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This book, previously entitled simply Sonography in
Obstetrics and Gynecology, is now entitled Fleischer’s
Sonography in Obstetrics and Gynecology, in honor of the
lead author, Arthur C. Fleischer, MD, whose brilliance,
intellect, and experience have spanned eight editions.
Arthur C. Fleischer was born in Miami, Florida in
1952. His parents were Lucille and Eugene. Lucille was
a lifelong learner and educator, graduating from Hunter
College in 1942 (when she was 17), obtaining a Master’s
in Education from the University of Miami in 1951, and
graduating first in her class at the University of Miami
School of Law in 1958. Eugene attended the University of
Miami after military service, became a general contractor
in Miami, and was instrumental in starting a new Reform
Jewish congregation, Temple Beth Am in Kendall, Florida.
Art Fleischer’s grandparents were Hungarian immigrants
who came to New York City from Budapest in 1921. As
a child, Art was fortunate to excel at equestrian competi-
tions and was state champion from 11 to 18 years of age. At
Emory University, he completed his thesis on ultrasound
enhancement of treatments and received his BS degree,
magna cum laude, in biology in 1973. He met Lynn in 1974
through the introduction from a mutual medical school
friend, and they were married in 1975.
In 1976, he received the MD degree from the Medical
College of Georgia at Augusta, and in 1980, he complet-
ed the Radiology Residency/Fellowship at Vanderbilt
University Medical Center inNashville, Tennessee.
Dr. Fleischer began his medical career in 1974 as the
Acting Director of Diagnostic Ultrasound at the Medical
College of Georgia. He came to Vanderbilt University School
of Medicine in 1976 and has held the following positions:
Acting Director of Diagnostic Ultrasound; Clinical Fellow in
Ultrasound; Assistant Professor (Radiology and Obstetrics
and Gynecology); and Associate Professor (Radiology and
Obstetrics and Gynecology). Additionally, Dr. Fleischer was
Visiting Professor in Radiology (Diagnostic Ultrasound)
at Thomas Jefferson University Hospital. Presently, he is
Professor of Radiology and Radiological Sciences (1987);
Professor of Obstetrics and Gynecology (Secondary) (1987);
Medical Director of the Sonography Training Program
(1981); and Medical Director of Ultrasound.
Dr. Fleischer has been active in several specialty
societies, including the American Institute of Ultrasound
in Medicine (Board of Governors, Fellow), the American
College of Radiology (Fellow), the Society of Radiologists in
Ultrasound (Fellow), and the Society for the Advancement
of Women’s Imaging (Cofounder and President).
Professor Fleischer has authored more than 200
research papers regarding clinical aspects of diagnostic
ultrasound and 23 textbooks involving the use of diagnostic
sonography in obstetrics/gynecology. He has received numer-
Fleischer_FM_i-xxiv.indd 21
TRIBUTE
ous awards and honors, among them are the Larry Mack
Award for Best Research Paper by the Society of Radiologists
in Ultrasound in 1998, the William Fry Award for Outstanding
Contributions to Ultrasound by the American Institute
of Ultrasound in Medicine in 1999, the Frank H. Boehm
Award for Contribution to Continuing Medical Education
by Vanderbilt University School of Medicine in 2005, and the
Distinguished Alumnus Award from the Medical College of
Georgia in 2007. In 2011, Dr. Fleischer was honored with the
Cornelius Vanderbilt Chair in Radiology.
Art and Lynn have three children, Braden, Jared, and
Amy, and one grandson, Jakob. When asked about her
father, Amy had the following words:
The essence of Dr. Fleischer (our dad, or “Daddio,” as we
know him) is exemplified by an unconditional love of learn­
ing. Whether our family discussions took place at the dinner
table or at his favorite lunch spot (let’s be honest, most of
our chats involved food), he always exuded an enthusiasm
for learning.
In fact, the most valuable gift our dad gave us (besides
life itself!) is his infectious curiosity. His passion for new
technology is not only evidenced by the every-growing stack
of medical and academic publications he has authored
(during his 40-year career) but also by the abundant sea of
gadgets in his office! His thirst for innovative tools and tech­
nology is unquenchable, even when our mom threatens to
purge his “toys” in order to make a path through the house.
In amongst these toys, a plethora of textbooks, articles, pho­
tos, and old x-ray films make our home a monument to his
staggering medical career. To us, such tangible evidence—of
which this book is now a vital part—will always serve to
represent his most deeply held belief in the value of asking
good questions while seeking new understanding about the
world.
Amy Fleischer, MS, OTR/L, on behalf of Art’s
three children
Luis Gonçalves, MD, has the following observations:
There are moments in life when one wonders about how the
Universe conspires to align with perfection those people who
eventually become a permanent part of our path on Earth.
I would like to take this moment to acknowledge the oppor­
tunity of having Arthur Fleischer cross my path 24 years
ago at Vanderbilt University. Art has certainly inspired me
then and will continue to inspire those of us who have been
fortunate enough to have crossed his path and know first-
hand the enormity of the human being who teaches and
leads with a light heart.
08/09/17 5:18 pm
 Tribute xxii

Eugene C. Toy, MD, on behalf of the tens of thousands of knowledge, and so much zeal, and so much compassion
physicians, sonographers, residents and students who have can be in one person!” Dr. Fleischer has been one the cor­
been touched by Dr. Art Fleischer, has these words: nerstones in advancing imaging in women’s health over the
past 40 years, particularly in the areas of gynecologic ultra­
Art Fleischer has been a tremendous inspiration to everyone
sound. Not only has he propelled this embryologic science
around him. He has an amazing sense of humor, a consci­
into a maturing and exciting field in science and informa­
entiousness that goes far beyond the normal “call of duty,”
tion, he has also put his own personal heart and soul into
and a dedication to women’s health through imaging and
gynecologic sonography. I feel so fortunate to be able to call
the prevention and diagnosis of disease. Art is an amazing
Art Fleischer my friend, mentor, and inspiration. For the
educator, and I have sat in his conferences amazed at how
tens of thousands who use imaging to help treat women, and
much he is able to teach—from the anatomical structures,
the millions of women who are dependent on this modal­
to the imaging, to the disease. More than all of this, Art has
ity for their care, we pause a moment to give tribute to a
a tremendous love for people and cares so deeply about all
man who worked tirelessly in his significant contributions
of those who are fortunate enough to cross paths with him.
to the science and art of gynecologic sonography. For this
One physician who was in a medical school radiology rota­
reason, we have entitled this book, Fleischer’s Sonography
tion with Art summed it up: “I don’t know how so much
in Obstetrics and Gynecology.

