. 1.8 Longitudinal view of the right kidney (RK) and liver (L) obtained with a trapezoidal array. The format is a sector with a flat apex.
as scanning with a single-element transducer (Fig. 1.5). With TWO-DIMENSIONAL ARRAYS

early linear arrays, each sound pulse traveled in the same The array transducers described previously allow for vari-
direction (parallel) and was oriented perpendicular to the able depth and electronically controlled focusing of the
transducer surface, resulting in a rectangular image (Fig. sound beam in the plane of the image but not in the direc-
1.6A). Currently, beam steering is available with most lin- tion perpendicular to the plane of imaging. The net effect of
ear array transducers so that a trapezoidal format is also
available (Fig. 1.6B). The major advantages of linear array
transducers are high resolution in the near field and a large
superficial field of view. Focusing is more uniform in the
center and periphery of the image because there is little or
no beam steering. The major disadvantages of linear arrays A
are their limited deep field of view and their large size,
which limits their use in areas where access is limited, such
as in intercostal scanning.
The disadvantages of the linear array transducers can
be minimized by steering the sound pulses so that they
diverge from each other. The two types of probes that
diverge sound pulses are the vector and curved linear
arrays. Both transducers produce images with sector dis-
play formats and large superficial fields of view. The vector
or trapezoidal array transducers can be thought of as small
linear arrays that operate only in the trapezoidal format
(Fig. 1.7). They produce a sector-like image format with a
flat apex (Fig. 1.8) in contradistinction to the pointed apex B
of the sector transducer. The curved linear array trans- Curved array viewed from the side. A: Operation is similar
ducer (also known as the curved array, convex array, and Fig. 1.9
to the linear array shown in Figure 1.7. B: The image format
curvilinear array) (Fig. 1.9) produces an image with a con- is a sector. Due to the curved surface of the transducer, the apex of the
vex instead of a flat apex (Fig. 1.10). sector is curved.
Fig. 1.10 Longitudinal view of the right kidney (RK) and the liver (L) obtained with a curved array transducer.
conventional in-plane focusing is on lateral resolution in controlled electronically, allowing for integration of color
the plane of imaging. Focusing the beam in the out-of-plane Doppler techniques and other time-consuming techniques.
direction (also called the elevation plane) affects the out-of-
plane resolution, which is identical to the slice thickness. THREE-DIMENSIONAL VOLUME PROBES
With the conventional array transducers, the slice thickness As the name suggests, three-dimensional volume probes
is fixed and cannot be varied by the operator (Fig. 1.11). are dedicated 3D ultrasound transducers that are capable
A solution to variable focusing in the elevation plane is of volume acquisition. They are bulky in size and house a
the matrix or two-dimensional array (Fig. 1.12). These 2D array transducer in a casing. The 2D array transducer
probes have crystal elements that are stacked in columns as is surrounded by a coupling gel and is driven by a motor
well as rows. They allow for variable slice thickness that is as it sweeps through a preselected volume angle. Added to
Focusing of standard array transducers. A: Illustration of

Fig. 1.11
one individual composite sound pulse generated by firing
three adjacent elements of a linear array transducer. B: The slice
thickness is least in the middle of the pulse due to the curvature of the
elements. This is fixed and cannot be controlled by the operator. The
in-plane focusing is least in the middle of the pulse due to the elec-
A B tronic focusing. This is variable.
B
Comparison of conventional array and two-dimensional array. A: Conventional dual scans of the radial artery (cursors) in transverse
Fig. 1.12
and longitudinal plane obtained with an operating frequency of 9 MHz. Notice that the artery appears relatively anechoic on the trans-
verse image because in this plane, volume-averaging effects are not an issue. However, in the longitudinal plane, the slice thickness is greater than
the lumen of the vessel and volume-averaging effects with the adjacent soft tissues produce significant echoes within the lumen. B: Two-dimensional
array scans obtained with an operating frequency of 9 MHz. Because the slice thickness can be better controlled and reduced with this type of
transducer, the luminal diameter no longer exceeds the thickness of the slice and this eliminates the volume averaging in the longitudinal plane.
the motor is a magnetic sensing device that coordinates the

