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 SECOND EDITION

Kamaya | Wong-You-Cheong
Bhatt | Morgan | Lane | Wasnik
ii
 SECOND EDITION

Aya Kamaya, MD, FSRU, FSAR

Professor
Department of Radiology
Interim Chief, Body Imaging Division
Director, Ultrasound
Standford University
Stanford, California

Jade Wong-You-Cheong,
MBChB, MRCP, FRCR, FSRU, FSAR
Professor
Department of Diagnostic Radiology and Nuclear Medicine
University of Maryland School of Medicine
Director of Ultrasound
University of Maryland Medical Center
Baltimore, Maryland

Shweta Bhatt, MD Barton F. Lane, MD

Professor of Radiology Assistant Professor
Mayo Clinic University of Maryland School of Medicine
Jacksonville, Florida Clinical Director of CT
Department of Diagnostic Radiology and
Nuclear Medicine
Tara A. Morgan, MD Baltimore, Maryland
Associate Professor of Radiology and
Biomedical Imaging
Department of Abdominal Imaging and Ultrasound Ashish P. Wasnik, MD, FSAR
Director of Ultrasound-Guided Interventions Associate Professor of Radiology
University of California, San Francisco Director, Ultrasound
San Francisco, California Michigan Medicine: University of Michigan
Ann Arbor, Michigan

iii
 Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

DIAGNOSTIC ULTRASOUND: ABDOMEN & PELVIS, SECOND EDITION ISBN: 978-0-323-79402-2

Inkling: 978-0-323-79404-6
Copyright © 2022 by Elsevier. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying,
recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright
Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or
property as a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

Previous edition copyrighted 2016.

Library of Congress Control Number: 2021936710

Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
With love and gratitude to my incredibly supportive husband, Yuji, our sweet
kids, Kenzo (10) and Mika (7), my parents & parent-in-laws, my mentor,
Brooke Jeffrey, who inspired my academic career, and my wonderful
colleagues, fellows, residents, and sonographers at Stanford.
d.

AK

Dedicated to: Patrick, for being my rock at all times and for making me
laugh when I need it most; Mark, Michael, Mindy, and my family, for their
love and support; and to all the amazing sonographers
aph at UMMC.

JWYC

v
 Contributing Authors
Maram Aljuaid, MD Gayatri Joshi, MD, FAIUM
Radiology Resident Assistant Professor of Radiology
Department of Radiology and Diagnostic Imaging Department of Radiology and Imaging Sciences
University of Maryland Medical Center Assistant Professor of Emergency Medicine
Baltimore, Maryland Department of Emergency Medicine
King Saud University Emory University School of Medicine
Riyadh, Saudi Arabia Atlanta, Georgia

Neha Antil, MD, DNB Cody Keller, MD

Postdoctoral Fellow Postdoctoral Fellow
Department of Radiology Department of Radiology
Stanford University School of Medicine Stanford University School of Medicine
Stanford, California Stanford, California

David Burrowes, MD Jane S. Kim, MD

Clinical Assistant Professor
Cumming School of Medicine
University of Calgary
Calgary, Alberta, Canada
Frank Chen, MD
Assistant Professor
Department of Radiology
Mayo Clinic
Jacksonville, Florida
Akshya Gupta, MD
Assistant Professor
Department of Imaging Sciences
University of Rochester
Rochester, New York
Ghada Issa, MD
Assistant Professor
Department of Diagnostic Imaging
The Warren Alpert Medical School of Brown University
Providence, Rhode Island
Priyanka Jha, MBBS
Associate Professor
Department of Radiology and Biomedical Imaging
University of California, San Francisco
San Francisco, California
Assistant Professor of Pediatrics and Radiology
Division of Diagnostic Radiology & Imaging
Children’s National Hospital
George Washington School of Medicine
Washington, District of Columbia
Lori Mankowski Gettle, MD, MBA, FSRU
Chief of Ultrasound
Assistant Professor of Radiology
University of Wisconsin School of Medicine and
Public Health
Madison, Wisconsin
Maria A. Manning, MD
Section Chief, Gastrointestinal Radiology
Associate Physician-in-Chief
American Institute of Radiologic Pathology
Professor of Radiology
Georgetown University School of Medicine
Washington, District of Columbia
Alexandra Medellin, MD
Clinical Assistant Professor
Department of Radiology
University of Calgary
Calgary, Alberta, Canada
L. Nayeli Morimoto, MD
Clinical Assistant Professor
Department of Radiology
Stanford University School of Medicine
Stanford, California