Fleischer_FM_i-xxiv.indd 22 08/09/17 5:18 pm

 PART 1

GENERAL OBSTETRIC
SONOGRAPHY

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 2 Part 1 GENERAL OBSTETRIC SONOGRAPHY
Chapter 1
ULTRASOUND BIOEFFECTS AND SAFETY:
WHAT THE PRACTITIONER SHOULD KNOW
Jacques S. Abramowicz
Key Terms1
1. Acoustic streaming: movement of tissue or fluid,
resulting from the passage of alternating positive
and negative pressures of the ultrasound wave. Can
also result from movements of bubbles, as a result of
changes in pressure.
2. ALARA principle: stands for As Low As Reasonably
Achievable, a way to obtain the best, clinically rel-
evant image while keeping ultrasound intensity and
exposure as low as possible.
3. Cavitation: bubble activity, secondary to ultrasound
insonation. The positive aspect of the ultrasound
pressure wave causes compression of the bubble
while the negative part, also called rarefactional,
causes production of the bubbles or expansion of
existing ones. Cavitation can be stable or inertial.
• Stable cavitation: bubble activity where bubble
does not collapse (see inertial cavitation) but is
moving back and forth in the tissue or fluid, thus
potentially causing the surrounding medium to
flow (ie, stream, hence the term streaming).
• Inertial (previously known as transient) cavita-
tion: bubbles that are compressed and expanded
but with each compressing (positive) component,
causing the volume to diminish ever more, until
collapse occurs. This collapse can generate tre-
mendously elevated temperature and pressure
for an extremely short time and over an extremely
short space (called an adiabatic reaction). This can
result in production of several more bubbles, local
cell damage, and/or generation of free radicals.
4. Derating: action of multiplying a value measured in
water with standard methods by a correction factor
to account for the attenuation of the ultrasound field
by the tissue traversed by the beam (usually 0.3 dB/
cm/MHz).
5. Dwell time: the time during which the ultrasound
beam impinges on a specific organ, body part, or
entire organism.
6. Mechanical index (MI): expresses the potential for
nonthermal (also known as mechanical) effects in
tissues traversed by the ultrasound wave. Depends
on the pressure and the frequency ( = P/ f ).
Fleischer_CH01_p001-p024.indd 2
● Eyal Sheiner
7. Output Display Standard (ODS): actual name—
Standard for Real-Time Display of Thermal and
Mechanical Acoustic Indices on Diagnostic Ultra-
sound Equipment. Introduced to make end users
aware, in real time, of the potential effects of ultra-
sound in tissues. See also mechanical index and
thermal index.
8. Radiation force: force resulting from absorption of
some of the energy of the acoustic wave by tissue
and transformation into heat.
9. Scanned mode: refers to the ultrasound beam
moving through the field, with energy distributed
over a large volume, such as in B-mode and color-
flow Doppler.
10. Thermal index (TI): expresses the potential for
temperature increase in tissues traversed by the
ultrasound wave. It is given by the ratio of the power
emitted by the transducer to the ultrasonic power
required to raise tissue temperature by 1°C for the
specific exposure conditions. This is a relative indi-
cation and does not necessarily correspond to the
actual temperature increase. One of three thermal
indices is displayed, based on whether soft tissue
(TIS, mostly first and early second trimesters), bone
(TIB, late second and third trimesters), or adult cra-
nium (TIC) is being scanned.
11. Unscanned mode: the ultrasound beam is station-
ary with power concentrated along a single line,
such as in M-mode and spectral Doppler.
INTRODUCTION
“Is this safe for my baby?” Ultrasound practitioners hear
this question almost every day in clinical practice. The
answer generally given is: “Of course. Ultrasound is not
x-rays, it is not invasive; it has been used for close to sixty
years and is perfectly safe.” While this answer may, in fact,
contain some correct facts (ultrasound is not x-rays), the
concept of perfect safety is not scientifically valid, and
furthermore, the level of knowledge regarding poten-
tial effects of ultrasound in tissues is, by and large, very
low among end-users of this technology. Ultrasound in
obstetrics is convenient, painless, and results are available
immediately. The belief exists that is does not pose any risk
08/09/17 10:50 am
 Chapter 1 Ultrasound Bioeffects and Safety: What the Practitioner Should Know
to the pregnant patient or her fetus. Ultrasound, however,
is a form of energy and, as such, has effects in biological
tissues (bioeffects). The physical mechanisms responsible
for these effects are nonthermal (mechanical) or thermal.
The nonthermal mechanisms can further be separated
into acoustic cavitation (inertial and noninertial) and
noncavitational mechanisms, ie, acoustic radiation force
(time-averaged force exerted by the ultrasound beam),
acoustic radiation torque (producing in the insonated tis-
sue a tendency to rotate or spin), and acoustic streaming
(circulatory flow). It is the role of science to show whether
any of these bioeffects may be harmful. The question has
been debated since the introduction of ultrasound in clini-
cal obstetrics, particularly as it relates to the fetal nervous
system2,3 and continues to be discussed currently.4-9(1)
This chapter presents basic notions of acoustics and
physics as they relate to ultrasound, examines some
literature on bioeffects and the safety of ultrasound,
reviews statements of various ultrasound organizations,
and affords a practical approach to limit the potential risks
to the fetus of exposure to diagnostic ultrasound (DUS).
BASIC PHYSICS OF ULTRASOUND
A detailed description of ultrasound physics can be found
in various publications.10-12 However, certain properties of
ultrasound are very important when trying to understand
safety and bioeffects. Equally important are tissue charac-
teristics, such as attenuation coefficient. A basic knowl-
edge of instrument controls (“knobology”) is essential not
only for appropriate clinical usage, but it is imperative to
avoid potential harm.
The Ultrasound Wave
Sound is a mechanical vibratory form of energy. It propa-
gates through a medium by means of the motions of
the particles in the medium, under the influence of the
alternating positive and negative components of the wave.
Megapascal (MPa) is the unit for pressure. Ultrasound
instrumentation can generate peak pressures of 5 MPa
and above. This is in comparison to the atmospheric pres-
sure, which is 0.1 MPa. Several other characteristics define
the ultrasound beam. The ultrasonic wave progresses in
the insonated tissue at a velocity that is related to the
sound characteristics as well as the tissue properties. For
practical purposes, the average speed of sound propaga-
tion in biological tissues is estimated at 1540 ms/sec.
Frequency is the number of cycles per second, measured
in hertz (Hz). The limits of human hearing spans from
approximately 20 to 20,000 Hz. Diagnostic ultrasound is,
generally, 2 to 10 million Hz (megahertz, MHz). Wave-
length is the distance between 2 corresponding points
on a particular wave. It is inversely proportional to the
frequency. Equipment resolution (the shortest distance
between 2 objects or parts of an object to be represented
by 2 separate echoes) depends on the wavelength: axial
resolution ranges between 2 and 4 wavelengths. Hence,
the shorter the wavelength (ie, the higher the frequency),
the better the resolution (the distance between 2 points
is smaller). The trade-off is that the higher the frequency
Fleischer_CH01_p001-p024.indd 3
3
6
Resolution
Penetration
5
4
3
2
1
0
Figure 1-1. Resolution (solid line) and penetration (dotted line) as a
function of increasing frequency, represented by the x-axis. Units on the
y-axis are not actual but representative of increasing values. The green
arrow represents the goal of improving penetration at high frequencies.
(better resolution), the lower the penetration of the beam
through a given tissue (Figure 1-1).
Diagnostic ultrasound is pulsed, ie, pulses of acoustic
energy separated by “silent” gaps. The number of pulses
occurring in 1 second is the pulse repetition frequency
(PRF) and is controlled by the instrument in B-mode. In
Doppler mode, it can be altered by the end user. Another
important parameter is the duty factor: this is the fraction
of time that the pulsed ultrasound is on. With an increase
in PRF, the duty factor increases. The pulse amplitude
reflects pressure and is the maximum variation from the
baseline, expressed in MPa’s. Since the ultrasound wave is
sinusoidal, there are periods of positive and negative pres-
sure. When the ultrasound wave exerts pressure on the
resisting insonated tissue, work is produced. The ability of
the wave to do work is its energy (in joules). The rate at
which the energy is transformed from one form to another
is the power (in watts or milliwatts). Intensity represents
the rate at which energy passes through area unit. Average
intensity of a beam is expressed by the beam power (in
milliwatts, mW), divided by the cross-sectional area of the
beam (in cm2) and is, therefore, expressed in mW/cm2. As
stated earlier, DUS is performed with a pulsed wave. The
intensity is proportional to the square of the instantaneous
ultrasound wave pressure. There are pulses of energy
intermingled with periods where no energy is emitted.
Depending on the time and location of the measurement,
several parameters can be described in relation to time
or space: temporal peak intensity (the greatest intensity),
average intensity over time, ie, including “silent” time
between pulses (temporal-average intensity), maximal
intensity at a particular location (spatial-peak intensity),
as well as average-spatial intensity. By combining time
and space, 6 intensities can be described: spatial average–
temporal average (ISATA), spatial average–pulse average
08/09/17 10:50 am
 4 Part 1 GENERAL OBSTETRIC SONOGRAPHY
 VALUES OF ISPTA BY MODALITY
Table 1-1 AND YEAR OF DEFINITION
Modality/ 1976 1986
Application Values Values
Fetal imaging 46 94
Cardiac 430 430
Peripheral vessel 720 720
Ophthalmic 17 17
Note: All are derated values in mW/cm .
2
Data from Nyborg WL. Biological effects of ultrasound: development of safety
guidelines. Part II: general review. Ultrasound Med Biol. 2001;27:301-333;
Abramowicz JS. Prenatal exposure to ultrasound waves: is there a risk? Ultra-
sound Obstet Gynecol. 2007;29:363-367; Gressens P, Huppi PS. Are prenatal
ultrasounds safe for the developing brain? Pediatr Res. 2007;61:265-266.
(ISAPA), spatial average–temporal peak (ISATP), spatial peak–
temporal average (ISPTA), spatial peak–pulse average (ISPPA),
and spatial peak–temporal peak (ISPTP). The most practical,
and commonly referred to, is the ISPTA.
The maximal permitted value varies by clinical applica-
tion. This had been determined in 1976 by the US Food and
Drug Administration (FDA),13 but was modified in 1986.14
The most recent definition dates from 1992.15 These values
are shown in Table 1-1. One can observe from the table that,
for fetal imaging, the ISPTA has been allowed to increase by a
factor of almost 16-fold from 1976 and almost 8-fold from
1986 to 1992, yet, all epidemiological information available
regarding fetal effects predates 1992. A remarkable fact is
that intensity for ophthalmic examination has not changed
from the original 17 mW/cm2, a value approximately 42.5
times lower than the present allowed value for fetal scanning.
This will be addressed in more detail further in the chapter.
Tissue Characteristics
When the ultrasound wave travels through a medium, its
intensity diminishes with distance.16 In completely homo-
geneous, idealized materials, the signal amplitude would be
reduced only because the wave is spreading. Biologic tissues,
however, are different and induce further weakening by
absorption and scattering (an effect called attenuation) and
by reflection. Many models have been described to help cal-
culate attenuation, particularly in obstetrical scanning,17 but
the most commonly used model uses an average attenuation
of 0.3 dB/cm/MHz.18 It is important to note that the attenu-
ation increases logarithmically with frequency and distance
traveled. Technically, many measurements of acoustic power
are performed in water, which has almost no attenuation.
To apply these calculations to tissues, values are multiplied
by this factor, an action called derating.19 Absorption is the
sound energy being converted to other forms of energy, and
scattering is the sound being reflected in directions other
than its original direction of propagation. Since attenua-
tion is proportional to the square of sound frequency, it
becomes evident why higher frequency transducers have less
penetration (but better resolution; see Figure 1-1). One needs,
therefore, to be closer to the organ of interest, such as through
Fleischer_CH01_p001-p024.indd 4
transesophageal or, in obstetrics and gynecology, transvaginal
scanning. Another possibility is increasing the power of the
instrument, resulting in improved resolution, as depicted by
the green arrow in Figure 1-1. This is seemingly simple, but
1992
instrument outputs are regulated in the United States (see
Values
The Output Display Standard section). Another important
720 parameter is acoustic impedance, which can be described
as the opposition to transmission or progression of the ultra-
720 sound wave. It is proportional to the velocity of sound in the
tissue (estimated at 1540 ms/sec) and to the tissue density.
720
17
Instrument Outputs
Although some publications of various instrument outputs
are available,20-22 these are generally quickly outdated, since
manufacturers introduce new commercial machines to the
market (or modify existing ones) at a rate too fast for imme-
diate objective evaluation. From a clinical standpoint, there is
no easy way to verify the actual output of the instrument in
use. In addition to the variety of instruments, each attached
transducer will generate a specific output, further compli-
cated by the different modes that may be applied.23 When
comparing modes, the ISPTA increases from B-mode (34 mW/
cm2, average) to M-mode to color Doppler to spectral Dop-
pler (1180 mW/cm2). Average values of the temporal aver-
aged intensity are 1 W/cm2 in Doppler mode but can reach 10
W/cm2.23 Therefore, caution should be exercised when apply-
ing Doppler mode, particularly in the first trimester. Color
Doppler, while having higher intensities than B-mode, is still
much lower than spectral Doppler. This is mainly due to the
mode of operation—sequences of pulses, scanned through
the region of interest (ROI or “box”). Most measurements are
obtained from manufacturers’ manuals, having been derived
in laboratory conditions. Real-life conditions may be differ-
ent.24 Furthermore, machine controls can alter the output. If
one keeps in mind that, for instance, the degree of tempera-
ture elevation is proportional to the product of the amplitude
of the sound wave by the pulse length and the PRF, it becomes
immediately evident why any change (augmentation) in these
properties can add to the risk of elevating the temperature, a
potential mechanism for bioeffects (see Thermal Effects). The
3 important parameters under end-user control are the scan-
ning (or operating) mode, including transducer choice; the
system setup and output control; and the dwell time.
1. Scanning mode: as mentioned previously, B-mode
carries the lowest risk, and spectral Doppler carries the
highest (with M-mode and color Doppler in between).
High pulse repetition frequencies are used in pulsed
Doppler techniques, generating greater temporal aver-
age intensities and powers than B- or M-mode, and
hence greater heating potential. An additional risk is
that since, in spectral Doppler, the beam needs to be
held in relatively constant position over the vessel of
interest, there may be a further increase in temporal
average intensity. Naturally, transducer choice is of
great consequence since it will determine frequency,
penetration, resolution, and field of view.
2. System setup: starting or default output power and,
particularly, mode (B-mode, Doppler, etc) control
changes. A subtler element is fine tuning performed
08/09/17 10:50 am
 Chapter 1 Ultrasound Bioeffects and Safety: What the Practitioner Should Know 5

by the examiner to optimize the image and influence

output but with no visible effect (except if one follows
thermal index [TI] and/or mechanical index [MI] dis-
plays). Controls that regularize output include focal
depth (usually with greatest power at deeper focus but
occasionally, on some machines, with highest power
in the near field); increasing frame rate; and limit-
ing the field of view, for instance, by high-resolution
magnification or certain zooms (Figure 1-2).
3. In Doppler mode, changing sample volume and/or
velocity range (all done to optimize received signals)
changes output. Video Clip 1 demonstrates change in
output (as observable by change in TI) when changing
the focal distance. A very important control in every
mode is receiver gain. It often has similar effects to
the above controls on the recorded image but none
on the output of the outgoing beam, and is therefore
completely safe to manipulate (Figure 1-3). In other A
words, the receiver gain should be maximized before
output is increased. In addition, over the years, output
of instruments has increased.22, 25

C
Figure 1-3. A: Image obtained with 100% power (blue arrow). Note
MI = 1.2 and TI + 0.1 (yellow arrow). B: Power has been reduced to 85%
B (blue arrow). Note MI = 0.7 and TI + 0.0 (yellow arrow). This image is less
diagnostic. C: Receiver gain has been increased. Power is unchanged from
Figure 1-2. Acoustic output changes (as reflected by changes in TI).
B (nor are MI and TI) but image is as diagnostic as A.
A: Nonzoomed image. Please note TI = 0.2. B: Zoomed image. Please
note TI = 1.0 (arrow).