slices of acquisition with their relative position to each
other. This allows an acquisition of volume by maintaining
the geometric relationships. Maintaining geometric accu-
Coupling racy is important for spatial orientation and measurements
fluid when the information is viewed in multiplanar format or
as a volume (Fig. 1.13).
2D Array Transducer Selection
The selection of a transducer for a given application is
dependent on the distance of the object of interest from the
transducer. In general, the highest-frequency transducer
Gear for that permits penetration of sound to the target organ
moving
Case array should be used. Frequencies of 5.0 or occasionally 3.5
MHz are usually required for evaluation of deeper struc-
tures in the abdomen or pelvis. In obese children and ado-
lescents, frequencies as low as 2.0 MHz may be necessary.
For evaluation of superficial structures, 7.5- to 13.0-MHz
transducers are usually used.
Position
INTRACAVITARY PROBES
Motor sensing Recently, transducers have been designed that can be
device placed within various body lumens. These transducers
can be positioned close to the organ of interest, and thus,
higher frequencies can be used and higher-resolution
images can be obtained. The ability to image organs
without having to transmit the sound beam through the
abdominal wall and intra-abdominal tissues helps to
minimize the image-degrading properties of adipose
Cable tissue. The overall result is that the images are of much
higher quality than those obtained with a standard trans-
abdominal approach. The two most common intralumi-
Three-dimensional transducer. Illustration shows the nal probes are the transrectal and transvaginal transduc-
Fig. 1.13
basic design of a volume transducer. Inside the outer cas-
ers (Fig. 1.14). These are currently used in adults to
ing is a two-dimensional transducer that sweeps through a predefined
angle to acquire a volume. The magnetic sensor is incorporated inside
the probe’s outer case.
A B
Hemorrhagic ovarian cyst demonstrated with a 3.5-MHz transducer from a transabdominal approach (A) and a 7.5-MHz transvaginal
Fig. 1.14
approach (B). A nonspecific ovarian cyst is seen on the transabdominal scan. The improved resolution on the transvaginal scan demon-
strates lacy fibrinous intraluminal membranes typical of hemorrhagic cysts.
image the prostate and female pelvic organs, respectively. conventional sound waves are generated at the surface of the
The endovaginal transducer has some applications in transducer and progressively decrease in intensity as they
adolescent girls (see Chapter 13). The rectal transducer travel through the body. The same frequency that is transmit-
has no widespread use in children. ted into the patient is subsequently received to create the
sonographic image. Although many harmonic frequencies are
ENDOSCOPIC PROBES generated with propagation of the initial wave, the current
Very small transducers have been added to flexible endo- technology uses only the second harmonic, which is twice the
scopes to evaluate pathology in both the upper and lower gas- transmitted frequency, for harmonic imaging. A filter is used
trointestinal tract in adults. In the upper gastrointestinal tract, to remove the original transmitted frequency so that only the
these transducers can aid in evaluating esophageal and returning high-frequency harmonic signal is processed to pro-
periesophageal abnormalities, gastric wall lesions, and peri- duce an image (9–15).
gastric organs. In the lower gastrointestinal tract, these endo- Experimental studies have shown that harmonic beams
scopic probes have been used to evaluate colonic carcinomas are narrower than the transmitted beam and have fewer
and other mucosal and submucosal lesions. These transduc- side-lobe artifacts. Side-lobe artifacts are artifactual echoes
ers have not had widespread applications in children. that are especially noticeable in fluid-filled structures. The
reduced width of the beam improves lateral resolution and
INTRA-ARTERIAL PROBES the reduction in artifacts improves the signal-to-noise
Intra-arterial probes are the most recent addition to the ratio. The increased lateral resolution improves the resolu-
armamentarium of intraluminal sonographic devices. They tion of small objects. The higher signal-to-noise ratio
have been used in adults to evaluate a variety of abnor- results in images where the tissues appear brighter and cav-
malities of the arterial wall. ities appear darker (Fig. 1.15) (9,12,14). Furthermore,
because harmonic signals are produced after the beam
enters the tissues of the body, the defocusing effects of body
HARMONIC IMAGING wall fat are minimized. Results of clinical series have shown
Tissue harmonic sonography is based on the principle of non- that harmonic imaging can improve resolution of lesions
linear distortion of the fundamental sound signal as it travels containing calcification (i.e., ureteral stones), fat, and air (9,
through body tissues. Harmonic wave frequencies are higher- 12). Harmonic imaging is particularly valuable in improv-
integer multiples of the fundamental or transmitted sound fre- ing lesion visibility in obese patients.
quency. They are produced by propagation of the sound wave Harmonic imaging also appears to have several theoret-
within tissues and progressively increase in intensity before ical advantages over conventional contrast-enhanced