vi
 Henal Motiwala, MD Justin Ruey Tse, MD
PGY3/R2 Assistant Professor
Department of Diagnostic Radiology Stanford University School of Medicine
University of Maryland Medical Center Stanford, California
Baltimore, Maryland
Fauzia Vandermeer, MD
Ankur Pandey, MD Staff Radiologist
Radiology Resident WellSpan Radiology
Department of Diagnostic Radiology and WellSpan Health
Nuclear Medicine York, Pennsylvania
University of Maryland Medical Center
Baltimore, Maryland Stephanie R. Wilson, MD
Clinical Professor of Radiology and Medicine
Amir M. Pirmoazen, MD University of Calgary
Postdoctoral Fellow Calgary, Alberta, Canada
Department of Radiology
Stanford University School of Medicine Amelia Wnorowski, MD
Stanford, California Assistant Professor
Department of Diagnostic Radiology and
Margarita V. Revzin, MD, MS Nuclear Medicine
Associate Professor of Radiology University of Maryland School of Medicine
Department of Radiology and Biomedical Imaging Baltimore, Maryland
Yale University School of Medicine
New Haven, Connecticut

Shuchi K. Rodgers, MD Additional Contributors

Associate Chair, Body Imaging
Director of Ultrasound Amit B. Desai, MD
Department of Radiology
Richard E. Fan, PhD
Einstein Medical Center
Clinical Associate Professor of Radiology Mary Frates, MD
Sidney Kimmel Medical College
Thomas Jefferson University Danielle Richman, MD, MS
Philadelphia, Pennsylvania Geoffrey Sonn, MD
Ali M. Tahvildari, MD
Clinical Assistant Professor (Adjunct)
Department of Radiology
Stanford University School of Medicine
Stanford, California

Katherine To'o, MD
Staff Radiologist
Section Chief, Abdominal Imaging
VA Palo Alto Health Care System
Palo Alto, California
Clinical Associate Professor (Affiliated)
Department of Radiology
Stanford University School of Medicine
Stanford, California

vii
viii
 Preface
Ultrasound is often the 1st imaging study in initial evaluation of patients presenting with
abdominal or pelvic pain, abnormal biochemical tests, suspected mass, or gynecologic
symptoms. Depending on the ultrasound findings, patients may go on to further imaging,
or in many cases, the clinical decision is based on ultrasound findings alone. It is therefore
imperative that the radiologist confidently recognize the sonographic appearance of specific
diagnoses. The more the radiologist knows about the sonographic appearance of specific
entities, the less likely a patient will be referred for potentially unnecessary further imaging.

We feel this book provides this information to you in an easily digestible and visually appealing
format. We have tailored this book for the well-rounded abdominal radiologist who uses all
imaging modalities in evaluation of the abdomen and pelvis but with a focus on ultrasound.
You will find numerous examples of grayscale, color, power, and spectral (pulsed) Doppler
imaging in each patient and, when applicable, contrast-enhanced ultrasound. Numerous
cine clips of each entity are available in the eBook and online, helping to enhance the visual
understanding of each entity. Correlation with CT and MR is provided in many chapters.
Detailed artistic renderings of each disease entity further complement the visual splendor of
the book.

In this era, when conservative use of radiation exposure from CT, as well as judicious use of
iodinated- or gadolinium-based contrast, are increasingly important, ultrasound is an attractive
and optimal imaging modality. Ultrasound is more available and accessible, especially in
resource-limited settings. Moreover, ultrasound technology continues to improve, resulting
in dramatic changes in image quality in the last decade with higher resolution imaging, noise-
reduction techniques, and increased Doppler sensitivity. 3D transducers are in widespread
use. Contrast-enhanced ultrasound and shear wave elastography are the newest ultrasound
techniques that are becoming standard diagnostic and screening tools.

The 1st edition of our book, Diagnostic Ultrasound: Abdomen and Pelvis, was well received
and continues to be highly popular. However, a new edition is warranted. New reporting
and management guidelines, such as O-RADS for ovary, US LI-RADs and CEUS LI-RADS for
liver, and new criteria for many other diagnoses have been included in this edition. Access
to over 2,000 additional digital images and hundreds of new cine clips is provided online and
in the eBook. We are excited to bring all this information to you in a single comprehensive,
beautifully illustrated resource. Please enjoy!

Aya Kamaya, MD, FSRU, FSAR Jade Wong-You-Cheong,

Professor
MBChB, MRCP, FRCR, FSRU, FSAR
Department of Radiology Professor
Interim Chief, Body Imaging Division Department of Diagnostic Radiology
Director, Ultrasound and Nuclear Medicine
Stanford University University of Maryland School of Medicine
Stanford, California Director of Ultrasound
University of Maryland Medical Center
Baltimore, Maryland

ix
x
Acknowledgments
LEAD EDITOR
Kathryn Watkins, BA

LEAD ILLUSTRATOR
Lane R. Bennion, MS

TEXT EDITORS
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Nina I. Themann, BA
Terry W. Ferrell, MS
Megg Morin, BA