Fleischer_CH01_p001-p024.indd 5 08/09/17 10:50 am

 6 Part 1 GENERAL OBSTETRIC SONOGRAPHY
4. Dwell time: is directly under the control of the exam-
iner. Interestingly, dwell time is not taken into account
in the calculation of the safety indices (thermal index,
TI and mechanical index, MI,) nor, in general, until
now, reported in clinical or experimental studies.
However, one needs to remember that it takes only
one pulse to induce cavitation, and about a minute
to raise temperature to its peak. Directly related with
dwell time is examiner experience: knowledge of
anatomy, bioeffects, instrument controls, and scanning
techniques. It can be safely assumed that the more
experienced the examiner, the less scanning time will
be needed to obtain the needed diagnostic images.
A standardized method of providing the end user
a parameter related to acoustic output and expressing
potential for bioeffects is clearly needed; hence, the gener-
ation of the Output Display Standard, based on the 2 most
likely interactions of ultrasound with tissues: thermal
and nonthermal or mechanical.26
THERMAL EFFECTS
Normal core human body temperature is generally accepted
to be 37°C (98.6°F) with a diurnal variation of ±0.5°C to 1.0°C,
although 36.8°C ± 0.4°C (95% confidence interval) may be
closer to the actual mean for large populations.27 During
the entire gestation, temperature of the human embryo/
fetus is higher than maternal core body temperature28 and
gradually rises until the final trimester (near term). The fetal
temperature generally exceeds that of the mother by 0.5°C.29
Thermally induced teratogenesis (production of congenital
malformations in an embryo or fetus) has been demon-
strated in many animal studies, as well as several controlled
human studies.30 While elevated maternal temperature in
early gestation has been associated with an increased inci-
dence of congenital anomalies,31 the majority of these studies
do not involve ultrasound-induced temperature elevation.
Edwards and others have demonstrated that hyperther-
mia is teratogenic for numerous animal species, including
humans,32 and suggested a 1.5°C temperature elevation
above the normal value as a universal threshold.33 Some
scientists believe that there are, indeed, temperature thresh-
olds for hyperthermia-induced birth defects, hence the As
Low As Reasonably Achievable (ALARA) principle. There
is, however, some evidence that any positive tempera-
ture differential for any period of time has some effect. In
other words, that there may be no thermal threshold for
hyperthermia-induced birth defects.34 From careful thermal
dose determinations, derived from published literature in
this area, it may be that hyperthermia-induced birth defects
are produced in accordance with an Arrhenius relation for
chemical rate effects, and thus have no threshold.35 Any tem-
perature increment for any period of time has some effect.
Likewise, the higher the temperature differential or the lon-
ger the temperature increment, the greater the likelihood of
producing an effect. Gestational age is a vital factor: milder
exposure during the preimplantation period can have similar
consequences to more severe exposures during embryonic
and fetal development and can result in prenatal death and
abortion or a wide range of structural and functional defects.
Fleischer_CH01_p001-p024.indd 6
The organ at greatest risk is the central nervous
system (CNS) due to a lack of compensatory growth of
damaged neuroblasts. In experimental animals the most
common defects are of the neural tube, microphthalmia,
cataract, and microencephaly, with associated functional
and behavioral problems.32 Defects of craniofacial develop-
ment including clefts,36 the axial and appendicular skeleton,37
the body wall, teeth, and heart38 are also commonly found.
Hyperthermia in utero (due to maternal influenza) has
been described as a risk factor for congenital anomalies39,40
and subsequent childhood psychological/behavioral distur-
bances41 and, more particularly, schizophrenia.42 Nearly all
these defects have been found in human epidemiological
studies following maternal fever or hyperthermia during
pregnancy. It should be emphasized that these investigations
have not involved ultrasound-induced hyperthermia effects.
Yet, there are data on the effects of hyperthermia and mea-
surements of in vivo temperature induced by pulsed ultra-
sound, but not in human beings.43-46 These data have been
widely reviewed.32,35,47-49 There is, however, a serious lack of
data that examine the effects of ultrasound while rigorously
excluding other confounding factors. Two widely accepted
facts are that ultrasound has the potential to elevate the
temperature of the tissues being scanned,50-53 and elevated
maternal temperature, whether from illness or exposure to
heat, can produce teratologic effects.31,32,35,54-56 The major
question is, therefore, whether DUS can induce a harmful
rise in temperature in the fetus.57-59 Some believe that this
temperature rise is, in fact, a major mechanism for ultrasound
bioeffects.30,35 Temperature elevation in the insonated tissue
can be calculated and estimated fairly accurately if the field is
sufficiently well characterized.60,61 For prolonged exposures,
temperature elevations of up to 5°C have been obtained.57
Temperature change in insonated tissues depends on the
balance between heat production and heat loss. A particular
tissue property that strongly influences the amount of heat
transported is local perfusion, which very clearly diminishes
the risk, if present. Similar experimental conditions caused
a 30% to 40% lower maximal temperature increase in live
versus dead sheep fetuses exposed in the near field,45 while
in guinea pig fetuses exposed at the focus the difference was
approximately 10%.46 These findings were estimated to be
secondary to vascular perfusion in live animals. A significant
cooling effect of vascular perfusion was observed only when
the guinea pig fetuses reached the stage of late gestation near
term, when the cerebral vessels were well developed. In the
midterm, there was no significant difference when guinea
pig fetal brains were exposed, alive (perfused) or postmortem
(nonperfused), in the focal region of the ultrasound beam.46
In early pregnancy, under 6 weeks gestation, there
appears to be minimal maternal-fetal circulation, that is,
minimal fetal perfusion, which may potentially reduce heat
dispersion.62 The lack of perfusion is one reason why the
spatial peak-temporal average intensity (ISPTA) for ophthal-
mic applications has been kept very low, in fact much lower
than peripheral, vascular, cardiovascular, and even obstetric
scanning, despite the general increase in acoustic power
that was allowed after 1992 (see Table 1-1). There are some
similarities in physical characteristics between the early,
first-trimester embryo and the eye. Neither is perfused; they
can be of similar size; and protein is present (in an increasing
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 Chapter 1 Ultrasound Bioeffects and Safety: What the Practitioner Should Know
Figure 1-4. First trimester (11 weeks) measurement of the crown-
rump length: the entire fetus is within the ultrasound beam (“whole body
scanning”).
proportion in the fetus). As mentioned previously, one must
then wonder why, from the time intensities were checked
and recommended in clinical practice, ISPTA was from the
beginning and has continued to be maintained at 17 mW/
cm2, while for fetal imaging it was allowed to reach 720
mW/cm2, up from 46 mW/cm2. At about weeks 4 to 5, the
gestational sac is about the size of the eye (2.5 cm in diam-
eter), and by week 8 it is around 8 cm in diameter. This may
allow whole-body fetal scanning (and possibly temperature
increase), a concept that is generally ignored in the literature
dealing with thermal effects of ultrasound (Figure 1-4).
The issue of transducer heating, which may be par-
ticularly relevant in the first trimester, specifically if per-
forming endovaginal scanning, is also often ignored.63,64
There are additional concerns in early gestation because
of minimal or lack of perfusion. Only at about weeks
10 to 11 does the embryonic circulation actually linkup
with the maternal circulation.65 There may thus be some
underestimation of the actual DUS-induced temperature
in early gestation, mainly because of the absence of perfu-
sion. The perfusion issue is in addition to modifications
of tissue temperature due to ambient maternal and fetal
temperatures. Furthermore, motions (even very small)
of the examiner’s hand as well as the patient’s breathing
and body movements (in the case of obstetric ultrasound,
both the mother and the fetus) tend to spread through
the region being heated. However, for spectral (pulsed)
Doppler studies, it is necessary to have the transducer as
steady as possible. This is because, in general, blood ves-
sels are small in comparison to the general organ or body
size being scanned with B-mode imaging, and hand move-
ments while performing Doppler studies will have more
undesired effects on the resulting image. As described
earlier, the intensity (ISPTA) and acoustic power associated
with Doppler ultrasound are the highest of all the general-
use categories. Ziskin66 reported that among 15,973 Dop-
pler ultrasound examinations, the average duration was 27
minutes (and the longest 4 hours!).
There is a mathematical/physical relation between tem-
perature elevation and several beam characteristics. The
Fleischer_CH01_p001-p024.indd 7
7
elevation is proportional to the product of the wave ampli-
tude, length of the pulse, and PRF. Hence, manipulating any
of these via instrument controls will alter the in situ condi-
tions. It is clear that temperature increases of 1°C are easily
reached in routine scanning.67 Elevation of up to 1.5°C were
obtained in the first trimester and up to 4°C in the second
and third trimesters, particularly with the use of pulsed Dop-
pler.68 There is a large body of literature on heat shock pro-
teins (HSPs), the production of which is triggered by a core
temperature increase and the function of which is to protect
against hazardous effects of elevated temperature as well as
to induce some thermotolerance, ie, the ability to withstand
higher elevations than in the past, with no harmful results.69
While their production is activated by whole-body tempera-
ture elevation, and may be speculated in ultrasound-induced
thermal effects, it has not been shown to actually occur dur-
ing experimental (or clinical) insonation.
MECHANICAL EFFECTS
Ultrasound bioeffects also occur through mechanical mech-
anisms.70,71 These are interactions between the ultrasound
wave and the tissue that do not cause a significant degree
of temperature increase (less than 1°C above physiologic
temperature). These include acoustic cavitation as well as
radiation torque and force, and acoustic streaming second-
ary to propagation of the ultrasound waves. While included
in this category, some effects are, in fact, the result of the
mechanical interaction but are actually physical (shock
wave) or chemical (release of free radicals) effects. Table 1-29
summarizes nonthermal effects described in the literature
in laboratory or animal experiments—and not in humans—
which may be pertinent to fetal ultrasound.
Investigations with laboratory animals clearly indicate
that nonthermal interactions of ultrasound fields with tis-
sues can produce biological effects in vivo.71 It is interesting
 MAJOR NONTHERMAL EFFECTS
OF ULTRASOUND OBSERVED
IN THE LABORATORY AND
Table 1-2
IN ANIMALS AND WITH THE
POTENTIAL TO AFFECT THE
FETUS
Free-radical generation
Increase in cell membrane permeability
Erythrocyte agglutination
Growth restriction (transient decrease)
DNA single-strand break
Increased sister chromatid exchange
Increased mutation frequency
Capillary petechiae
Vasoconstriction
Lung microvascular hemorrhage
Intestine microvascular hemorrhage
Neuronal migration delay
Auditory tract stimulation
Tactile radiation pressure perception effect
Cardiac, premature contractions
Modified with permission from Stratmeyer ME, Greenleaf JF, Dalecki D, et al.
Fetal ultrasound: mechanical effects. J Ultrasound Med. 2008 Apr;27(4):597-605.
08/09/17 10:50 am
 8 Part 1 GENERAL OBSTETRIC SONOGRAPHY
to note that chemical effects of ultrasound were described
more than 80 years ago!72 Cavitation seems to be the major
factor in mechanical effects73 as it has been demonstrated to
occur in living tissues under ultrasound insonation.74,75 Two
types of cavitation can be described—stable and inertial
(previously defined as transient)—both of which need the
presence of gas bubbles to occur. Stable cavitation indi-
cates vibrations or small backward and forward move-
ments with possible resulting microstreaming. Inertial
cavitation indicates expansion and reduction in volume,
secondary to alternating positive and negative pressures
generated by the ultrasound wave. Expansion in growth is
less with each cycle until collapse occurs with production
of very high pressure (hundreds of atmospheres) and very
elevated temperature (thousands of degrees), but on such a
small area (less than 100 nm) and for such a brief time (few
tens of nanoseconds) that it will not be felt and is very hard
to measure (adiabatic reaction—occurring without the gain
or loss of heat) but can produce microstreaming—a phe-
nomenon that has been described also with no clear involve-
ment of bubbles,76-78 or even release of free radicals.79,80
Acoustic streaming is easily demonstrated by watch-
ing ultrasound-induced movements of solid-matter-
containing fluids in insonated cavities (see Video 1).
Radiation torque refers to the induction, in objects
found in the acoustic field, of rotation or of the tendency
to rotate. Biological effects of ultrasound in animals such as
local intestinal,81 renal,82 and pulmonary83 hemorrhages have
been attributed to mechanical effects, although cavitation
could not always be implicated. Furthermore, since gas bub-
bles do not seem to be present in fetal lungs or bowels (where
effects have been described in neonates or adult animals), the
risk from mechanical effect secondary to cavitation appears
to be minimal.84 There are several other effects that do not
appear to involve cavitation such as tactile sensation of the
ultrasound wave, auditory response, cell aggregation, and cell
membrane alteration. Hemolysis has also been reported.85 It
seems, however, that the presence of some cavitation nuclei
is necessary for hemolysis to occur. At present, there is no
clear clinical indication for the use of ultrasound contrast
agents (a source of cavitation nuclei, when injected into the
body before ultrasound examination) in fetal ultrasound, and
to date, no studies have specifically investigated the interac-
tion of ultrasound and microbubble contrast agents in fetal
tissues in vivo. Nevertheless, it should be noted that in the
presence of such contrast agents, fetal red blood cells are
more susceptible to lysis from ultrasound exposure in vitro.86
Additionally, fetal stimulation caused by pulsed ultra-
sound insonation has been described, with no appar-
ent relation to cavitation.87 This effect may be secondary
to radiation forces associated with ultrasound exposures.
These forces were suspected at the earliest stages of ultra-
sound research88 and are known to possibly stimulate audi-
tory,89 sensory,90 and cardiac tissues.91 No harmful effects
of DUS, secondary to nonthermal mechanisms, have been
reported in human fetuses. A very intriguing nonthermal
effect of ultrasound is acceleration of bone fractures heal-
ing in animals and humans.92 Because of these known
effects of ultrasound in living tissues and the fact that pres-
sures involved with Doppler propagation are much higher
than B-mode, caution is further recommended, based on
Fleischer_CH01_p001-p024.indd 8
scientific evidence of potential effect, particularly in the first
trimester.93
THE OUTPUT DISPLAY STANDARD
In 1992, the FDA yielded to pressure from ultrasound
clinical users as well as manufacturers to increase the power
output of instruments. The rationale for this request was
that higher outputs would generate better images, and thus
improve diagnostic accuracy. To allow clinical users of
ultrasound to use their instruments at higher powers than
originally intended and to reflect the two major potential
biological consequences of ultrasound (mechanical and
thermal, see above), the American Institute of Ultrasound
in Medicine (AIUM), the National Electrical Manufacturers’
Association (NEMA), and the FDA (with representatives
from the Canadian Health Protection Branch, the National
Council on Radiation Protection and Measurements,94 and
14 other medical organizations30) developed a standard
related to the potential for ultrasound bioeffects. The full
name was the Standard for Real-Time Display of Thermal
and Mechanical Indices on Diagnostic Ultrasound Equip-
ment, generally known as the Output Display Standard
or ODS.15 The importance of this document and what it
describes is that it represents historically the first attempt
at providing the end user with quantitative safety-related
information. One important result is that the end users are
able to see how manipulation of the instrument controls
during an examination causes alterations in the output and,
thus, on the exposure. As a consequence, for fetal imaging
the output, as expressed by the ISPTA, went from a previous
value of 92 to 720 mW/cm2 (see Table 1-1).
To allow the output to reach such levels, the manufac-
turers were requested to display, on screen and in real-time,
two types of indices with the intent of making the user aware
of the potential for bioeffects, as described earlier. These
indices are the thermal index (TI), to provide some indica-
tion of potential temperature increase, and the mechanical
index (MI), to provide indication of potential for nonther-
mal (ie, mechanical) effects15,30,95 (Figure 1-5). The TI is the
ratio of total acoustic power to the acoustic power estimated
Figure 1-5. Onscreen TI (= 0.3, red arrow) and MI (= 1, yellow arrow).
08/09/17 10:50 am
 Chapter 1 Ultrasound Bioeffects and Safety: What the Practitioner Should Know
to be required to increase tissue temperature by a maximum
of 1°C. It is an estimate of the maximal temperature rise at
a given exposure. There are 3 variants: for soft tissue (TIS),
to be used mostly in early pregnancy when ossification is
low; for bones (TIB), to be used when the ultrasound beam
impinges on bone at or near the beam focus, such as late
second and third trimesters of pregnancy; and for transcra-
nial studies (TIC) when the transducer is essentially against
bone, mostly for examinations in adult patients, but also
in neonatal scanning, which is an area that is, generally,
ignored. These indices were required to be displayed if equal
to or over 0.4. It needs to be made very clear that TI does
not represent an actual or an assumed temperature increase.
It bears some correlation with temperature rise in degrees
Celsius but in no way allows an estimate or a guess as to
what that temperature change actually is in the tissue.95
The MI represents the potential for nonthermal damage in
tissues but is not based on actual in-situ measurements. It is
a theoretical formulation of the ratio of the pressure to the