eventually decreasing because of attenuation. By comparison, Doppler sonography in the evaluation of tissue blood flow.
A B
Harmonic ultrasound. A: Conventional scan of the liver obtained at a fundamental frequency of 3.4 MHz. A lesion is seen (cursors), but
Fig. 1.15
diffuse internal echoes make it impossible to diagnose a cyst with confidence. B: Harmonic scan of the same lesion obtained with a
transmit frequency of 1.9 MHz and a harmonic signal of 3.8 MHz. The lesion now appears anechoic and the diagnosis of a simple cyst can be made
with confidence.
By receiving the second harmonic frequency, backscatter spatial relationships and sizes in ultrasound must often
from contrast agents is much greater than that from tissue. be synthesized in the mind of the sonologist from multi-
In addition, flash artifacts are eliminated, shadowing arti- ple real-time images that display only portions of the rel-
facts are minimized, and both spatial and temporal resolu- evant anatomy. It is often difficult to illustrate pertinent
tions are improved (16–20). Experimental studies have sug- findings and relevant anatomy to clinicians when using
gested that contrast-enhanced harmonic imaging may help high-frequency probes.
in detection of early acute urinary obstruction and focal Image registration–based position-sensing techniques
renal perfusion defects, such as those associated with can now extend the sonographic field of view. The
pyelonephritis or infarction (20,21). extended field-of-view (EFOV) technology generates
panoramic images with no loss in resolution and without
an external position sensor (Fig. 1.16). The technology
EXTENDED FIELD-OF-VIEW IMAGING uses an echo-tracking–based technique for estimating
Compared to other imaging techniques such as CT and probe motion that is applicable to all conventional real-
MRI, sonography has the advantages of being less time transducers (22,23). Geometric measurement accu-
expensive, having real-time capabilities, and being non- racy up to a 60-cm scan distance has been verified in phan-
invasive. On the other hand, anatomic spatial relation- toms (24). Small-scale tissue motion and off-plane probe
ships and lesion size are readily appreciated using tech- motion do not compromise accuracy.
niques with large fields of view such as CT or MRI. One
disadvantage of ultrasound is its limited field of view.
This is especially true with the high-resolution linear REAL-TIME COMPOUNDING
array transducer, which has a limited field of view due to With conventional linear array imaging, the sound beams
the small footprint of the transducer. Thus, anatomic are steered straight down. With real-time compounding,
B
Extended field-of-view scans. A: Conventional longitudinal scan of the right lower quadrant shows a complex fluid collection (FC).
Fig. 1.16
B: Extended field-of-view scan shows the relationship of the fluid collection (FC) and the right kidney (K).
B
Real-time compounding. A: Conventional scan of the rotator cuff. B: Scan obtained with real-time compounding produces a smoother
Fig. 1.17
image with better display of tissue interfaces and superior display of the fibrillar architecture of the cuff (arrow).
the sound is steered at multiple angles, as well as straight THREE-DIMENSIONAL ULTRASOUND IMAGING
down, and the resulting frames are averaged together. Most recently, 3D sonography has been developed (22,
Weak reflectors such as fluid will produce a minimal signal 25–28). The potential of this application is a virtually
from all directions. Intermediate reflectors may produce a unlimited viewing perspective, which should allow more
small signal from some angles but a larger signal from accurate evaluation of anatomic structures and disease
other angles. Strong reflectors will produce a large signal entities and more accurate volumetric measurements than
from many angles. When the signals resulting from the dif- can be obtained from conventional 2D sonography. Data
ferent sound angles are averaged together, the result is to for 3D sonography are acquired as a stack of parallel
accentuate high-level reflectors and de-emphasize weak cross sections with the use of a 2D sector scanner or as a
reflectors. The net result is an improvement in image qual- volume with the use of a mechanical or an electronic array
ity (Fig. 1.17). In addition, since noise varies randomly probe. The resultant 3D images can be displayed with a
from frame to frame, the frame averaging reduces image variety of formats, including multiplanar reformatting
noise. It is important to realize that as frame averaging and surface rendering (Fig. 1.18). Virtual endoscopy (fly-
increases, it takes longer to generate an individual frame, through) using perspective volume rendering also is possi-
so structures that move rapidly, such as the heart, may be ble (29). Attention has been most focused on gray scale,
blurred. but 3D imaging is also possible in the color and power
B
Multiplanar display of information in a three-dimensional scan. A: Three orthogonal views of a gallbladder with calculi (arrows). Bot-
Fig. 1.18
tom right image shows an additional surface-rendered view of the gallbladder calculus. B: Like computed tomography multiple axial
images are displayed of a lesion in the liver and its relationship to the diaphragm, inferior vena cava, and hepatic vein. The top left image is a ref-
erence image in sagittal plane.
Power Doppler three-dimensional view of renal parenchy-