ILLUSTRATIONS
Richard Coombs, MS
Laura C. Wissler, MA

IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

MEDICAL EDITOR
Ann Podrasky, MD, FSRU, FAIUM

ART DIRECTION AND DESIGN

Tom M. Olson, BA

PRODUCTION EDITORS
Emily C. Fassett, BA
John Pecorelli, BS

xi
xii
 Sections
PART I: Anatomy
SECTION 1: Abdomen
SECTION 2: Pelvis

PART II: Diagnoses

SECTION 1: Liver
SECTION 2: Biliary System
SECTION 3: Pancreas
SECTION 4: Spleen
SECTION 5: Urinary Tract
SECTION 6: Kidney Transplant
SECTION 7: Adrenal Gland
SECTION 8: Abdominal Wall/Peritoneal Cavity
SECTION 9: Bowel
SECTION 10: Scrotum
SECTION 11: Female Pelvis

PART III: Differential Diagnoses

SECTION 1: Liver
SECTION 2: Biliary System
SECTION 3: Pancreas
SECTION 4: Spleen
SECTION 5: Urinary Tract
SECTION 6: Kidney
SECTION 7: Abdominal Wall/Peritoneal Cavity
SECTION 8: Prostate
SECTION 9: Bowel
SECTION 10: Scrotum
SECTION 11: Female Pelvis

xiii
 TABLE OF CONTENTS

Part I: Anatomy DIFFUSE PARENCHYMAL DISEASE

162 Hepatitis
SECTION 1: ABDOMEN Aya Kamaya, MD, FSRU, FSAR
4 Liver 166 Hepatic Cirrhosis
Aya Kamaya, MD, FSRU, FSAR Aya Kamaya, MD, FSRU, FSAR
20 Biliary System 170 Hepatic Fibrosis/Elastography
L. Nayeli Morimoto, MD Amir M. Pirmoazen, MD and Aya Kamaya, MD, FSRU,
30 Spleen FSAR
Ali M. Tahvildari, MD 172 Hepatic Steatosis
38 Pancreas Aya Kamaya, MD, FSRU, FSAR and Amir M. Pirmoazen,
Margarita V. Revzin, MD, MS MD
44 Kidneys 176 Hepatic Schistosomiasis
Lori Mankowski Gettle, MD, MBA, FSRU Aya Kamaya, MD, FSRU, FSAR and Neha Antil, MD, DNB
60 Bowel 178 Sinusoidal Obstruction Syndrome (Venoocclusive
Alexandra Medellin, MD and Stephanie R. Wilson, MD Disease)
78 Abdominal Lymph Nodes Aya Kamaya, MD, FSRU, FSAR
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, 180 Ultrasound LI-RADS
FSAR Aya Kamaya, MD, FSRU, FSAR
82 Peritoneal Spaces and Structures
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, CYST AND CYST-LIKE LESIONS
FSAR 184 Hepatic Cyst
88 Abdominal Wall Aya Kamaya, MD, FSRU, FSAR and Neha Antil, MD, DNB
Tara A. Morgan, MD 188 Biliary Hamartoma
Aya Kamaya, MD, FSRU, FSAR
SECTION 2: PELVIS 190 Caroli Disease
98 Ureters and Bladder Neha Antil, MD, DNB and Aya Kamaya, MD, FSRU, FSAR
Ashish P. Wasnik, MD, FSAR 194 Biloma
108 Prostate Gayatri Joshi, MD, FAIUM and Aya Kamaya, MD, FSRU,
Katherine To'o, MD and Richard E. Fan, PhD FSAR
116 Testes 196 Mucinous Cystic Neoplasm of Liver
Shweta Bhatt, MD Cody Keller, MD and Aya Kamaya, MD, FSRU, FSAR
128 Uterus 200 Pyogenic Hepatic Abscess
Barton F. Lane, MD Aya Kamaya, MD, FSRU, FSAR and Neha Antil, MD, DNB
138 Cervix 204 Amebic Hepatic Abscess
Barton F. Lane, MD Aya Kamaya, MD, FSRU, FSAR and Neha Antil, MD, DNB
142 Vagina 206 Hepatic Echinococcus Cyst
Barton F. Lane, MD Aya Kamaya, MD, FSRU, FSAR and Neha Antil, MD, DNB
146 Ovaries 210 Hepatic Diffuse Microabscesses
Priyanka Jha, MBBS Aya Kamaya, MD, FSRU, FSAR and Neha Antil, MD, DNB
212 Peribiliary Cyst
Aya Kamaya, MD, FSRU, FSAR
Part II: Diagnoses
FOCAL SOLID MASSES
SECTION 1: LIVER 214 Hepatic Cavernous Hemangioma
INTRODUCTION AND OVERVIEW David Burrowes, MD and Aya Kamaya, MD, FSRU, FSAR
218 Focal Nodular Hyperplasia
158 Approach to Hepatic Sonography David Burrowes, MD and Aya Kamaya, MD, FSRU, FSAR
Shuchi K. Rodgers, MD 222 Hepatic Adenoma
Justin Ruey Tse, MD and Aya Kamaya, MD, FSRU, FSAR