square root of the ultrasound frequency (hence, the higher
the frequency, the lesser risk of mechanical effect).
Both the TI and MI can and should be followed as an
indication of change in output during the clinical examina-
tion with higher values indicating the potential for higher
thermal and nonthermal effects than lower values. A clear
mandate in the ODS original document was education
of the end user as a major part in the implementation of
the indices. Attempts have been made to educate the end
users,96 but, unfortunately, this aspect of the ODS does not
seem to have succeeded as end users’ knowledge of bioef-
fects, safety, and output indices is found lacking.97,98
In a questionnaire that was distributed to ultra-
sound end users (82% were obstetricians) attending review
courses and hospital grand rounds, only 17.7% gave the
correct answer of the definition of the TI, and only 3.8%
described MI properly. Almost 80% of end users did not
know where to find the acoustic indices when various
responses included the machine documentation, a text-
book, a complicated calculation or in real time on the
ultrasound monitor (the correct answer).97 Similar results
were recorded in surveys abroad, performed in Europe,
Asia, or the Middle East98,99,100,101 indicating that clini-
cal end users worldwide show poor knowledge regarding
safety issues of ultrasound during pregnancy.102,103 More
recently, knowledge of residents in obstetrics and gyne-
cology was also found to be grossly lacking 104 and, fur-
thermore, similar results were obtained when surveying
sonographers, with no difference in years of experience.105
Compliance with the ALARA (as low as reasonably
achievable) principle by practitioners seeking credential-
ing for nuchal translucency (NT) measurement between
11 and 14 weeks’ gestation was evaluated. Only 5% of the
providers used the correct TI type (TIb) at lower than 0.5
for all submitted images, 6% at lower than 0.7, and 12% at
1.0 or lower. A TI (TIb or TIs) higher than 1.0 was used
by 19.5% of the providers. Proficiency in NT measurement
and educational background (physician or sonographer)
did not influence compliance with ALARA. The authors
concluded that clinicians seeking credentialing in NT do
not demonstrate compliance with the recommended use
of the TIb in monitoring acoustic output.106
Fleischer_CH01_p001-p024.indd 9
9
Furthermore, several assumptions were made, which
prompts some questions on the clinical value of these
indices. Maybe the most significant (from a clinical aspect)
is the choice of the homogeneous attenuation path model
(defined as the H3 model), with an attenuation coefficient
of 0.3 dB/cm/MHz, as detailed previously in Tissue Char-
acteristics. The reason to employ models of that nature is
the impossibility, for obvious reasons, to perform certain
measurements in pregnant women. This coefficient may
be an overestimation of the attenuation in many clinical
scenarios, a situation that would underestimate the actual
exposure. In National Council on Radiation Protection
and Measurements (NCRP) report number 140,30 there is
an entire chapter (Chapter 9) indicating conditions where
both indices may be inaccurate, eg, long fluid path (full
bladder, amniotic fluid, ascites, or hydrocephalus) or path
through increased amounts of soft tissue such as obese
patients. Because of these uncertainties, the accuracy of
the TI and MI may be within a factor of 2 or even 6.107 For
example, an on-screen TI of 1 may correspond to an actual
value of 0.5°C or 2°C if the error factor is 2, but possibly
0.33°C or 6°C, if the error factor is 6 (as previously stated,
these are not actual temperature indications). A further
disturbing and confusing element is that outputs reported
by manufacturers are not necessarily equivalent to those
calculated in the laboratory.108
Risk Assessment
Risk means the chance or the possibility of loss or bad
consequence. It refers to the possibility, with a certain
degree of probability, of damage to health, environment,
and objects, in combination with the nature and magni-
tude of the damage.109 These are the 3 important charac-
teristics of risk: probability of occurrence, and nature and
magnitude of harm. It has been, specifically, applied to the
use of medical instruments.110 A complicating factor that
makes definition and classification difficult is that the con-
cept of risk means various things to different people. Age,
background, education, morals, religion, and many other
traits will direct this evaluation and not only the absolute
possible result of the activity, putting the participant at
risk. For instance, in bungee jumping, rupture of the elas-
tic cord and subsequent death may be, indisputably, the
worst possible outcome, but different people evaluate this
and make decisions that are not necessarily based on this
absolute result. Furthermore, the reason to take a possible
risk has to be taken in consideration.
Two approaches are possible in risk evaluation: how
much harm is acceptable to obtain the desired results
(risk-benefit ratio) or how much harm can be avoided by
withholding the action or modifying it (the precautionary
principle). The risk-benefit principle is what is almost
universally used in medicine to justify a medical diag-
nostic procedure (such as ultrasound) or a therapeutic
intervention. If the benefit to be obtained from the proce-
dure in terms of diagnosis (ultrasound) or intervention (a
newly discovered and not yet commercialized cancer or
AIDS drug, for instance) is deemed to be sufficient, then,
even if this diagnostic or interventional procedure car-
ries some risks (recognized or presumed to be possible),
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 10 Part 1 GENERAL OBSTETRIC SONOGRAPHY
the benefit overrides these risks, assuming the subject
understands those risks and is willing to take them. The
precautionary principle (PP) is a diametrically opposed
ethical, political, and economic approach stating that if
a certain action may cause severe damage to the public,
in the absence of a scientific consensus that harm would
not ensue, the burden of proof falls on those who would
advocate taking that action.111 This principle is much
less familiar to the medical field, although “first do no
harm” is its direct application, but it may be extremely
relevant when considering safety and risks of a proce-
dure, such as prenatal ultrasound. The concept origi-
nated in the 19th century when John Snow, a London,
UK, physician, determined that cholera was due to the
extensive, common use of an unclean water supply and
recommended closing of this source of water, although it
was the sole one in a large vicinity.112 This may have been
the first epidemiological analysis of a disease. Although
the beginning of the PP was medical, it became a social
idea in Germany in the 1930s as Vorsorge, “forecaring.”
This later became the Vorsorgeprinzip, the forecaring or
precautionary principle, in West German environmental
law in the 1970s.113 The idea was adopted by decision and
policy makers but, remarkably, much more extensively
in Europe than in the United States. Some key concepts
in the original formulation were environmental harm to
a population and responsibility: “When an activity raises
threats of harm to human health or the environment,
precautionary measures should be taken even if some
cause and effect relationships are not fully established
scientifically. In this context the proponent of an activity,
rather than the public, should bear the burden of proof”
(the Wingspread Statement on the Precautionary Prin-
ciple114). From environmental research it spread to toxi-
cology and was first applied only recently in the United
States to a clinical medical field.115 However, several med-
ical mishaps clearly belong to the history of the develop-
ment of the PP—from the diethylstilbestrol debacle116
to the thalidomide tragedy.117 While referring mostly to
environmental issues, such as global warming, the PP can
certainly be extended to other medical activities (such
as diagnostic ultrasound) and be applied to individuals
(such as fetuses). The simple enunciation of the prin-
ciple, particularly in reference to diagnostic ultrasound
in general, and entertainment ultrasound in particular, is
that even if a particular action or procedure has not been
proven to be harmful, it is better to avoid it so as not to
take the risk until safety is established through clear, sci-
entific evidence, popularly expressed as “better safe than
sorry.”118 This is also the basis of the Hippocratic Oath,
which includes the recommendation to first do no harm.
A major difference with the risk-benefit principle is that
proponents of the PP believe that public action is neces-
sary if there is any evidence of likely or substantial harm,
however limited but plausible, and the burden of proof
is shifted from showing the presence of risk to demon-
strating its absence.119 As such, epidemiologic research
on chronic diseases and the use of surrogates for human
studies (eg, animal research or tissue cultures) have been
shown to be uncertain.120 There are several variations of
the PP, but all have some common key elements:
Fleischer_CH01_p001-p024.indd 10
1. There must be scientific uncertainty about nature of
harm, probability, magnitude, and causality (fulfilled
by DUS).
2. Mere speculation is not enough to invoke the PP.
Scientific analysis must have triggered the process
(also fulfilled by DUS).
3. Per definition, the PP deals with procedures with
probability of unclear outcome, in that it is differ-
ent from prevention or from risk-benefit assessment
where some clear knowledge or precise suspicion
exists, and where decision may be made to go ahead
despite this risk by, for instance, taking additional
measures to attempt and limit the danger. Clearly,
the ALARA principle is the exact application of this
element121,122 (fulfilled by DUS).
4. In general, the PP applies to unacceptable (“serious,”
“irreversible,” “global”) high levels of risk to large
populations, present or future, local or distant123
(may not be the case for DUS).
5. One needs to intervene (not observe or procrasti-
nate) before damage has been demonstrated (eg, “do
not perform DUS”).
6. The intervention must be proportional to the pos-
sible risk: indicating DUS may be acceptable but not
nonclinical use of DUS. A level of “zero risk” is prob-
ably never attainable.
Those who support the PP make the following very
strong argument for precaution: serious damage may be
caused if one uses a risk-based approach. A well-known
example is what constitutes toxic levels of lead in paint.
As early as 1897, it was known that lead may be toxic, but
at first the upper limit of safety for children was assumed
to be 60 μg/dL of blood, and this had terrible results. The
“safe” level was reduced over the years to 40, then 20, then
10, which it is today, although some scientists feel that
even 2 μ/dL may pose some risk.124 The basic conclusion of
risk analysis with the PP is that measures against a possible
risk should be taken (such as exposure avoidance) even if
the available evidence is weak (or maybe absent) regard-
ing the existence of that risk as a scientifically established
fact.125 In many European countries this “stop first then
study” approach (a clear application of the PP) has been
adopted (particularly for chemicals). The exact opposite
is often true in the United States where something, once
introduced, has to be proven harmful by science before
being removed or forbidden. A major goal of the PP is to
help delineate (preferably quantitatively) the possibility
that some exposure is hazardous, even in cases where this
is not established beyond reasonable doubt.126 The classi-
cal statistical approach to hypothesis testing is unhelpful
because lack of significance can be due to either uninfor-
mative data or genuine lack of effect (type II error).127
There are many critics of the PP because of the risk
of exaggeration in caution and slowing down of scientific
progress.128,129 A major issue is that the PP relies very heav-
ily on a single conjecture: prevention is better than cure.
There is no scientific evidence for this. Furthermore, it
may be true that, often, it is better to be “safe than sorry”
and the primum non nocere (first do no harm) principle is
a direct application of this, but preventative measures can
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 Chapter 1 Ultrasound Bioeffects and Safety: What the Practitioner Should Know
be long lasting and possibly incapacitating, whereas cures
can be targeted and effective.128 What is more, no moral
opinion is formed of people when treating them, but if the
main focus is upon precaution, then it can be deemed mor-
ally wrong not to take preventative measures. The whole
precaution approach is imbued with what may appear to
many as an excessively moralistic tone and a “I am the
expert and therefore know what is best for you” attitude.130
Furthermore, the probability of a problem occurring that
one tries to avoid has to be high (which does not apply, as
far as we know, to ultrasound) and preventative measures
have to be effective. Hence this approach may be adopted
with some restrictions and this is, in fact, exactly what
ALARA recommends.122 Most scientists and professional
organizations have recommended such a practice in clini-
cal obstetrical ultrasound.131-133
HISTORICAL RESEARCH
The first descriptions of ultrasound as an imaging mode
date from the 19th century.134 The French engineer Paul
Langevin designed an ultrasound machine using Pierre
Curie’s principle of the piezoelectric effect. During World
War I, he attempted to use this instrument to detect sub-
marines through echo location (hence the later coined
term SONAR: Sound Navigation And Ranging). He also
demonstrated that the waves produced by his machine
could kill small animals in an insonated water bath, and
could cause pain to his assistants when they were required
to plunge their hands in the water bath in the path of the
beam. Other bioeffects observed included the searing of
skin when touching a resonant quartz bar, and explosive
atomization (!) of fluid drops from the end of the rod. Since
that time, the question of effects and safety has been on
the minds of researchers88 and has given rise to literature
too extensive to review in detail.2,3,6,49,131,135-147 Initially, cell
suspensions and cell and tissue cultures were employed,
and many reports described clear effects of the ultrasound
waves on these, mostly secondary to cavitational and
other nonthermal mechanisms, such as cell aggregation,148
membrane damage,149 and cell lysis.150 Plants were another
extensively studied organism for effects of ultrasound,151
particularly the Elodea leaf, since internal gas channels
are present.152 Insects have been exposed to ultrasound
with significant effects, such as death of eggs and larvae as
well as abnormal development, presumably secondary to
the presence of gas-filled channels.153 Additionally, altera-
tions at the chromosomal and even DNA levels have been
described.154 These effects have been reviewed extensively
elsewhere,5,30 and while they are of major scientific and
historical importance, they are not of major relevance to
clinical exposure of human fetuses.
Animal Research
Effects of ultrasound were demonstrated in animals more
than 80 years ago.88 Since then, multiple studies have
been performed with ultrasound on a wide variety of
species. Studies of gross effects on the brain and liver of
cats were first performed with well-defined lesions and
demyelination in the brain155 and tissue damage in the
Fleischer_CH01_p001-p024.indd 11
11
liver,156 resulting from ultrasound exposure of a few sec-
onds at 1 and 3 MHz, respectively. Other observed effects
include limb paralysis as a result of spinal cord injury in the
rat,157,158 as well as lesions in the liver, kidney, and testicles
of rabbits.159 While some effects are likely due to mechani-
cal influences, very high temperature elevations (much
higher than anything reachable with diagnostic ultra-
sound) have also been observed and may be more directly
involved with the tissue damage. Effects in muscles have
been obtained, but with outputs much higher than those
usually generated in clinical studies,160 and so have intes-
tinal81 and lung161 hemorrhages, also at acoustic pressures
well above those generated by ultrasound fields. These are
helpful in understanding the mechanisms involved with
possible bioeffects of DUS. It should also be noted that
some similar effects have also been demonstrated with
acoustic fields much closer to clinically pertinent ones, in
particular lung and intestinal hemorrhage.81 Several major
clinical end points for bioeffects that could have direct
relevance to human studies include fetal growth and birth
weight, effects on brain and CNS function, and change in
hematological function, and these will be considered in
more detail. Decreased birth weight after prenatal expo-
sure to ultrasound has been reported in the monkey162,163
and the mouse,164,165 but not convincingly in the rat.166
Therefore, clear species differences seem to exist,167 mak-
ing it difficult to generalize, and even more difficult to
extrapolate, to humans.
Tarantal and Hendrickx162 evaluated 30 pregnancies
in monkeys, half of which were exposed to ultrasound.
The scanned fetuses had lower birth weights and were
shorter than the control group. No significant differences
were noted between the groups with regard to the rate of
abortions, major malformations, or stillbirths. Moreover,
all showed catch-up growth when examined at 3 months
of age.162 It should be noted that in-situ intensities were
higher than what is considered routine in clinical obstet-
rical imaging in humans. Hande and Devi168 evaluated
the effect of prenatal exposure to diagnostic ultrasound
on the development of mice. Swiss albino mice were
exposed to diagnostic ultrasound for 10 minutes on day
3.5 (preimplantation period), 6.5 (early organogenesis
period), or 11.5 (late organogenesis period) of gestation.
Sham-exposed controls were maintained for comparison.
Fetuses were dissected out on the 18th day of gestation,
and changes in total mortality, body weight, body length,
head length, brain weight, sex ratio, and microphthalmia
were recorded. Exposure on day 3.5 of gestation resulted
in a small increase in the resorption rate and a significant
reduction in fetal body weight. Low fetal weight and an
increase in the incidence of intrauterine growth-restriction
were produced by exposure on day 6.5 postcoitus.168
Others have also demonstrated restricted growth
in newborns after in utero exposure to DUS.169 Subtler
findings have also been described. Pregnant Swiss albino
mice were exposed to diagnostic ultrasound (3.5 MHz, 65
mW, ISPTP = 1 W/cm2, ISATA = 240 W/cm2) for 10, 20, or
30 minutes on day 14.5 (fetal period) of gestation.170 Sham-
exposed controls were studied for comparison. There were
significant alterations in behavior in the exposed groups as
revealed by decreased locomotor and exploratory activity,
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 12 Part 1 GENERAL OBSTETRIC SONOGRAPHY
and an increase in the number of trials needed for learn-
ing. No changes were observed in physiological reflexes
and postnatal survival. The authors concluded that ultra-
sound exposure during the early fetal period can impair