Fig. 1.19
mal vessels as an indication of good perfusion in a trans-
plant kidney in the right lower quadrant. The adjacent iliac vessels are
labeled.
Doppler mode (Fig. 1.19). Clinical applications so far have

been primarily in adults and have concentrated on evalua-
tion of fetal anatomy, although the gynecologic structures,
prostate, kidneys, urinary bladder, heart, and carotid arter-
ies have also been investigated. Three-dimensional ultra-
sound can provide a different perspective to a pathology
and, especially in pediatrics, the small size of the abdomen
can allow for large multiplanar reconstructions that show
spatial relationships better than 2D imaging alone (Fig.
1.20). Although 3D imaging is gaining popularity as a clin-
ical tool, further technical developments, particularly faster
B
data acquisition and reconstruction, will be needed before
this technology becomes practical for widespread use. Three-dimensional scan of renal mass. A: Two-dimen-
Fig. 1.20
sional scan shows a large renal mass (nephroblastoma).
B: Three-dimensional coronal plane rendering shows the spatial rela-
DOPPLER SONOGRAPHY tionship of the mass with the liver and invasion of the renal vein and
The ultrasound signals reflected back to the transducer inferior vena cava (arrows). The curved white line at the top of the liver
contain amplitude, frequency, and phase information. represents the diaphragm in coronal plane.
Real-time two-dimensional images use only the amplitude
of the returning echoes to generate gray-scale information.
An analysis of the frequency of the returning echo can also target (blood flow velocity), c the speed of sound in soft
yield important information. Sound that reflects off a mov- tissue, and the angle between the direction of blood
ing target undergoes a change in frequency as it returns to flow and sound beam. The faster the object is moving, the
the transducer. This is the Doppler effect. Objects moving greater the Doppler shift (30,31).
toward the transducer reflect sound at a higher frequency An accurate estimate of target velocity requires precise
than that of the incident beam. Objects moving away measurement of both the Doppler frequency shift and the
reflect sound at a lower frequency. The difference between angle of insonation relative to the vessel of interest. At an
the transmitted and received frequency is called the angle of insonation of 90 degrees, there is no flow toward
Doppler frequency shift. The magnitude of the Doppler or away from the transducer and, hence, no detectable
frequency shift is determined by the equation: Fd 2 Ft Doppler frequency shift. At an angle of 60 degrees, the fre-
(V/c) cos , where Fd the Doppler frequency shift, Ft quency shift is approximately 50% of that detected at an
the transmitted frequency, V the speed of the moving angle of 0 degrees. The use of Doppler angles less than
60 degrees is recommended for making velocity measure- ducer is displayed above a reference line; the Doppler shift
ments (4). from objects moving away from the transducer is depicted
below the line.
Continuous-wave Doppler The major disadvantage of pulsed Doppler sonography
A number of transducer designs have evolved to take is that only a single point in the vessel can be sampled at
advantage of the Doppler principle. The earliest and sim- one time. The evaluation of an entire vessel can be time
plest Doppler instrumentation transmits a continuous consuming and require a great deal of perseverance. In
wave rather than a pulsed wave. This device consists of addition, pulsed Doppler relies on the gray-scale image to
one crystal, which continuously transmits sound, and a identify a vessel for interrogation. Therefore, analysis of
second crystal, which continuously receives the returning vessels in small organs, such as the testes, can be extremely
echoes. Continuous-wave Doppler ultrasonography is able difficult because the vessels are too small to be resolved
to determine the direction of blood flow. Its major disad- with gray-scale imaging.
vantage is that it cannot determine the exact source of the
Doppler signal because motion coming from any depth Color Doppler
along the sound beam produces a signal. Color Doppler ultrasonography represents an improvement
over duplex Doppler sonography because it is sensitive to
Pulsed Doppler Doppler signals throughout the field of view. It provides
Pulsed Doppler ultrasonography has largely replaced con- both a real-time gray-scale image of tissue morphology and
tinuous-wave Doppler sonography. The pulsed Doppler an image displaying blood flow in color. Color Doppler
device transmits short pulses of sound and then listens for ultrasonography analyzes the phase information, fre-
the returning echo. Because the speed of the sound is con- quency, and amplitude of the returning echoes. Signals
stant, the delay in the time between the transmission and from moving red blood cells are assigned a color based on
reception is proportional to the distance. By varying the the direction of the phase shift (i.e., the direction of blood
delay time between the transmission and reception of the flow toward or away from the transducer) and a shade. By
sound wave, it is possible to determine the source (i.e., convention, movement toward the transducer is recorded
depth) from which the Doppler signal arises. The standard in red and movement away from the transducer in blue
gray-scale image is used to visualize the vessels of interest (Fig. 1.22A). The shade or degree of saturation of the color
and to position the Doppler sample volume at selected is displayed as a function of the relative velocity of the mov-
points within the vessel. This combination of gray-scale ing red cells. Rapid movement, which produces a high-
sonography with pulsed Doppler sonography is called frequency shift, is assigned a lighter color, approaching
duplex Doppler sonography (Fig. 1.21). By convention, white. Slower flow produces a lower-frequency shift and is
the Doppler shift from objects moving toward the trans- assigned a darker color. Stationary objects produce no
Duplex Doppler scan of the right kidney showing the sample volume in the renal sinus and a corresponding renal venous waveform
Fig. 1.21
beneath the image. Venous flow is away from the transducer and is therefore recorded below the baseline.
A B
Color and power Doppler imaging of the common carotid and jugular vein. The Doppler pulse is steered from the left to the right (thick
Fig. 1.22
white arrow). A: Color Doppler view. Flow in the common carotid is directed from the right to the left (thin white arrow), which is toward
the Doppler pulse. This produces a positive frequency shift and is therefore displayed as red. Flow in the jugular vein (thin black arrow) is in the
opposite direction producing a negative frequency shift and a blue color display. B: Power Doppler view shows flow in the vessels but does not dif-
ferentiate the direction of flow.
phase shift and, therefore, are assigned a gray-scale value, of this technique is that it is less dependent on the angle of
as in conventional gray-scale imaging. incidence. As the angle of incidence changes, the total
The major advantage of color Doppler sonography over energy is not affected in power Doppler imaging, and hence,
pulsed Doppler sonography is that the entire vessel or large flow can be seen in vessels that travel at right angles to the
parts of the vessel can be displayed. This display format is ultrasound beam. Conventional color flow Doppler is
ideal for showing small areas of turbulence or stenosis that dependent on the vessel beam angle and as the Doppler shift
may not be seen by duplex Doppler imaging. Color flow frequency nears zero, flow becomes less apparent.
Doppler also allows visualization of vessels in small organs Power Doppler sonography is also slightly more sensi-
that may not be detectable on conventional gray-scale images. tive to low-flow signal. In the power Doppler display, low-
The limitations of color flow Doppler imaging include angle level noise is assigned to a homogeneous background even
dependence, aliasing, and insensitivity to low-flow signal. when the gain is increased greatly. This results in an
increase in the usable dynamic range of the scanner, which