xiv
 TABLE OF CONTENTS
226 Hepatocellular Carcinoma 292 Porcelain Gallbladder
David Burrowes, MD and Aya Kamaya, MD, FSRU, FSAR Maria A. Manning, MD
232 Hepatic Metastases 294 Hyperplastic Cholecystosis (Adenomyomatosis)
Aya Kamaya, MD, FSRU, FSAR Maria A. Manning, MD
236 Hepatic Lymphoma 296 Gallbladder Carcinoma
David Burrowes, MD and Aya Kamaya, MD, FSRU, FSAR Maria A. Manning, MD
238 CEUS LI-RADS
Shuchi K. Rodgers, MD DUCTAL PATHOLOGY
300 Biliary Ductal Dilatation
VASCULAR CONDITIONS L. Nayeli Morimoto, MD and Aya Kamaya, MD, FSRU,
244 Transjugular Intrahepatic Portosystemic Shunt (TIPS) FSAR
Aya Kamaya, MD, FSRU, FSAR 302 Choledochal Malformation
246 Portal Vein Occlusion Neha Antil, MD, DNB and Aya Kamaya, MD, FSRU, FSAR
Aya Kamaya, MD, FSRU, FSAR 306 Choledocholithiasis
248 Budd-Chiari Syndrome L. Nayeli Morimoto, MD and Aya Kamaya, MD, FSRU,
Aya Kamaya, MD, FSRU, FSAR FSAR
250 Portal Vein Gas 308 Biliary Ductal Gas
Aya Kamaya, MD, FSRU, FSAR L. Nayeli Morimoto, MD and Aya Kamaya, MD, FSRU,
252 Portal Hypertension FSAR
Danielle Richman, MD, MS and Mary Frates, MD 310 Cholangiocarcinoma
256 Hepatic Artery Pseudoaneurysm/Aneurysm David Burrowes, MD and Aya Kamaya, MD, FSRU, FSAR
Akshya Gupta, MD and Shweta Bhatt, MD 314 Ascending Cholangitis
Justin Ruey Tse, MD and Aya Kamaya, MD, FSRU, FSAR
LIVER TRANSPLANTS 316 Recurrent Pyogenic Cholangitis
260 Liver Transplant Hepatic Artery Cody Keller, MD and Aya Kamaya, MD, FSRU, FSAR
Stenosis/Thrombosis
Aya Kamaya, MD, FSRU, FSAR SECTION 3: PANCREAS
262 Liver Transplant Portal Vein Stenosis/Thrombosis INTRODUCTION AND OVERVIEW
Aya Kamaya, MD, FSRU, FSAR
263 Liver Transplant Hepatic Venous 320 Approach to Pancreatic Sonography
Stenosis/Thrombosis Tara A. Morgan, MD
Aya Kamaya, MD, FSRU, FSAR
264 Liver Transplant Biliary Stricture PANCREATITIS
Aya Kamaya, MD, FSRU, FSAR 324 Acute Pancreatitis
Tara A. Morgan, MD
SECTION 2: BILIARY SYSTEM 326 Pancreatic Pseudocyst
Margarita V. Revzin, MD, MS
INTRODUCTION AND OVERVIEW 330 Chronic Pancreatitis
268 Approach to Biliary Sonography Tara A. Morgan, MD
Maria A. Manning, MD
SIMPLE CYSTS AND CYSTIC NEOPLASMS
GALLSTONES AND MIMICS 332 Mucinous Cystic Pancreatic Tumor
272 Cholelithiasis Tara A. Morgan, MD
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, 334 Serous Cystadenoma of Pancreas
FSAR Tara A. Morgan, MD
276 Gallbladder Polyps 336 Intraductal Papillary Mucinous Neoplasm (IPMN)
Maria A. Manning, MD Tara A. Morgan, MD