brain function in the adult mouse.170 Likewise, Hande
et al171 found that anxiolytic activity and latency in learn-
ing were more noticeable in ultrasound-treated animals.
The authors exposed pregnant Swiss mice to diagnostic
levels of ultrasound (3.5 MHz, maximum acoustic out-
put: ISPTP = 1 W/cm2 and ISATA = 240 mW/cm2, acoustic
power = 65 mW) for 10 minutes on postcoital day 11.5
or 14.5. At 3 and 6 months postpartum, offspring were
subjected to behavioral tests. The effect was more pro-
nounced in the 14.5 days postcoital group than in the
11.5 days group. They concluded that exposure to diag-
nostic ultrasound during late organogenesis period or
early fetal period in mice may cause changes in postna-
tal behavior.171 Temperature elevations were induced by
ultrasound in guinea pig fetal brains.46 In fact, mean tem-
perature increases of 4.9°C close to parietal bone and 1.2°C
in the midbrain were recorded after 2-minute exposures,
albeit at exposure conditions higher than what is usually
employed in clinical examinations.46 This greatest temper-
ature rise recorded close to the skull correlated with both
gestational age and progression in bone development.43
The skull bone becomes progressively thicker and denser
between 30 and 60 days’ gestational age (normal gesta-
tion for guinea pigs is 66 to 68 days). After only 2 minutes
of insonation with an ISPTA of 2.9 W/cm2 (about 4 times
higher than currently permitted by the FDA for diagnostic
use), mean maximum temperature increases varied from
1.2°C at 30 days to 5.2°C at 60 days. It is important to note
that most of the heating (80% of the mean maximum tem-
perature increase) occurred within 40 seconds. The rate of
heating is relevant to the safety of clinical examinations in
which the dwell time may be an important factor. Because
maximal ultrasound-induced temperature increase occurs
in the fetal brain near bone, worst-case heating will occur
later in pregnancy, when the ultrasound beam impinges on
bone, and less will occur earlier in pregnancy, when bone is
less mineralized. However, milder insults early in gestation
may be as significant (or more) than more severe ones in
later stages.
Neurons of the cerebral neocortex in mammals, includ-
ing humans, are generated during fetal life in the brain pro-
liferative zones and then migrate to their final destinations
by following an inside-to-outside sequence. Ang et al172
evaluated the effect of ultrasound waves on neuronal
positioning within the embryonic cerebral cortex in mice.
Neurons generated at embryonic day 16 and destined
for the superficial cortical layers were chemically labeled
in over 335 animals. A small, but statistically significant,
number of neurons failed to acquire their proper position
and remained scattered within inappropriate cortical lay-
ers and/or in the subjacent white matter when exposed to
ultrasound for a total of 30 minutes or longer during the
period of their migration. The magnitude of dispersion of
labeled neurons was variable but systematically increased
with duration of exposure to ultrasound (although not
linearly, with some extended exposure yielding less effect
than lower ones). These investigators concluded that
Fleischer_CH01_p001-p024.indd 12
further research in larger and slower-developing brains of
nonhuman primates and continued scrutiny of unneces-
sarily long prenatal ultrasound exposure is warranted. It
is unclear whether a relatively small misplacement in a
relatively small number of cells that retain their origin cell
class is of any clinical significance. It is also important to
note that there are several major differences between the
experimental setup of Ang et al172 and the clinical use of
ultrasound in humans.6 The most noticeable difference
was the length of exposure of up to 7 hours in the setup of
Ang et al. No real mechanistic explanation was given for
the findings, and furthermore, there was no real dose effect
with high effects at the penultimate high dose, but less so
at the highest dose. Moreover, scans were performed over
a small period of several days. The experimental setup was
such that embryos received whole-brain exposure to the
beam, which is rare in humans, although quite possible in
the earliest stages of gestation. In addition, brains of mice
are much smaller than those in humans, and develop over
days. This should not completely deter from the study,
but encourages caution. It should be noted that some have
described a complete lack of effects of prenatal ultrasound
exposure on postnatal development and growth173 or
behavior.174 The influence of prenatal ultrasound exposure
on the blood–brain barrier (BBB) integrity as measured by
the permeation of Evans blue (EB) through the BBB during
the postnatal development of 139 rats was evaluated by
Yang et al.175 Diagnostic levels of ultrasound (2.89 MHz,
mechanical index = 1.1, acoustic output power = 70.5 mW)
for 1 and 2 hours per day, for 9 consecutive days were used
on Sprague-Dawley rats. Offspring were assessed postna-
tally on days 10, 17, 24, and 38. A statistically significant
amount of EB extravasation into the cerebrum and cer-
ebellum could be detected on postnatal day 10 (but not
later), following exposure to diagnostic levels of ultrasound
during embryonic development. The authors concluded
there is a need for further investigation of the effects of
ultrasound exposure during the potentially vulnerable
period of intense BBB development in the human fetus.
This study did not provide clear evidence that there is
cause for concern for clinical prenatal diagnostic imaging
in humans. The study had several methodological flaws,
and specifically, the acoustic exposure was intense and
untranslatable to clinical practice.176
In another study177 chick brains were exposed, in ovo,
on day 19 of a 21-day incubation period to B-mode (5 or
10 minutes), or to pulsed Doppler (1, 2, 3, 4, or 5 minutes)
ultrasound. After hatching, learning and memory function
were assessed at day 2 post hatch. B-mode exposure did
not affect memory function. However, significant memory
impairment occurred following 4 and 5 minutes of pulsed
Doppler exposure. Short-, intermediate-, and long-term
memory was equally impaired, suggesting an inability
to learn. Chicks were also unable to learn with a second
training session. In this study, exposure to pulsed Doppler
ultrasound adversely affected cognitive function in chicks.
Although some methodological issues exist and extrapo-
lation to humans is unwarranted, these findings justify
further investigations.
The hematological system is the second major system
to be investigated for ultrasound effects. The following have
08/09/17 10:50 am
 Chapter 1 Ultrasound Bioeffects and Safety: What the Practitioner Should Know
been assessed: hemolysis, coagulation factors and platelets,
and leukocyte production and function.178 Increased hemo-
lysis has been demonstrated for ultrasound in (human)
fetal cells as compared to adult cells, but only in the pres-
ence of ultrasound contrast agents, with human cells being
less fragile than certain tested animals.86,179 Other altera-
tions have been described in the hemolytic system180 but
appear to be of minimal, if any, clinical significance.
Human Research and Epidemiology
In 2005, the American Institute of Ultrasound in Medicine
(AIUM) published the following statement: “Based on the
epidemiological data available and on current knowledge
of interactive mechanisms, there is insufficient justification
to warrant a conclusion of a causal relationship between
diagnostic ultrasound and recognized adverse effects in
humans. Some studies have reported effects of exposure to
diagnostic ultrasound during pregnancy, such as low birth
weight, delayed speech, dyslexia, and non–right-handed-
ness. Other studies have not demonstrated such effects.
The epidemiological evidence is based on exposure condi-
tions prior to 1992, the year in which acoustic limits of
ultrasound machines were substantially increased for fetal/
obstetrical applications.”181 Applied to ultrasound, epide-
miology is the study of effects on human populations as a
result of ultrasound scanning and, in the case of obstetri-
cal ultrasound, this should include the pregnant patient as
well as her infant. Laboratory animal experiments under
similar diagnostic exposure levels have shown some effects
from ultrasound, under certain conditions. Effects have
also been reported in humans, but a definitive statement
regarding risk should, ideally, include direct analysis of
the effects in human populations. Several epidemiologi-
cal studies have been published.4,49,182 For an extensive
discussion, including elements of statistics, see Chapter
12 in NCRP report number 140,30 an extensive review by
Newnham,143 and AIUM document, Conclusions Regard-
ing Epidemiology for Obstetric Ultrasound.183,184. Relevant
details will be summarized.
Several biological end points have been analyzed in the
human fetus/neonate in an attempt to determine whether
prenatal exposure to diagnostic ultrasound had observ-
able effects: intrauterine growth restriction (IUGR) and
low birth weight, delayed speech, dyslexia, neurological
and mental development or behavioral issues, and, more
recently, non–right-handedness. Occasional studies report
an association between diagnostic ultrasound and some
specific abnormalities such as lower birth weight,182 delayed
speech,185 dyslexia,186 and non–right-handedness.187,188
With the exception of low birth weight (also demonstrated
in monkeys,179) these findings have never been duplicated,
and the majority of studies have been negative for any asso-
ciation. Moore et al189 examined a large number of infants
(over 2000, half of them exposed to ultrasound) and found a
small but statistically significant lower mean birth weight of
exposed versus nonexposed infants. However, information
was collected several years after exposure, no indications for
the examination are known, and no exposure information is
available. This lack of detail about the exposure parameters
is, very often, the major problem in analyzing these reports.
Fleischer_CH01_p001-p024.indd 13
13
In a later study, the authors concluded that the relation-
ship of ultrasound exposure and reduced birth weight may
be due to shared common risk factors, which lead to both
exposure and a reduction in birth weight.190 Another ret-
rospective study, with Moore as a coauthor, reported a 2.0
greater risk of low birth weight after 4 or more exposures to
diagnostic ultrasound.144 These results were not reproduced
in other retrospective studies.189 In a large study (originally
10,000 pregnancies exposed to ultrasound matched with
500 controls) with a 6-year follow-up, Lyons et al191 did not
find differences in birth weight (nor increased congenital
malformations, chromosomal abnormalities, infant neo-
plasms, speech or hearing impairment, or developmental
problems).
Newnham et al192 performed a randomized control
trial including more than 2800 parturients. Of these,
about half received 5 ultrasound imaging and Doppler
flow studies at 18, 24, 28, 34, and 38 weeks’ gestation, and
half received a single ultrasound imaging at 18 weeks.
They found an increased risk of IUGR when exposed
to frequent Doppler examinations, possibly via some
effects on bone growth. However, when children from
the previously mentioned study were examined at 1 year
of age, there were no differences between the study and
control groups. In addition, after examining their original
subjects after 8 years, no evidence of long-term adverse
impact in neurological outcome was noted by the same
group.192 Similarly, no harmful effect of a single or 2 pre-
natal scans on growth were found in several randomized
studies.193,194 In fact, in some studies, birth weight was
slightly higher in the scanned group, but not significantly
so, except in one.195 In conclusion, decreased birth weight
has been extensively analyzed after DUS exposure in
utero, and it does not appear that such exposure is associ-
ated with reduced birth weight, although Doppler expo-
sure may have some risks.147 In a few studies that appear
to favor such an effect, a major problem is that there is
an important confounding factor: many studies include
pregnancies at risk for IUGR due to existing maternal or
fetal conditions.
A second major potential effect extensively evaluated
is delayed speech. In an attempt to determine if there is
an association between prenatal ultrasound exposure and
delayed speech in children, Campbell et al185 studied 72
children with delayed speech and found a higher rate of
ultrasound exposure in utero than the 144 control sub-
jects. Some issues render these results less valid: there
was neither a dose-response effect nor any relationship to
time of exposure, and many of the records were more than
5 years old. Another study of over 1100 children exposed
to ultrasound in utero and over 1000 controls found no
significant differences in delayed speech, limited vocabu-
lary, or stuttering.196
Dyslexia is another widely studied subject. In one study
over 4000 children, aged 7 to 12, exposed to ultrasound in
utero were used as a study group and compared to matched
controls to evaluate the appearance of adverse effects.186
Seventeen outcomes measures were examined, at birth
(APGAR scores, gestational age, head circumference, birth
weight, length, congenital abnormalities, neonatal infection,
and congenital infection) or in early infancy (hearing, visual
08/09/17 10:50 am
 14 Part 1 GENERAL OBSTETRIC SONOGRAPHY
acuity and color vision, cognitive function, and behavior).
No significant differences were found, except for a sig-
nificantly greater proportion of dyslexia in those children
exposed to ultrasound. The authors, however, indicated
that this could be an incidental finding, given the design
of the study and the presence of several confounding fac-
tors that could have contributed to the possible dyslexia
finding. On the other hand, it should be noted that expo-
sure conditions were probably much lower than modern
ultrasound systems, given that the fetal examinations were
performed from 1968 to 1972. Subsequently, a long-term
follow-up study was performed on over 2100 children.193,197
End points included evaluation for dyslexia along with
additional hypotheses, including an examination of non–
right-handedness said to be associated with dyslexia. These
studies198-200 included the specific examination of more than
600 children with various tests for dyslexia such as spelling
and reading. No statistically significant differences were
found between ultrasound-exposed children and controls
for reading, spelling, arithmetic, or overall performance as
reported by teachers. Specific dyslexia tests showed similar
rates of occurrence among scanned children and controls
in reading, spelling, and intelligence scores, and no discrep-
ancy between intelligence and reading or spelling. Since the
original finding of dyslexia was not confirmed in subsequent
randomized controlled trials, it is considered unlikely that
routine ultrasound screening exams can cause dyslexia.
However, these studies did raise the issue of laterality (in
terms of handedness).
The topic of non–right-handedness as a result of pre-
natal exposure has caused much ink to be used in extensive
discussions and reports. The first report of a possible link
between prenatal exposure to ultrasound and subsequent
non–right-handedness in insonated children was published
in 1993 by Salvesen et al,198 but according to the authors,
“only barely significant at the 5% level.” In a later analysis of
the data, they described that the association was restricted to
males.193 A second group of researchers (with Salvesen, the
main author of the first study, included but with a new popu-
lation, in Sweden as opposed to Norway) published similar
findings of a statistically significant association between
ultrasound exposure in utero and non–right-handedness in
males.187 Salvesen then published a meta-analysis of these 2
studies and of previously unreported results.188 No difference
was found in general, but a small increase in non–right-
handedness was present when analyzing boys separately.
No valid mechanistic explanation is given in the studies to
explain the findings. In conclusion, although there may be a
small increase in the incidence of non–right-handedness in
male infants, there is not enough evidence to infer a direct
effect on brain structure or function or even that non–right-
handedness is an adverse effect. An intriguing recent study
showed that fetuses self-touched their faces more often with
the left hand than the right, as observed by ultrasound, in
correlation to stress levels of the mother.189 Furthermore, lat-
erality is, mostly, genetically determined.190 Other end points
that have been considered but not found to be associated
with ultrasound exposure include congenital malformations,
hearing problems and malignancies.204,205
There has been no published epidemiological study
that found negative effects of obstetrics ultrasound in
Fleischer_CH01_p001-p024.indd 14
populations scanned after 1992, when regulations were
altered and acoustic output of diagnostic instruments
were permitted to reach levels many times higher than
previously allowed (from 94 to 720 mW/cm2 ISPTA for fetal
applications). There are no epidemiological studies related
to the output display standard (thermal and mechanical
indices) and clinical outcomes. The safety of new technolo-
gies such as harmonic imaging and three-dimensional (3D)
ultrasound, as well as that of probe self-heating, needs to
be investigated.
Clinical Exposimetry
There is, unfortunately, no way to perform actual sono-
graphic exposure measurements in the human fetus. Pres-
sure, intensity, and power are not measured in situ, but
are estimated from laboratory obtained measurements.
Several tissue models have been developed to help with
this estimation, depending mostly on approximate attenu-
ation coefficients for various tissues or beam paths.30,50 A
large range of variation is expected secondary to individual
patient characteristics, such as weight and thickness of tis-
sues.206 Because of these possible variations, the reasonable
worst-case scenario is usually considered. There are scarce
data on instruments’ acoustic output (nor patient acous-
tic exposure) for routine clinical ultrasound examina-
tions. Acoustic output was recorded in several prospective
observational studies investigating first-trimester ultra-
sound,207,208 Doppler studies,209 and 3D/four-dimensional
(4D) studies.210 Basically, first-trimester ultrasound was
associated with very low TI values (with a mean of 0.2 ±
0.1).207 The TI was significantly higher in the pulsed wave
Doppler (mean 1.5 ± 0.5, range 0.9-2.8) and color flow
imaging studies (mean 0.8 ± 0.1, range 0.6-1.2) as com-
pared to B-mode ultrasound (mean 0.3 ± 0.1, range 0.1-0.7;
P < .01).209 In the same study, TI was above 1.5 in 43% of
the Doppler studies.209 Mean TI during the 3D (0.27 ± 0.1)
and 4D examinations (0.24 ± 0.1) was comparable to the TI
during the B-mode scanning (0.28 ± 0.1; P = .343).210 There
is ever-increasing use of 3D/4D ultrasound in clinical
Figure 1-6. TI and MI during M-mode examination. Please note
TI = 0.8 (arrow).
08/09/17 10:50 am
 Chapter 1 Ultrasound Bioeffects and Safety: What the Practitioner Should Know 15