Power Mode Doppler allows for the use of higher gain settings. The result is a
An alternative to frequency-based color flow Doppler imag- minimal increase in the sensitivity to blood flow. In con-
ing is power Doppler imaging, which estimates the inte- ventional color flow Doppler, noise appears over the entire
grated power or strength of the Doppler signal rather than Doppler frequency shift, which means that gain settings
estimating the mean frequency shift, which is the parameter must be limited in order to reduce excessive noise. If the
typically encoded in color in standard color Doppler imag- gain is too high, flow signal is obscured by a background
ing (32–35). The power of the Doppler signal is related to of random noise.
the number of red blood cells producing the Doppler fre- Power Doppler sonography has significant limita-
quency shift. The Doppler detection sequence used in power tions. Perhaps the most significant limitation is that
Doppler sonography is identical to that employed in fre- power Doppler gives no information about direction of
quency-based color Doppler imaging. However, once the blood flow. Another important limitation is that it is
Doppler shift has been detected, the frequency components more susceptible to flash artifact, which are zones of
are removed through integration. Because all the frequency intense color that result from motion of soft tissues, such
data are removed, power Doppler sonography provides no as that resulting from respiration, and motion of the
information about velocity. In power Doppler imaging, the transducer. An important artifact present on color
hue and brightness of the color signal represent the total Doppler images is called aliasing (see Chapter 2). This
energy of the Doppler signal (Fig. 1.22B). artifact is very useful in localizing areas of high-flow
Power Doppler imaging has several theoretical advan- velocity and is not demonstrated on power Doppler. Addi-
tages over color Doppler imaging (32–35). One advantage tionally, power Doppler sonography does not measure the
speed of blood flow (i.e., tissue perfusion), but rather oscillation, and pulsed oscillation excitation. Ultrasound
depicts an estimate of fractional moving blood volume. extricates the data related to elasticity from the reflected
True perfusion is time dependent and requires an estimate waves. Essentially, the longitudinal (axial and lateral) strains
of how rapidly a volume of blood moves through tissue are estimated from the ultrasound signals (47,48).
(i.e., frequency) (34). Finally, flow that is too slow to pro- Malignant lesions are often regarded as causing changes
duce a Doppler shift (i.e., capillary flow) is not detectable in mechanical properties of a tissue, and thus, a large com-
by power Doppler imaging, nor is it detectable by the ponent of ultrasound elastography effort has been devoted to
standard color imaging techniques. However, it is possible trying to differentiate between benign and malignant lesions
that with contrast agents, such extremely slow flow may (49–51). Generally speaking, lesions that are malignant are
be detectable by power Doppler imaging (21). stiffer than benign lesions in their elastography characteris-
Because of these limitations and only marginal and tics. The elastography data obtained can be superimposed on
often imperceptible increases in flow sensitivity, power the gray-scale image and a real-time simultaneous visualiza-
Doppler has remained an ancillary mode, with color tion of the 2D image and the elastography image is obtained.
Doppler being the primary flow imaging technique. Never- Alternatively, the elastography image can be color coded
theless, power Doppler sonography has proven useful in with different colors representing different levels of stiffness
clinical practice. It has been shown to be effective in (Fig. 1.23). By convention, red color represents hard or stiff
depicting normal vasculature in the kidney, brain, and areas, while green or purple represents the less stiff or softer
testes and in detecting abnormalities that alter perfusion, areas of the lesion. Early studies have looked at breast and
such as ischemia, inflammation, and tumor (36–43). thyroid lesions with varying success. The initial clinical
results suggest that this is a theoretically promising new
method for differentiation of benign and malignant lesions.
ELASTOGRAPHY
Different ultrasound methods have been used over the years
to document relationships in terms of tissue elasticity CONTRAST AGENTS
between normal organs and pathologic lesions (44–46). The concept of using an ultrasound contrast agent to
Elastography is a method of estimating the difference enhance blood pool signals was first described by Gramiak
between the stiffness, or elasticity, of normal and abnormal and Shah in 1968 (52). These investigators injected saline
tissues using ultrasound. Compressibility parameters of tis- into the left atrium during cardiac catheterization. The
sues are evaluated by subjecting them to external pressure saline produced visible echoes on echocardiographic
using an ultrasound transducer. These changes of tissue dis- recordings in the normally anechoic lumen of the aorta
placement or degree of distortion secondary to external and the chambers of the heart. Further investigation
pressure are recorded using a high-frequency transducer and showed that backscattered echoes were the result of free
differentiated according to static compression, dynamic air bubbles that came out of solution during the injection
A B
Elastography scan of a thyroid nodule. A: Representative gray-scale image of a hypoechoic indeterminate nodule. B: Color depiction of
Fig. 1.23
the strain results. Correlation with the color scale on the right of the image shows the periphery of the nodule (arrows), which has a red
hue and constitutes the stiffer or harder (nonelastic) component of the nodule. The central portion of the nodule, which has a green hue, constitutes
the softer central component. Overall, this nodule is stiffer than the rest of the thyroid gland, which theoretically increases the risk of malignancy.
itself. The limitation of free bubbles is that they are large, 6. Wells PNT. Ultrasound imaging. Phys Med Biol 2006;51:
so they are filtered by the lungs, and they are unstable, R83–R98.
7. Ziskin MC. Fundamental physics of ultrasound and its propa-
going back into solution within several seconds. Hence, gation in tissue. Radiographics 1993;13:705–709.
free bubbles, while suitable for imaging the right cardiac 8. Kremkau FW. Multiple-element transducers. Radiographics
chambers, are not effective for imaging left-sided chambers 1993;13:1163–1176.
or abdominal vessels or organs (53). 9. Choudhry S, Gorman B, Charboneau JW, et al. Comparison of
Subsequent investigations have attempted to create tissue harmonic imaging with conventional US in abdominal
disease. Radiographics 2000;20:1127–1135.
more stable blood pool particles by encapsulating the air 10. Desser TS, Jeffrey BR. Tissue harmonic imaging techniques:
bubbles in a shell (54). Several such agents have been com- physical principles and clinical applications. Semin Ultrasound
bined with albumin and with galactose (55–57). Experi- CT MR 2001;22:1–10.
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Med Biol 1997;6:345–357.
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16. Burns PN. Harmonic imaging with ultrasound contrast agents.
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CHAPTER
Ultrasound Artifacts
WILLIAM D. MIDDLETON, MARILYN J. SIEGEL, AND NIRVIKAR DAHIYA
2
Gray-Scale Artifacts Slice-thickness Artifacts Three-dimensional Ultrasound Artifacts
Mirror-image Artifacts Anisotropy
Ultrasound Contrast Agents: Artifacts
Refraction Artifacts
Doppler Artifacts Blooming artifact
Reverberation Artifacts
Technically Related Doppler Artifacts Systolic Peak Velocity Increase
Ring-down Artifacts
Anatomically Related Doppler Artifacts High-intensity Transient Signals
Side-lobe Artifacts
Tissue Vibration Artifacts
Shadowing
Twinkle Artifact
Increased Through-transmission
he basis of all diagnostic sonograms is the detection large, smooth gas–soft tissue interfaces, such as the lung.
T and display of acoustic energy reflected from interfaces