GALLBLADDER WALL PATHOLOGY SOLID-APPEARING PANCREATIC

280 Acute Calculous Cholecystitis NEOPLASMS
Maria A. Manning, MD 338 Pancreatic Ductal Carcinoma
284 Acute Acalculous Cholecystitis Tara A. Morgan, MD
Maria A. Manning, MD 342 Pancreatic Neuroendocrine Neoplasm
288 Chronic Cholecystitis Tara A. Morgan, MD
Maria A. Manning, MD 344 Solid Pseudopapillary Neoplasm
290 Xanthogranulomatous Cholecystitis Tara A. Morgan, MD
Maria A. Manning, MD

xv
 TABLE OF CONTENTS
PANCREAS TRANSPLANT CYSTS AND CYSTIC DISORDERS
346 Approach to Pancreatic Transplant Sonography 406 Simple Renal Cyst
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, Barton F. Lane, MD and Ankur Pandey, MD
FSAR 410 Complex Renal Cyst
350 Pancreas Transplant Vascular Complications Ankur Pandey, MD and Barton F. Lane, MD
Ashish P. Wasnik, MD, FSAR and Jade Wong-You-Cheong, 414 Cystic Disease of Dialysis
MBChB, MRCP, FRCR, FSRU, FSAR Barton F. Lane, MD and Ankur Pandey, MD
354 Pancreas Transplant Nonvascular Complications 418 Cystic Nephroma
Ashish P. Wasnik, MD, FSAR and Jade Wong-You-Cheong, Barton F. Lane, MD
MBChB, MRCP, FRCR, FSRU, FSAR 420 Autosomal Dominant Polycystic Kidney Disease
Barton F. Lane, MD
SECTION 4: SPLEEN
URINARY TRACT INFECTION
INTRODUCTION AND OVERVIEW
424 Acute Pyelonephritis
360 Approach to Splenic Sonography Lori Mankowski Gettle, MD, MBA, FSRU
Ali M. Tahvildari, MD 426 Renal Abscess
Lori Mankowski Gettle, MD, MBA, FSRU
SPLENIC LESIONS 428 Emphysematous Pyelonephritis
366 Splenomegaly Lori Mankowski Gettle, MD, MBA, FSRU
Ali M. Tahvildari, MD 430 Pyonephrosis
368 Splenic Cyst Lori Mankowski Gettle, MD, MBA, FSRU
Ali M. Tahvildari, MD 432 Xanthogranulomatous Pyelonephritis
370 Splenic Tumors Lori Mankowski Gettle, MD, MBA, FSRU
Ali M. Tahvildari, MD 434 Tuberculosis, Urinary Tract
374 Splenic Infarct Ashish P. Wasnik, MD, FSAR
Ali M. Tahvildari, MD
SOLID RENAL NEOPLASMS
SECTION 5: URINARY TRACT 436 Renal Cell Carcinoma
INTRODUCTION AND OVERVIEW Lori Mankowski Gettle, MD, MBA, FSRU
440 Renal Angiomyolipoma
378 Approach to Urinary Tract Sonography Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU,
Lori Mankowski Gettle, MD, MBA, FSRU FSAR
442 Upper Tract Urothelial Carcinoma
NORMAL VARIANTS AND PSEUDOLESIONS Ashish P. Wasnik, MD, FSAR
382 Column of Bertin, Kidney 444 Renal Lymphoma
Jane S. Kim, MD Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU,
384 Renal Junction Line FSAR
Jane S. Kim, MD
386 Renal Ectopia VASCULAR CONDITIONS
Jane S. Kim, MD 448 Renal Artery Stenosis
388 Horseshoe Kidney Gayatri Joshi, MD, FAIUM
Jane S. Kim, MD 452 Renal Vein Thrombosis
390 Ureteral Duplication Gayatri Joshi, MD, FAIUM
Jane S. Kim, MD 454 Renal Infarct
394 Ureteral Ectopia Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU,
Jane S. Kim, MD FSAR
396 Ureteropelvic Junction Obstruction 456 Perinephric Hematoma
Jane S. Kim, MD Gayatri Joshi, MD, FAIUM
CALCULI AND CALCINOSIS PROSTATE
398 Urolithiasis 458 Prostatic Hyperplasia
Katherine To'o, MD and Aya Kamaya, MD, FSRU, FSAR Katherine To'o, MD and Richard E. Fan, PhD
400 Nephrocalcinosis 462 Prostatic Carcinoma
Katherine To'o, MD and Aya Kamaya, MD, FSRU, FSAR Katherine To'o, MD, Richard E. Fan, PhD, and Geoffrey
402 Hydronephrosis Sonn, MD
Ashish P. Wasnik, MD, FSAR