Figure 1-7. TI and MI during color Doppler exam. Please note TI = 0.6 Figure 1-8. TI and MI during spectral Doppler examination. Please
(arrow). note TI = 2.4 (arrow).

medicine, thus knowledge about bioeffects and safety is
mandatory.211 Figures 1-6 through 1-9 are examples of
actual screen shots during clinical exams, for M-mode,
color Doppler, spectral Doppler, and 3D acquisition,
respectively. Figure 1-10 demonstrates that extremely
elevated TIs are easily reachable with spectral Doppler,
although in manufacturer’s fetal setting.
Adequate diagnostic information may be obtained
with low output levels (as documented by values of the
TI). This is seen in Figure 1-11 and Video 1. This has
been reported in the literature, specifically for Doppler,
the mode with the highest output, both in early and later
pregnancy.212,213 It should be noted that, under pressure
from Bioeffects and Safety Committees of various profes-
sional organizations (American Institute of Ultrasound
in Medicine-AIUM, European Federation of Ultrasound
in Medicine and Biology-EFSUMB, International Society
for Ultrasound in Obstetrics and Gynecology-ISUOG,
and World Federation for Ultrasound in Medicine and
Biology-WFUMB), several manufacturers have changed
their default settings, specifically for pulsed Doppler in
fetal mode, from very high (as it was originally, presumably
in an attempt to obtain better images) to very low, with
the end user capable or raising the output, if desired. Since
acoustic output is high in Doppler, special precaution is
recommended, particularly in early gestation.214

Figure 1-9. TI and MI during multiplanar acquisition in 3D scanning. Please note TI = 0.4 (arrow).

Fleischer_CH01_p001-p024.indd 15 08/09/17 10:50 am

 16 Part 1 GENERAL OBSTETRIC SONOGRAPHY
Figure 1-10. Second-trimester spectral Doppler. Please note TI = 3.3
(arrow). This is with the instrument on “fetal” setting.
A B
C D
Figure 1-11. Color and spectral Doppler of umbilical artery. A: Color Doppler with high output power (as reflected by TI = 0.7). B: Lower output
power (TI = 0.1). C: Spectral Doppler with high output power (as reflected by TI = 2.4). D: Lower output power (TI = 0.6). Image is equally diagnostic.
Fleischer_CH01_p001-p024.indd 16
Because of the possible errors inherent in the calcula-
tion of the TI and MI, various attempts have been made to
find a better quantification of the potential risk.215 These
have not been adopted by the clinical community.
The other side of the equation is, “What are we looking
for?” Ultrasound is neither radiation nor thalidomide, and
it is certain that ultrasound does not kill fetuses, does not
cause limb amputations, and does not cause gross structural
anomalies.216 But are we looking where we should, and have
we studied enough cases in a scientific fashion, looking at
subtle changes? The answer is clearly, “No.” We have been
looking for macroscopic, gross findings and have not found
any, but is it possible that harmful effects of ultrasound
have been missed because the wrong time frame refer-
ence was used? Two possible factors are described for such
errors.217 If one uses a term human pregnancy (280 days
[40 weeks]) to life expectancy of 70 years (25,550 days) ratio,
then 7 in utero days are comparable to about 631 ex-utero
days. Therefore, it is conceivable that a much shorter time
interval (1 day) should be used to group fetuses to evaluate
08/09/17 10:51 am
Another random document with
no related content on Scribd:
be in the Scheldt, struggling in his gun-boat against a gale which, in
spite of all his endeavors and seamanship, drove him ashore, under
the guns of the Belgians. A crowd of Belgian volunteers leaped
aboard, ordered him to haul down his colors and surrender. Von
Speyk hurried below to the magazine, fell upon his knees in prayer,
flung a lighted cigar into an open barrel of powder, and blew his ship
to atoms, with nearly all who were on board. If he, by this sacrifice,
prevented a Dutch vessel from falling into the enemy’s power, he
also deprived Holland of many good seamen. The latter country,
however, only thought of the unselfish act of heroism, in one who
had been gratuitously educated in the orphan house at Amsterdam,
and who acquitted his debt to his country, by laying down his life
when such sacrifice was worth making. His king and countrymen
proved that they could appreciate the noble act. The statue of Von
Speyk was placed by the side of that of De Ruyter, and the
government decreed that as long as a Dutch navy existed there
should be one vessel bearing the name of Von Speyk.
To return to the knights of earlier days, I will observe that indifferent
as many of them were to meeting death, they, and indeed other men
of note, were very far from being so as to the manner in which they
should be disposed of after death. In their stone or marble coffins,
they lay in graves so shallow that the cover of the coffin formed part
of the pavement of the church. Whittingham, the Puritan Dean of
Durham, took up many of their coffins and converted them into horse
or swine troughs. This is the dean who is said to have turned the
finely-wrought holy-water vessels into salting-tubs for his own use.
Modern knights have had other cares about their graves than that
alluded to above. Sir William Browne, for instance, one of George
II.’s knights, and a medical man of some repute, who died in 1770,
ordered by his will that when his coffin was lowered into the grave,
there should be placed upon it, “in its leathern case or coffin, my
pocket Elzevir Horace, comes viæ vitæque dulcis et utilis, worn out
with and by me.” There was nothing more unreasonable in this than
in a warrior-knight being buried with all his weapons around him.
And, with respect to warrior-knights and what was done with them
after death, I know nothing more curious than what is told us by
Stavely on the authority of Streder. I will give it in the author’s own
words.
“Don John of Austria,” says Stavely, “governor of the Netherlands for
Philip II. of Spain, dying at his camp at Buge” (Bouges, a mile from
Namur), “was carried from thence to the great church at Havre,
where his funeral was solemnized and a monument to posterity
erected for him there by Alexander Farnese, the Prince of Parma.
Afterward his body was taken to pieces, and the bones, packed in
mails, were privately carried into Spain, where, being set together
with small wires, the body was rejointed again, which being filled or
stuffed with cotton, and richly habited, Don John was presented to
the King, entire, leaning upon his commander’s staff, and looking as
if he were alive and breathing. Afterward the corpse being carried to
the Church of St. Laurence, at the Escurial, was there buried near
his father, Charles V., with a fitting monument erected for him.”
Considering that there was, and is, a suspicion that Philip II. had
poisoned his kinsman, the interview must have been a startling one.
But Philip II. was not, perhaps, so afraid of dead men as the fourth
Spanish king of that name. Philip IV., by no means an unknightly
monarch, was born on a Good Friday, and as there is a Spanish
superstition that they who are born on that day see ghosts whenever
they pass the place where any one has been killed or buried, who
died a violent death, this king fell into a habit of carrying his head so
high, in order to avoid seeing those spirits, that his nose was
continually en l’air, and he appeared to see nobody.
Romance, and perhaps faithful history, are full of details of the
becoming deaths of ancient knights, upon the field. I question,
however, if even Sir Philip Sidney’s was more dignified than that of a
soldier of the 58th infantry, recorded in Nichols’s “Anecdotes of the
Eighteenth Century.” A straggling shot had struck him in the
stomach. As he was too dreadfully wounded to be removed, he
desired his comrades would pray by him, and the whole guard knelt
round him in prayer till he died. Bishop Hurd remarked, when this
was told him, that “it was true religion.” There was more of religion in
such sympathy than there was of taste in the condolence of Alnwick,
on the death of Hugh, Duke of Northumberland—a rather irascible
officer, and Knight of the Garter. “O,” cried the Alnwick poet—

“O rueful sight! Behold, how lost to sense

The millions stand, suspended by suspense!”

But all fruitlessly were the millions so suspended, for as the minstrel
remarked in his Threnodia—

“When Time shall yield to Death, Dukes must obey.”

“Dying in harness,” is a favorite phrase in chivalric annals to illustrate

the bravery of a knight falling in battle, “clothed in complete steel.”
So to die, however, was not always to die in a fray. Hume says of
Seward, Earl of Northumberland, that there are two circumstances
related of him, “which discover his high sense of honor and martial
disposition. When intelligence was brought to him of his son
Osborne’s death, he was inconsolable till he heard the wound was
received on his breast, and that he had behaved with great gallantry
in the action. When he found his own death approaching, he ordered
his servants to dress him in a complete suit of armor, and sitting
erect on the couch, with a spear in his hand, declared that in that
position, the only one worthy of a warrior, he would patiently await
the fatal moment.”

See how the chief of many a field

Prepares to give his latest breath;
And, like a well-trimmed warrior, yield
Becomingly t’impending death—
That one, stern conqueror of all,
Of chieftain in embattled tower,
Of lord within his ancient hall,
And maiden in her trellised bower.

To meet that surest of all foes,

From off his soft and pillowed bed,
With dignity old Seward rose,
And to a couch of state was led.
Fainting, yet firm of purpose there,
 Stately as monarch on his throne,
Upright he sat, with kingly air,
To meet the coming foe, alone.

“Take from these limbs,” he weakly cried,

“This soft and womanish attire;
Let cloak and cap be laid aside—
Seward will die as died his sire:
Not clad in silken vest and shirt,
Like princes in a fairy tale;
With iron be these old limbs girt—
My vest of steel, my shirt of mail.

“Close let my sheaf of arrows stand;

My mighty battle-axe now bring;
My ashen spear place in my hand;
Around my neck my buckler sling.
Let my white locks once more be pressed
By the old cap of Milan steel;
Such soldier’s gear becomes them best—
They love their old defence to feel.

“’Tis well! Now buckle to my waist

My well-tried gleaming blade of Spain
My old blood leaps in joyful haste
To feel it on my thigh again.
And here this pendent loop upon,
Suspend my father’s dagger bright;
My spurs of gold, too, buckle on—
Or Seward dies not like a knight.”

’Twas done. No tear bedimmed his eyes—

His manly heart had ne’er known fear;
It answered not the deep-fetched sighs
Of friends and comrades standing near.
Death was upon him: that grim foe
Who smites the craven as the brave.
With patience Seward met the blow—
Prepared and willing for the grave.