within the body. The scanning technique and a number
of physical principles determine the quality of the resultant
Therefore, mirror-image artifacts are especially common
on sonograms of the right upper quadrant that include an
interface between the lung and adjacent soft tissues. The
images. The most basic principle is that sound travels in a mechanism of production of mirror-image artifacts is
straight line and at a constant speed. Therefore, the origin shown in Figure 2.1.
of a returning echo can be determined by converting the There are three well-recognized mirror-image artifacts
time taken for the echo to return to the transducer into a on sonograms of the right upper quadrant where the lung
distance based on the speed of sound in soft tissues. serves as a mirror. One of these artifacts is duplication of
Another principle is that individual reflectors generate only the liver, which produces supradiaphragmatic echogenicity
a single echo. Finally, as with any cross-sectional imaging similar to hepatic parenchyma. A second mirror image is
method, thickness of the slice is assumed to be infinitely duplication of the diaphragm (Fig. 2.2). A third mirror
thin. In the majority of instances, these principles hold true image is duplication of focal hepatic lesions that have an
and the sonogram is an accurate reproduction of the struc- echogenicity different from that of the normal hepatic
tures that are imaged. This chapter will describe those cir- parenchyma (Fig. 2.3). Because the diaphragm is curved,
cumstances in which violations of these principles result in the mirror image may not be an exact reproduction of the
an inaccurate reproduction of an internal structure or actual lesion. In addition, the mirror image may arise from
object. Echoes that do not correspond in location or inten- lesions that are outside of the plane of the image. If the
sity to actual structures are termed imaging artifacts. sound pulse travels out of the imaging plane after reflect-
Because artifacts follow the same basic physical principles ing off of the lung, an apparently isolated supradiaphrag-
of image production discussed in Chapter 1, it may be dif- matic lesion may be displayed.
ficult to avoid them. Therefore, it is important to recog- The trachea is another structure with a large, smooth
nize them so that they are not mistaken for pathologic gas interface. It is therefore capable of acting as a mirror
conditions (1–4). on sonograms of the neck (Fig. 2.4). Mirror images also
may be created in the abdomen or pelvis adjacent to a
highly reflective interface, such as gas-filled bowel (Fig.
GRAY-SCALE ARTIFACTS 2.5). The mirror-image artifact may simulate thickened gut
Mirror-image Artifacts (5). Pseudothickened gut occurs when there is a large con-
Acoustic mirrors can be compared to optical mirrors. tiguous pocket of gas without discrete bubbles. Successive
Optical mirrors have smooth surfaces that reflect a large reflections from the one large bubble reach the transducer
amount of light, which causes a visual duplication of struc- at progressively later times and are therefore artifactually
tures on the other side of the mirror. Flat surfaces will pro- duplicated distal to their true locations (5). Changing the
duce a mirror image that is identical in size and shape to angle of insonation may eliminate the artifact.
the original object, whereas curved surfaces (like mirrors
at the carnival) will produce a distorted mirror image (1). Refraction Artifacts
Because gas reflects almost 100% of the sound that hits Sound beam refraction occurs when sound passes obliquely
it, gas is the best acoustic mirror in the body. This phe- through an interface between two tissues that transmit the
nomenon is particularly common in areas where there are sound at different speeds (Fig. 2.6). The result is that the
21
Mirror-image artifact generation. Sound reflects at the