xvi
 TABLE OF CONTENTS
530 Pheochromocytoma
BLADDER Ashish P. Wasnik, MD, FSAR
466 Bladder Carcinoma 534 Adrenal Carcinoma
Ashish P. Wasnik, MD, FSAR Tara A. Morgan, MD
470 Ureterocele
Ashish P. Wasnik, MD, FSAR SECTION 8: ABDOMINAL
474 Bladder Diverticulum WALL/PERITONEAL CAVITY
Ashish P. Wasnik, MD, FSAR 540 Approach to Sonography of Abdominal
478 Bladder Calculi Wall/Peritoneal Cavity
Ashish P. Wasnik, MD, FSAR Tara A. Morgan, MD
480 Schistosomiasis, Bladder 544 Abdominal Wall Hernia
Ashish P. Wasnik, MD, FSAR Tara A. Morgan, MD
482 Urethral Diverticulum 548 Groin Hernia
Ashish P. Wasnik, MD, FSAR Tara A. Morgan, MD
552 Ascites
SECTION 6: KIDNEY TRANSPLANT
Tara A. Morgan, MD
INTRODUCTION AND OVERVIEW 556 Peritoneal Carcinomatosis
Tara A. Morgan, MD
486 Approach to Sonography of Renal Allografts 560 Peritoneal Space Abscess
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU,
FSAR FSAR
RENAL TRANSPLANT COMPLICATIONS 564 Segmental Omental Infarction
Alexandra Medellin, MD and Stephanie R. Wilson, MD
490 Allograft Hydronephrosis
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, SECTION 9: BOWEL
FSAR 568 Approach to Bowel Sonography
494 Perirenal Transplant Fluid Collections Alexandra Medellin, MD and Stephanie R. Wilson, MD
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, 572 Bowel Features
FSAR Alexandra Medellin, MD
498 Transplant Renal Artery Stenosis 578 Appendicitis
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, Tara A. Morgan, MD
FSAR 582 Appendiceal Mucocele
502 Transplant Renal Artery Thrombosis Tara A. Morgan, MD
Ashish P. Wasnik, MD, FSAR 586 Intussusception
504 Transplant Renal Vein Thrombosis Alexandra Medellin, MD and Stephanie R. Wilson, MD
Ashish P. Wasnik, MD, FSAR 590 Epiploic Appendagitis
506 Renal Transplant Arteriovenous (AV) Fistula Alexandra Medellin, MD and Stephanie R. Wilson, MD
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, 594 Diverticulitis
FSAR Tara A. Morgan, MD
508 Renal Transplant Pseudoaneurysm 598 Crohn Disease
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, Alexandra Medellin, MD and Stephanie R. Wilson, MD
FSAR 604 Bowel Masses
510 Renal Transplant Rejection Alexandra Medellin, MD and Stephanie R. Wilson, MD
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU,
FSAR SECTION 10: SCROTUM
512 Delayed Renal Graft Function
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, INTRODUCTION AND OVERVIEW
FSAR 612 Approach to Scrotal Sonography
Shweta Bhatt, MD
SECTION 7: ADRENAL GLAND
516 Adrenal Hemorrhage SCROTAL LESIONS
Amelia Wnorowski, MD and Fauzia Vandermeer, MD 614 Testicular Germ Cell Tumors
520 Myelolipoma Shweta Bhatt, MD and Frank Chen, MD
Amelia Wnorowski, MD and Fauzia Vandermeer, MD 618 Gonadal Stromal Tumors, Testis
524 Adrenal Adenoma Shweta Bhatt, MD and Frank Chen, MD
Amelia Wnorowski, MD and Fauzia Vandermeer, MD 622 Testicular Lymphoma/Leukemia
528 Adrenal Cyst Shweta Bhatt, MD and Frank Chen, MD
Amelia Wnorowski, MD and Fauzia Vandermeer, MD 624 Epidermoid Cyst
Shweta Bhatt, MD and Frank Chen, MD

xvii
 TABLE OF CONTENTS
626 Tubular Ectasia of Rete Testis 712 Retained Products of Conception
Shweta Bhatt, MD and Frank Chen, MD Aya Kamaya, MD, FSRU, FSAR
628 Testicular Microlithiasis 716 Gestational Trophoblastic Disease
Shweta Bhatt, MD and Akshya Gupta, MD Shuchi K. Rodgers, MD
632 Testicular Torsion/Infarction
Shweta Bhatt, MD OVARIAN CYSTS AND CYSTIC NEOPLASMS
636 Undescended Testis 720 Functional Ovarian Cyst
Amit B. Desai, MD and Shweta Bhatt, MD Priyanka Jha, MBBS
638 Epididymitis/Orchitis 722 Hemorrhagic Cyst
Amit B. Desai, MD and Shweta Bhatt, MD Gayatri Joshi, MD, FAIUM
642 Scrotal Trauma 726 Ovarian Hyperstimulation Syndrome
Shweta Bhatt, MD and Akshya Gupta, MD Priyanka Jha, MBBS
646 Hydrocele 730 Serous Ovarian Cystadenoma/Carcinoma
Shweta Bhatt, MD Priyanka Jha, MBBS
648 Spermatocele/Epididymal Cyst 734 Mucinous Ovarian Cystadenoma/Carcinoma
Shweta Bhatt, MD Priyanka Jha, MBBS
650 Adenomatoid Tumor 738 Ovarian Teratoma
Shweta Bhatt, MD and Akshya Gupta, MD Priyanka Jha, MBBS
652 Varicocele 742 Polycystic Ovarian Syndrome
Shweta Bhatt, MD and Akshya Gupta, MD Aya Kamaya, MD, FSRU, FSAR and Priyanka Jha, MBBS
744 Endometrioma
SECTION 11: FEMALE PELVIS Priyanka Jha, MBBS
INTRODUCTION AND OVERVIEW 748 O-RADS
Priyanka Jha, MBBS
656 Approach to Sonography of the Female Pelvis
Shuchi K. Rodgers, MD NON-OVARIAN CYSTIC MASSES
CERVICAL AND MYOMETRIAL PATHOLOGY 752 Hydrosalpinx
Margarita V. Revzin, MD, MS
658 Nabothian Cyst 756 Pelvic Inflammatory Disease
Henal Motiwala, MD and Barton F. Lane, MD Margarita V. Revzin, MD, MS
660 Cervical Carcinoma 760 Paraovarian Cyst
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, Margarita V. Revzin, MD, MS
FSAR 762 Peritoneal Inclusion Cyst
664 Adenomyosis Margarita V. Revzin, MD, MS
Maram Aljuaid, MD and Barton F. Lane, MD
668 Leiomyoma VAGINAL AND VULVAR CYSTS
Barton F. Lane, MD and Henal Motiwala, MD
766 Bartholin Cyst
672 Uterine Anomalies
Margarita V. Revzin, MD, MS
Barton F. Lane, MD
768 Gartner Duct Cyst
ENDOMETRIAL DISORDERS Margarita V. Revzin, MD, MS