The manner of the death, or rather of the dying of Seward, Earl of

Northumberland, was in part, unconsciously, imitated by the great
Mansfeldt. When the career of the latter was nearly at its close, his
fragile frame was already worn out by excess of action—his once
stout soul irritated by disappointment, and his former vigorous
constitution shattered by the ravages of a disease which had long
preyed on it in secret. The erst gallant knight lay helpless in the
miserable village of Zara, in Dalmatia. As he found his last moment
drawing near, he put on one of his richest uniforms, and girded his
favorite sword to his side. It was the one he most constantly carried
in battle. Thus accoutred, he summoned his chief officers to attend
him. He was held up by the two whom he most wished to distinguish,
because of their unwavering fidelity. Thus upheld, he exhorted all to
go on, unwearied, in the path of glory; and, living or dying, never to
bate a breath of inveterate hatred for Austria—whose government
has been accursed in all time, since there has been an Austria, for
its unmitigated infamy. “With the indifference of a man preparing for a
journey of no extraordinary importance,” thus speaks Naylor, when
describing the scene, “he continued tranquilly to converse with his
friends to the latest moment of his existence. His body was interred
with military pomp at Spalatio, in Dalmatia, at the expense of the
Venetians. Thus was the emperor delivered from an enemy who,
though often defeated, never ceased to be formidable; and whose
transcendent genius was so fertile in resources, that, without the
smallest funds to support the expenses of war, he maintained an
honorable contest during seven campaigns against the most
powerful monarchs in Europe.”

His hour at length is come:

The hero of a hundred fields,
Who never yielded, only yields
To Him who rules the tomb.

He whose loud trumpet’s blast,

Carried upon the trembling gale
The voice of death o’er hill and dale,
Is struck himself at last.

The same who, but of late,

Serenely saw destruction hurled,
And slaughter sweeping through the world,
Serenely meets his fate.
 The spirit of the brave,
That led him o’er the embattled plain
’Gainst lines of foes, o’er countless slain,
Waits on him to the grave.

And with his latest breath

The warrior dons his proud array,
Prepared to meet, and to obey,
His last commander—Death!

The mournful tears and sighs

Fall not for him who, like the swan,
Wears his best plumes, sings sweetly on,
Sounds his last song—and dies!

With regard to the burial of knights, we may observe that, down to a

comparatively late period the knights and barons of England were
buried with much solemn splendor. At the obsequies of a baron,
there was an official present who wore the armor of the defunct,
mounted a horse in full trappings, and carried the banner, shield, and
helmet, of the deceased. So, in Henry the Eighth’s time, Lord William
Courtney was buried with the ceremonies observed at the funeral of
an earl, to which rank it had been the king’s intention to elevate him.
On this occasion Sir Edmund Carew, a gallant knight, rode into the
church in full armor, with the point of his battle-axe downward—a
token, like a reversed torch, of death.
The latest instance I have met with of a union of ancient and modern
customs at the burial of a knight, occurred at Treves, in 1781, at the
interment of the Teutonic knight, General Frederick Casimir. This
gallant soldier’s charger was led to the brink of the grave in which
the body had just been deposited; the throat of the steed was swiftly
cut by an official, and the carcass of the horse was flung down upon
the coffin of the knight. Such sacrifices were once common enough.
At the funerals in England of cavalry soldiers, or of mounted officers,
the horse is still processionally conducted to the brink of the grave,
but we are too wisely economical to leave him there, or to fling him
into it.
Where chivalry had great perils and temptations, we need not be
surprised to find that there were many scions of noble houses who
either declined to win spurs by encountering mortal danger, or who
soon grew weary of making the attempt. Let us, then, consider the
unambitious gentlemen who grew “tired of it.”
 THE KNIGHTS WHO GREW “TIRED OF IT.”
“How blest are they that waste their weary hours
In solemn groves and solitary bower
Where neither eye nor ear
Can see or hear
The frantic mirth
And false delights of frolic earth;
Where they may sit and pant,
And breathe their pursy souls;
Where neither grief consumes, nor griping want
Afflicts, nor sullen care controls!
Away false joys! Ye murder where ye kiss;
There is no heaven to that, no life to this.”
Francis Quarles.

As marriage or the cloister was the alternative submitted to most

ladies in the days of old, so young men of noble families had small
choice but between the church and chivalry. Some, indeed,
commenced with arms, won knightly honors, cared nothing for them
when they had obtained the prize, and took up the clerical
profession, or entered monasteries. There are many distinguished
examples. There was first St. Mochua or Cluanus, who, after serving
in arms with great distinction, entered a monastery and took to
building churches and establishing cities. Of the former he built no
less than thirty; and he passed as many years in one church as he
had built of churches themselves. He was the founder of one
hundred and twenty cells. He is to be looked upon with respect. Old
warriors in our own days are often moved by the same impulse
which governed Mochua; and when we see retired admirals taking
the chair at meetings where Dr. Cumming is about to exhibit; or
infirm major-generals supporting, with unabated mental energy, their
so-called Puseyite pastors, we only look upon men who, acting
conscientiously, are worthy of respect, and are such Mochuas as
modern times and circumstances will admit of.
We have another example in Adelard, the cousin of Charlemagne.
He was a gay and gallant chevalier at his imperial cousin’s court,
and there was no stouter wielder of a sword in all the army; but
Alard, or Adelard, grew weary of camp and court alike. He fled from
some very pretty temptations in the one, as well as great perils in the
other. The young prince, he was only twenty, took the monastic habit
at Corbie, where he was employed as a gardener, and spoiled
cartloads of vegetables before he got his hand and his thoughts to
his new profession. He was occasionally busy too in the kitchen, but
not to the visible gratification of the monks. Charlemagne often
insisted on his appearing at court, where at last he held one or two
high offices; and, when he left, wrote a book for the guidance of
courtiers generally, by which the latter as little profited, say wicked
wits, as other nobility, for whom a nation has long prayed that grace,
wisdom, and understanding might be their portion. St. Adelard, for
the imperial knight was canonized, lived to be the chief authority in
the monastery where he had commenced as cook and gardener, and
St. Gerard composed an office in his honor, in gratitude for having
been cured of a violent headache through the saint’s interposition.
This seems to me one of the oddest ways of showing gratitude for a
small service that I ever heard of.
I believe that St. Cedd, Bishop of London, in very early days, was
also of a family whose profession was military. When or why he
entered the church I do not know; but he has some connection with
military matters in the fact that Tilbury Fort occupies part of the site
of a monastery which St. Cedd had founded, in which he resided,
and which was the pride of all the good people in the then pleasant
and prosperous city of Tillabury.
Touching St. Aldric, Bishop of Mans, there is no doubt whatever. He
was of a noble family, and commenced life at twelve years old, as
page to Louis le Debonnaire, at the court of Charlemagne. He was
speedily sick of the court, and as speedily sick of the camp. At the
age of twenty-one he withdrew to Metz, entered the clerical
profession, and became chaplain and confessor to the sovereign
whom he had once served as page. His military training made him a
very sharp disciplinarian during the quarter of a century that he was
bishop; and it is only to be regretted that he had not some influence
over the king whose conscience he directed, and of whom a legend
will be found in another part of this volume.
There was a second son of Eric, King of Denmark, known by the
name of St. Knudt or Canute. He was Duke of Schleswig, and was
much more of a monk than a duke. He was canonized accordingly
for his virtues. He had a rough way of joking. His knights were
nothing better than robbers and pirates, and he resolved to make
them forswear violence and live peaceably. They represented, in
vain, that they had a right to live as became knights, which Canute
did not dispute; he simply dissented from the construction of the right
as set down by the knights themselves. To prevent all mistakes on
the matter, he one day condemned seven of these gentlemen to be
hanged for acts of piracy. One of these exclaimed that, “fitting as the
sentence might be for his fellows, there must necessarily be
exemption for him.” He was like the German corporal in the “Etoile
du Nord,” who can very well understand that it is quite proper that a
man should be hanged, but could not comprehend that he himself
should be the man. The Schleswig knight claimed special exemption
on the ground that he was a kinsman of Canute. The latter allowed
that this entitled him to some distinction, and the saintly duke hung
his cousin six feet higher than any of his accomplices.
We come back more immediately to a knight who grew tired of his
vocation, in the person of Nathalan, a Scottish noble of the fifth
century. He sold arms, horses, and estate, divided the proceeds
among the poor, and devoted himself to preparations for ordination,
and the cultivation of vegetables. He bears a highly respectable
reputation on the roll of Bishops of Aberdeen.
We meet with a man more famous, in Peter of Sebaste, whose
pedigree showed more heroes than could be boasted by any of
Peter’s contemporaries. He is not an example, indeed, of a man
quitting the camp for the cloister; but he and two of his brothers
exhibit to us three individuals who might have achieved great worldly
profit, by adopting arms as a vocation, but who preferred the Church,
and became, all three, bishops.
We have a similar example in the Irish St. Felan. His high birth and
great wealth would have made him the flower of Irish chivalry, but he
selected another profession, and despising chivalry, entered the
Church. He went a Mundo ad Mundum, for it was from the hands of
Abbot Mundus that he received the monastic habit. Thus, as it was
wittily said, the world (Mundus) at once drove and drew him into the
Church. It is clear, however, that, like the old war-horse, he pricked
up his ears at the sound of battle, and took an interest in stricken
fields. To such conclusion we must come, if it be true, as is asserted
of him, that the battle of Bannockburn, in 1314, was won by Bruce
through the saint’s especial intercession. The Dukes of Normandy
owed equal obligations to St. Vaneng, who unbuckled the armor from
his aristocratic loins, to cover them with a frock; and built churches
for the Normans, where he offered up continual prayer for the
Norman dukes.
Then again, there was William Berringer, of the family of the Counts
of Nevers. No persuasion could induce the handsome William to
continue in the career he had embraced, the career of chivalry and
arms. His uncle, Peter the Hermit, may have had considerable
influence over him, and his change of profession was by no means
unprofitable, for the once horse-loving William became Archbishop of
Bourges: and he defended the rights of his Church against kings and
councils with as much boldness, zeal, and gallantry, as any knight
could have exhibited against the stoutest of assailants.
Among our English saints, the one who most nearly resembles him
is St. Egwin, who was of the royal blood of the Mercian kings, and
who, after a short trial of the profession of arms, retired to the
cloister, but was ultimately raised to the see of Worcester. The spirit
of the man may perhaps be seen through the legend which says that
on setting out on a penitential pilgrimage to Rome, he put iron
shackles on his legs, the key of which shackles he flung into the
Avon. This is very possible; but when we are told that on requiring
the key at a subsequent period, he found it inside a fish, we see that
the author of the legend has plagiarized from the original constructor
of the story of Polycrates and his ring.
St. Egwin was far less a benefactor to his fellow-men than St.
Benedict Biscop, a noble knight of the court of Oswi, the pious king
of the Northumbrians. When Benedict, or Bennet, as he is familiarly
called, retired from the profession of arms to follow that of the
Church, he continued quite as active, and twice as useful, as he had
been before. He was a great traveller, spent and gave liberally, and
brought over with him, from the continent, workers in stone to erect
that monastery at Weremouth which, in its ruins, commemorates his
name and deeds. He also brought from France the first glaziers who
ever exercised the art of glass-making in England. Altogether St.
Bennet is one of those who find means to effect good to others,
whatever may be the position they are in themselves.
Aelred of Ridal was a man of similar quality. He was a young North-
of-England noble, when he figured as the handsomest cavalier at the
court of that “sair saint to the Church,” the Scottish king, David. He
was remarkable for his good temper, and was as well-disciplined a
monk as he had been a military man; for when he once happened to
inadvertently break the rule of permanent silence, which prevailed in
the monastery at Ridal, into which he entered at the age of twenty-
five, he became so horror-stricken that he was eager to increase the
penalty put upon him in consequence. He had only dropped a single
word in the garden, to a monk who, like himself, had been a knight,
but who gave him in return so edifying a scowl, that in an instant
poor Aelred felt all the depth of his unutterable iniquity, and
accounted himself as criminal as if he had set fire to the neighboring
nunnery. He never afterward allowed himself the indulgence of
reading his favorite Cicero, but confined his reading to his own work
“On Spiritual Friendship,” and other books of a similar description.
The great St. Hilary was another of the men of noble family following
arms as a vocation, who gave up the profession for that of the
Church, and prospered remarkably in consequence. St. Felix of Nola
affords us an additional illustration of this fact. This noble young
soldier found no happiness in the business of slaughtering, and all
the sophistry in the world could not persuade him that it was
honorable. “It is a disgusting business,” said the Saint, “and as I can
not be Felix [happy] in performing it, I will see if I can not be Felix in
the Church;” and the punning saint found what he sought.
There is something more wonderful in the conversion of St. Maurus.
He was the son of a nobleman, had St. Benedict for a tutor, and was
destined to the career of arms. The tutor, however, having awoke
him one night, and sent him to pick a monk out of the river, whom
Benedict, in a dream, had seen fall in, Maurus, although no
swimmer, obeyed, walked upon the surface of the water, pulled out
the struggling monk, walked back with him, arm-in-arm, to the shore,
and immediately concluded that he was called to another vocation
than that of arms. As for St. John Calybyte, he would not be a
soldier, but ran away from home before his wealthy sire could
procure him a commission, and only returned to stand, disguised as
a mendicant, in front of his father’s house, where he received alms
till he died. A curious example of idiosyncrasy. St. Honoratus was
wiser. He was of a consular family; but, in declining the military
profession, he addressed himself with sincerity to be useful in the
Church; and the well-deserved result was that he became
Archbishop of Arles. St. Anthony, the patriarch of monks, made still
greater sacrifices, and chose rather to be a hermit than a
commander of legions. St. Sulpicius, the Debonnair, was both rich
and good-looking, but he cared less for helmet and feathers than for
cord and cowl, and the archbishopric of Bourges rewarded his self-
denial. There was more than one King Canute too, who, though not
surrendering royalty and generalship of armies, seemed really more
inclined, and indeed more fitted, to be studious monks than
chivalrous monarchs. Wulstan of Worcester was far more decided,
for finding himself, one night, most warmly admiring the young lady
who was his vis-à-vis in a dance, the gallant officer was so shocked
at the impropriety, that he made it an excuse for taking to the cowl
forthwith. He did not so ill by the exchange, for the cowl brought him
to the mitre at Worcester.
St. Sebastian was a far bolder man, seeing that although he hated a
military life, he, to the very utmost, did his duty in that state of life to
which it had pleased God to call him; and if half be true of what is
told of him, there never was knight of the actual days of chivalry who
performed such bold and perilous actions as St. Sebastian. What
was a cavalier, pricking against a dragon, to a Roman officer
preaching Christianity to his men, under Diocletian?
In later days we meet with St. Raymund of Pennafort, the wealthy
young lord, who, rather than serve for pay or plunder, went about
teaching philosophy for nothing. St. John, the Patriarch of
Alexandria, might have been known as a conqueror, but he preferred
being handed down, under the title of the Almoner. He was like that
St. Cadoc who chose rather to be abbot in, than prince of, Wales. St.
Poppo of Stavelo exhibited similar humility. He was rapidly rising in
the Flandrian army when he suddenly sunk into a cell, and became a
sort of Flemish John Wesley. He preached against all tournaments,
but only succeeded in abolishing the very exciting combats between
a knight and a bear, which were greatly patronized by Flemish
ladies, and at which parties staked great sums upon their favorite
animal.
St. Francis of Sales, on the other hand, that gentlemanly saint, was
saved from the knightly career which his noble birth seemed to
promise him, by a vow made by his mother, before he was born. She
was resolved that he should be a saint and not a soldier, and as all
things went as the lady desired, she placed her son in a position
direct for the Church, and the world certainly lost nothing by the
matron’s proceeding. I respect St. Francis of Sales all the more that
he had small human failings, and did not scatter damnation over
men whom he saw in a similar concatenation. Sulpicius Severus
was, in many respects, like him, save that he had some experience
of a soldier’s life. But he laid down the sword for the pen, and gave
us that admirable historical romance, in which he details so
graphically the life of another noble warrior, who quitted the
command of soldiers, to take up the teaching of men—St. Martin of
Tours.
There was a lady, St. Aldegonde, of the royal blood of France, in the
seventh century, who at least encouraged young knights to abandon
their fancied vocation, and assume that of monks or friars. She was,
most undeservedly, I dare say, assailed by scandalizing tongues
accordingly. Indeed, I never heard of lady more persecuted in this
way, except perhaps this particular lady’s namesake, who once
belonged to the gay troupe of the Varietés, and to whom the most
rattling of chansonniers alluded, in the line of a song, which put the
significant query of