Fig. 2.1
interface between the base of the lung and the diaphragm
and re-enters the liver. This reflected sound pulse interacts with struc-
tures in the liver and is subsequently reflected back to the
lung–diaphragm interface and then back to the transducer. Since the
sound is assumed to have traveled in a straight line, the structure in
the liver is duplicated above the diaphragm.
Mirror image of the diaphragm.

Fig. 2.2
Longitudinal view of the liver
shows the interface between the liver and
diaphragm (first line), the interface
between the diaphragm and lung (second
line), and the muscular tissue of the
diaphragm (d). The third line represents a
mirror image of the interface between the
liver and diaphragm. Also notice the simi-
lar echogenicity above and below the
diaphragm due to a mirror image of the
liver itself.
Mirror image of a hepatic hemangioma.

Fig. 2.3
Longitudinal view of the liver shows an
echogenic hemangioma (h) in the hepatic
parenchyma. This lesion has been duplicated in the
suprahepatic region (h). The solid arrows indicate the
path of the true sound beam. The dashed arrows indi-
cate the path of the assumed sound beam.
Mirror image caused by the trachea. Longitudinal view of

Fig. 2.4
the neck demonstrates duplication of multiple structures.
The gas in the trachea produces a reflecting surface (arrows) that acts
as a mirror to duplicate a nodule in the thyroid (N) and tracheal carti-
laginous rings (arrowheads).
A B
Mirror image of fluid-filled uterus. A: Transverse view of an obstructed left horn (L) of a duplicated uterus shows fluid in the endometrial
Fig. 2.5
cavity. Open arrows, nonobstructed right horn. B: Longitudinal view shows a mirror-image artifact of the uterus. In this case, gas in the
rectum (arrowheads) served as the mirror.
Sound beam refraction. When the ultrasonic wavefront

Fig. 2.6
passes obliquely from soft tissue into fat or fluid, refraction
occurs, causing the beam to be redirected.
23
Rectus muscle refraction artifact. Due to its shape and the