678 Hematometrocolpos MISCELLANEOUS OVARIAN MASSES

Barton F. Lane, MD
772 Sex Cord-Stromal Tumor
682 Endometrial Polyp
Margarita V. Revzin, MD, MS
Barton F. Lane, MD
776 Adnexal/Ovarian Torsion
686 Endometrial Carcinoma
Gayatri Joshi, MD, FAIUM
Maram Aljuaid, MD and Barton F. Lane, MD
780 Ovarian Metastases, Including Krukenberg Tumor
690 Endometritis
Priyanka Jha, MBBS
Barton F. Lane, MD
692 Intrauterine Device
Margarita V. Revzin, MD, MS Part III: Differential Diagnoses
PREGNANCY-RELATED DISORDERS SECTION 1: LIVER
696 Tubal Ectopic Pregnancy 784 Hepatomegaly
Amelia Wnorowski, MD and Fauzia Vandermeer, MD Aya Kamaya, MD, FSRU, FSAR
702 Unusual Ectopic Pregnancies 788 Diffuse Liver Disease
Amelia Wnorowski, MD and Fauzia Vandermeer, MD Aya Kamaya, MD, FSRU, FSAR
708 Failed 1st-Trimester Pregnancy
Amelia Wnorowski, MD and Fauzia Vandermeer, MD