Que fait Aldegonde avec le monde entier?

One of the most remarkable features in the characters of many of

these young nobles who were disinclined to take up arms, or who
laid them down for the religious vocation, is the dread they
entertained of matrimony. In illustration of this fact, I may notice the
case of St. Silvin of Auchy. There was not a gayer or braver knight at
the court of Childeric II., nor a more welcome wooer among the
ladies. In due time he proposed to a noble maiden, who was in a
flutter of happiness at the thought of carrying off such a bachelor
from a host of competitors. The wedding was brilliant, up to the
conclusion of the ceremony. That over, no persuasion could induce
the bridegroom to go to the breakfast. As he had been brought to the
altar, there he was resolved to remain. He denounced all weddings
as wicked vanities, and darting out of the church-door, left bride and
bridal party to take what course they would. There was no end of
conjectures as to the cause of the sudden fright which had seized
upon the young bridegroom. The latter set it down to inspiration, and
as he took to the cowl and led a most exemplary life, no one
presumed to doubt it, except the bride and her relations.
The case of St. Licinius is easier of explanation. He was the most
rollicking knight-bachelor at the court of Clotaire I. It must, however,
be said for him that he sowed his wild oats early, and fought none
the less stoutly for going to mass daily, and confessing once a
quarter. He was rich, and had a maiden neighbor who was richer.
The families of knight and maiden were united in thinking that the
estates of the two, encircled in one ring fence, would be one of the
most desirable of consummations. The maiden was nothing loath,
the knight alone was reluctant. He too, had his doubts about the
excellence of marriage, and it was only with very considerable
difficulty he was brought to woo the lady, who said “Yes” before the
plume in his bonnet had touched the ground when he made his bow
to her. The wedding-day was fixed, and as the old epitaph says,
“wedding-clothes provided.” On the eve of the eventful day, however,
Licinius, on paying a visit to the bride, found her suddenly attacked
with leprosy. The doctor protested that it would be nothing, but
Licinius declared that it was a warning which he dared not neglect.
He looked at the leprous lady, muttered the word “unpleasant,” and
at once betook himself, not to active military life, but to a religious
mission. In this occupation he is alleged to have performed such
miracles as to deserve canonization, if only the half of them were
true.
Now, a bride afflicted with leprosy may fairly be said to be an
unpleasant sight. Licinius may even be considered authorized to
hesitate in performing his promise, if not in altogether declaring off.
We can not say as much in extenuation of another knight who broke
his word to a lady, and was clapped into the Roman calendar of
deified men. This gentleman in question had a rather unchristian-
sounding name. He was called Abraham of Chiduna. At tilt and
tournament, and in tented field, there was no cavalier who sat more
perfectly in saddle, or handled his lance and wielded his battle-axe
with more terrible effect. He was of noble birth, of course; was
wealthy, somewhat addicted to light living, in his salad days, but a
man who lived soberly enough when those were over. He then
resolved to marry, and he had the “good taste,” if one may use a
term which, we are told, belongs to the literary milliner’s vocabulary,
to offer himself to, and ask the hand of a very pious maiden with a
highly satisfactory dower. The required conclusion was soon come
to, and one fine spring morning saw the two principals and their
respective friends in church. The knight, it is true, was the last to
arrive, and he had been, previously, as unwilling to get up and be
married, as Master Barnardine was to get up and be hanged. He
was finally brought to the altar, and after some little delay, such as
searching for the ring which he had misplaced, and only recovered
after much search, the nuptial knot was tied. When this had been
accomplished, surrounding friends approached to offer their
congratulations; but the icy Abraham coldly waved them back, and
announced his determination, then and there, to end his short-lived
married state. As he immediately rushed into the wood which was in
the vicinity of the church, there was a universal cry that he
contemplated suicide. The bride was conveyed home amid much
sympathy, and a general but an ineffectual search was made for the
“groom.” Yet, not altogether ineffectual, for at the end of seventeen
days he was discovered, offering up his orisons, in the midst of a
marsh. There he had been, he said, for a fortnight, and there he
declared he would remain, unless those who sought him consented
to the terms he should propose. These were, that he should be
allowed to retire to a cell which should be entirely walled up, save a
small square aperture for a window. The agreement was ratified, and
Abraham was shut up according to his desire; and by a long life of
seclusion, passed in preaching to all who approached the window,
and taking in all they brought through the same aperture, Abraham
has had “Beatus” attached to his name, and that name has been
recorded upon the roll of saints.
If there be any reader who objects to this story as unnatural, I would
remark to the same, that similar incidents may be met with in our
own time. In proof thereof I will briefly relate an anecdote which was
told me by the reverend father of a legal knight, who was himself the
officiating minister at the ceremony of which I am about to speak.
To the clergyman of a pretty village in Wales, due notice had been
given, and all preliminary legal observances having been fulfilled, he
awaited in his vestry, ready to marry an ex-sergeant and one of the
girls of the village. The canonical hours were fast gliding away, and
yet the priest was not summoned to the altar. By certain sounds he
could tell that several persons had assembled in the church, and he
had two or three times seen a pretty face peeping in at the vestry-
door, with a look upon it of pleasure to see that he was still there,
and of perplexity as if there was something to be told which only
waited to be asked for. At half-past eleven the face again peeped in,
whereupon the clergyman invited the owner of it to approach nearer.
The invitation was obeyed, and the clergyman inquired the reason
for the unusual delay, remarking at the same time, that if the parties
were not speedily prepared it would be too late to perform the
ceremony that day.
“Well sir,” said the nymph, “I was about asking your advice. I am the
bride’s sister; and there is a difficulty—”
“What is it?” asked the priest.
“Just this, sir,” said Jenny. “Sergeant Jones has promised to marry
sister Winnifred if father will put down five pounds. Father agrees;
but he says that if he puts down the money before the marriage, the
sergeant will walk off. And the sergeant will not come up to be
married till the money is put down. So, you see, sir, we are in a
terrible difficulty; and we want you to propose a method to get us out
of it.”
“There is nothing easier,” said the minister; “let your father put the
money into the hands of a trusty third person, who will promise to
place it in the sergeant’s possession as soon as he has married your
sister.”
Jenny Morgan saw the excellence of the device in a moment, rushed
back to the bridal parties, and they showed their appreciation of the
clergyman’s suggestion, by crowding to the altar as soon as the
preliminary proceeding recommended to them had been
accomplished. At length the clergyman came to the words, “Wilt thou
have this woman to thy wedded wife?”
“Jack,” said the ex-sergeant, looking round at the stake-holder, “have
you got the cash?”
“All right!” nodded Jack.
“Then I will,” said the sergeant; “and now, Jack, hand over the tin.”
The agreement was rigidly fulfilled; but had not the minister thought
of the means which solved the difficulty, Sergeant Jones would have
been nearly as ungallant to his lady as Abraham, Silvin, and Licinius,
had been to theirs.
But to return to Abraham. I have said this knight, on assuming his
monkly character, had caused himself to be walled up in his cell. I
have my suspicions, however, that it was a theatrical sort of wall, for
it is very certain that the saint could pass through it. Now, there
resided near him a lady recluse who was his “niece,” and whose
name was Mary. The two were as inseparable as the priest Lacombe
and Madame Guyon; and probably were as little deserving of
reproach. This Mary was the original of “Little Red Riding Hood.” She
used to convey boiled milk and butter, and other necessary matters
to her uncle Abraham. Now it happened that the ex-knight used also
to be visited by a monk whose name was Wolf, or who, at all events,
has been so called by hagiographers, on account of his being quite
as much of a beast as the quadruped so called. The monk was wont
to fall in with Mary as she was on her way to her uncle’s cell with
pleasant condiments under a napkin, in a wicker-basket. He must
have been a monk of the Count Ory fashion, and he was as
seductive as Ponchard, when singing “Gentille Annette” to the “Petit
Chaperon Rouge,” in Boieldieu’s Opera. The result was, that the
monk carried off Mary to a neighboring city—Edessa, if I remember
rightly—and if I am wrong, Mr. Mitchell Kemble will, perhaps, set me
right, in his bland and gentleman-like way. The town-life led by these
two was of the most disgraceful nature; and when the monk had
grown tired of it, he left Mary to lead a worse, without him. Mary
became the “Reine Pomare,” the “Mogadore,” the “Rose Pomponne”
of Edessa, and was the terror of all families where there were elder
sons and latch-keys. Her doings and her whereabouts at length
reached the ears of her uncle Abraham, and not a little astonished
were those who knew the recluse to see him one morning, attired in
a pourpoint of rich stuff, with a cloak like Almaviva’s, yellow buskins
with a fall of lace over the tops, a jaunty cap and feather on his head,
a rapier on his thigh, and a steed between his legs, which curveted
under his burden as though the fun of the thing had given it
lightness. At Mary’s supper, this cavalier was present on the night of
his arrival in Edessa. He scattered his gold like a Crœsus, and Mary
considered him worth all the more penniless knights put together.
When these had gone, as being less welcome, Abraham declared
his relationship, and acted on the right it gave him to rate a niece
who was not only an ungrateful minx, but who was as mendacious
as an ungrateful niece could well be. The old gentleman, however,
had truth on his side, and finally so overwhelmed Mary with its
terrible application, that she meekly followed him back to the desert,
and passed fifteen years in a walled-up cell close to that of her
uncle. The miracles the two performed are adduced as proofs of the
genuineness of the personages and their story; matters which I
would not dispute even if I had room for it.
The next knight whom I can call to mind as having been frightened
by marriage into monkery, is St. Vandrille, Count of the Palace to
King Dagobert. During the period of his knightship he was a very
Don Juan for gallantry, and railed against matrimony as conclusively
as a Malthusian. His friends pressed him to marry nevertheless; and
introduced him to a lady with a hundred thousand golden qualities,
and prospects as auriferous as those of Miss Kilmansegg. He took
the lady’s hand with a reluctance that might be called aversion, and
which he did not affect to conceal. When the nuptial ceremony was
concluded, Knight Vandrille, as eccentric as the cavaliers whose
similar conduct I have already noticed, mildly intimated that it was
not his intention to proceed further, and that for his part, he had
renounced the vanities of this world for aye. Taking the lady apart, he
appears to have produced upon her a conviction that the
determination was one he could not well avoid; and we are not told
that she even reproached him for a conduct which seems to me to
have been a thousand times more selfish and inexcusable than that
of the clever but despicable Abelard. The church, however, did not
disapprove of the course adopted, and St. Vandrille, despite his
worse than breach of promise, has been forgiven as knight, and
canonized as saint.
Far more excusable was that little Count of Arian, Elzear, the boy-
knight at the court of Charles II., King of Sicily, whom that monarch
married at the age of thirteen years, to Delphina of Glandeves, a
young lady of fifteen. When I say far more excusable, I do Elzear
some injustice, for the boy was willing enough to be wed, and looked
forward to making his lady proud of his own distinction as a knight.
Delphina, however, it was who proposed that they should part at the
altar, and never meet again. She despised the boy, and the little
cavalier took it to heart—so much so, that he determined to
renounce the career of arms and enter the church. Thereby chivalry
lost a worthy cavalier, and the calendar gained a very active saint.