Fig. 2.7
fact that it is surrounded by fat, the rectus muscle acts as a
strong refractor of sound. Since sound is assumed to travel in a straight
line, echoes arising from the refracted sound will be incorrectly dis-
played along the straight scan path. The end result is a phantom-image
artifact, such as duplication of abdominal and pelvic structures. Solid
line, true path of sound; hatched line, assumed path of sound.
sound is bent relative to the incident beam. This phenom- deep structure by sound beam refraction from a superficial
enon is analogous to redirection of light by an optical lens. structure. Duplication artifacts commonly occur at the junc-
The magnitude of the refraction is proportional to the tion of the rectus abdominus muscle and adjacent abdomi-
difference in the speed of sound between the two tissues. nal wall fat, when the transducer is positioned in a trans-
In the human body, the speed of sound in soft tissues is verse plane of section over the midline (6,7) (Fig. 2.7). The
approximately 1540 meters/sec. The speed of sound in result is a duplication of deep abdominal and pelvic struc-
fluid is approximately 1480 meters/sec, and through fat tures. In the upper abdomen, this midline type of artifact
it is approximately 1450 meters/sec. Therefore, refrac- causes vessels, such as the superior mesenteric artery or vein
tion artifacts are most frequent between soft tissue and and azygos vein, to be duplicated (Fig. 2.8). In the pelvis, the
fat and to a lesser extent between soft tissue and fluid artifact can cause the uterus, gestational sacs, or intrauter-
interfaces. ine devices to appear duplicated. Duplication-type refrac-
There are two major types of refraction artifacts: a tion artifacts can also arise when the kidneys are scanned
duplication artifact and a shadowing artifact (1). The most because of the refraction of sound at the interface between
common type of refractive artifact involves duplication of a the spleen and liver and adjacent fat (Fig. 2.9) (8). In this
A B
Rectus muscle refraction artifact. A: Transverse view of the upper abdomen with the transducer positioned lateral to the midline shows
Fig. 2.8
the left lobe of the liver (L), aorta (A), vena cava (C), and a single azygous vein (arrow). B: With the transducer positioned in the midline,
rectus muscle refraction has resulted in duplication of the azygous vein (arrows).
Chapter 2 • U LT R A S O U N D A R T I F A C T S 25
A B
Renal duplication artifact. A: Longitudinal view of the liver (L) and the right kidney (K) shows a normal sonographic appearance and a
Fig. 2.9
measured renal length of 105 mm. B: With the transducer positioned more inferiorly, the inferior edge of the liver and perihepatic fat (F)
cause a refractive duplication of the upper pole cortex (arrows) and the superior central sinus fat (f). This duplication of upper pole structures has
also caused the renal length to be artifactually exaggerated to 114 mm.
case, the refraction error results in apparent duplication of by defocusing and loss of beam energy or intensity at the
the superior aspect of the kidney. Less often, the refraction edge of the fluid or cystic structure (Fig. 2.11) (1).
artifact simulates a suprarenal mass. Renal duplication arti-
fact occurs more frequently in the left kidney than in the Reverberation Artifacts
right kidney. Reverberation artifacts result when there is repetitive reflec-
Although refractive duplication artifacts are most tion of the returning sound signal (i.e., the sound bounces
prominent at soft tissue–fat interfaces, as mentioned previ- back and forth between two interfaces) (1–4). Most com-
ously, they can also occur between soft tissue–fluid inter- monly, sound reflects off of highly reflective acoustic inter-
faces (9,10). Duplication of the diaphragm is not uncom- faces in the near field and then returns to the transducer,
mon on sonograms of the right upper quadrant in patients where it is reflected back into the patient. That pulse inter-
with hepatic cysts (9) or ascites (Fig. 2.10). acts with the same near-field interfaces and is reflected back
The second type of refractive artifact typically occurs at to the transducer a second time (Fig. 2.12) or multiple times
the edge of a fluid collection and has the appearance of a (Fig. 2.13). This produces an additional echo or several sets
refractive shadow (1). The refractive shadowing is caused of echoes that are interpreted as arising from a structure
Diaphragmatic duplication artifact. Transverse view of the liver (L) shows perihepatic ascites (A). In this case, refraction between the
Fig. 2.10
liver and ascitic fluid has caused a refractive duplication of the diaphragm (arrows).
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

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Pediatric Sonography 4th Edition,

W from many people. As editor, it would not have been pos-

1 Physical Principles and Instrumentation . . . 1 11 Urinary Tract . . . . . . . . . . . . . . . . . . . . . 384

2 Ultrasound Artifacts . . . . . . . . . . . . . . . . 21 12 Adrenal Glands, Pancreas, and Other

16 Spinal Ultrasonography . . . . . . . . . . . . . . 647

Physical Principles and

Acoustics Real-Time Imaging Doppler Sonography

U playing normal and abnormal anatomy for many years.

Phased array viewed from the side. In this illustration, there

Focusing of array transducers. Sixteen-element phased

as scanning with a single-element transducer (Fig. 1.5). With TWO-DIMENSIONAL ARRAYS

Focusing of standard array transducers. A: Illustration of

the motor is a magnetic sensing device that coordinates the

Power Doppler three-dimensional view of renal parenchy-

Doppler mode (Fig. 1.19). Clinical applications so far have

T and display of acoustic energy reflected from interfaces

Mirror-image artifact generation. Sound reflects at the

Mirror image of the diaphragm.

Mirror image of a hepatic hemangioma.

Mirror image caused by the trachea. Longitudinal view of

Sound beam refraction. When the ultrasonic wavefront

Rectus muscle refraction artifact. Due to its shape and the

Newala, too, suffers from the distance of its water-supply—at least

The water-supply of New Newala is in the bottom of the valley,

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAKONDE LOCK AND KEY AT JUMBE CHAURO

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

Some consolation was afforded me by a brassfounder, whom I

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

LAST SMOOTHING BEFORE

FIRING THE BRUSH-PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

MANUFACTURE OF BARK-CLOTH AT NEWALA

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