xviii
 TABLE OF CONTENTS
790 Cystic Liver Lesion
Aya Kamaya, MD, FSRU, FSAR
SECTION 6: KIDNEY
794 Hypoechoic Liver Mass 864 Enlarged Kidney
Aya Kamaya, MD, FSRU, FSAR Ghada Issa, MD and Jade Wong-You-Cheong, MBChB,
798 Echogenic Liver Mass MRCP, FRCR, FSRU, FSAR
Aya Kamaya, MD, FSRU, FSAR 868 Small Kidney
802 Target Lesions in Liver Ghada Issa, MD and Jade Wong-You-Cheong, MBChB,
Aya Kamaya, MD, FSRU, FSAR MRCP, FRCR, FSRU, FSAR
804 Multiple Hepatic Masses 872 Hypoechoic Kidney
Aya Kamaya, MD, FSRU, FSAR Ghada Issa, MD and Jade Wong-You-Cheong, MBChB,
808 Hepatic Mass With Central Scar MRCP, FRCR, FSRU, FSAR
Aya Kamaya, MD, FSRU, FSAR 876 Hyperechoic Kidney
810 Periportal Lesion Ghada Issa, MD and Jade Wong-You-Cheong, MBChB,
Aya Kamaya, MD, FSRU, FSAR MRCP, FRCR, FSRU, FSAR
814 Irregular Hepatic Surface 880 Cystic Renal Mass
Aya Kamaya, MD, FSRU, FSAR Ghada Issa, MD
816 Portal Vein Abnormality 884 Solid Renal Mass
Aya Kamaya, MD, FSRU, FSAR Ghada Issa, MD and Jade Wong-You-Cheong, MBChB,
MRCP, FRCR, FSRU, FSAR
SECTION 2: BILIARY SYSTEM 888 Renal Pseudotumor
Ghada Issa, MD and Jade Wong-You-Cheong, MBChB,
GALLBLADDER
MRCP, FRCR, FSRU, FSAR
820 Diffuse Gallbladder Wall Thickening 890 Dilated Renal Pelvis
Ashish P. Wasnik, MD, FSAR Lori Mankowski Gettle, MD, MBA, FSRU
824 Hyperechoic Gallbladder Wall
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, SECTION 7: ABDOMINAL
FSAR WALL/PERITONEAL CAVITY
826 Focal Gallbladder Wall Thickening/Mass 896 Diffuse Peritoneal Fluid
Ashish P. Wasnik, MD, FSAR Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU,
828 Echogenic Material in Gallbladder Lumen FSAR
Ashish P. Wasnik, MD, FSAR 898 Solid Peritoneal Mass
830 Dilated Gallbladder Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU,
Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU,
FSAR
FSAR 902 Cystic Peritoneal Mass
BILE DUCTS Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU,
FSAR
834 Intrahepatic and Extrahepatic Duct Dilatation
L. Nayeli Morimoto, MD and Aya Kamaya, MD, FSRU, SECTION 8: PROSTATE
FSAR 908 Enlarged Prostate
SECTION 3: PANCREAS Katherine To'o, MD and Richard E. Fan, PhD
910 Focal Lesion in Prostate
838 Cystic Pancreatic Lesion Katherine To'o, MD and Richard E. Fan, PhD
Tara A. Morgan, MD
842 Solid Pancreatic Lesion SECTION 9: BOWEL
Tara A. Morgan, MD 916 Bowel Wall Thickening
846 Pancreatic Duct Dilatation Alexandra Medellin, MD and Stephanie R. Wilson, MD
Margarita V. Revzin, MD, MS
SECTION 10: SCROTUM
SECTION 4: SPLEEN
924 Diffuse Testicular Enlargement
850 Focal Splenic Lesion Shweta Bhatt, MD
Ali M. Tahvildari, MD 926 Decreased Testicular Size
SECTION 5: URINARY TRACT Shweta Bhatt, MD
928 Testicular Calcifications
856 Intraluminal Bladder Mass Shweta Bhatt, MD
Ashish P. Wasnik, MD, FSAR 930 Focal Testicular Mass
858 Abnormal Bladder Wall Shweta Bhatt, MD
Ashish P. Wasnik, MD, FSAR 934 Focal Extratesticular Mass
Shweta Bhatt, MD

xix
 TABLE OF CONTENTS
938 Extratesticular Cystic Mass
Shweta Bhatt, MD

SECTION 11: FEMALE PELVIS

942 Cystic Adnexal Mass
Priyanka Jha, MBBS
946 Solid Adnexal Mass
Priyanka Jha, MBBS
950 Extraovarian Adnexal Mass
Margarita V. Revzin, MD, MS
954 Enlarged Ovary
Priyanka Jha, MBBS
958 Enlarged Uterus
Barton F. Lane, MD
960 Abnormal Endometrium
Barton F. Lane, MD

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 SECOND EDITION

Kamaya | Wong-You-Cheong
Bhatt | Morgan | Lane | Wasnik
 PART I
SECTION 1

Abdomen

Liver 4
Biliary System 20
Spleen 30
Pancreas 38
Kidneys 44
Bowel 60
Abdominal Lymph Nodes 78
Peritoneal Spaces and Structures 82
Abdominal Wall 88
 Liver
Anatomy: Abdomen

□ Blood collects into central veins → hepatic veins

GROSS ANATOMY
□ Bile collects into ducts → stored in gallbladder and
Overview excreted into duodenum
• Liver: Largest gland and largest internal organ (average • Segmental anatomy
weight: 1,500 g) ○ 8 hepatic segments
○ Function – Each receives secondary or tertiary branch of hepatic
– Processes all nutrients (except fats) absorbed from artery and portal vein
gastrointestinal (GI) tract; conveyed via portal vein – Each drained by its own bile duct (intrahepatic) and
– Stores glycogen, secretes bile hepatic vein branch
○ Relations ○ Caudate lobe = segment 1
– Anterior and superior surfaces smooth and convex – Has independent portal triads and hepatic venous
– Posterior and inferior surfaces indented by colon, drainage to IVC
stomach, right kidney, duodenum, inferior vena cava ○ Left lobe
(IVC), and gallbladder – Lateral superior = segment 2
○ Covered by peritoneum except along gallbladder fossa, – Lateral inferior = segment 3
porta hepatis, and bare area – Medial superior = segment 4a
– Bare area: Nonperitoneal posterior superior surface – Medial inferior = segment 4b
where liver abuts diaphragm ○ Right lobe
– Porta hepatis: Portal vein, hepatic artery, and bile – Anterior inferior = segment 5
duct within hepatoduodenal ligament – Posterior inferior = segment 6
○ Falciform ligament – Posterior superior = segment 7
– Extends from liver to anterior abdominal wall – Anterior superior = segment 8
– Separates right and left subphrenic peritoneal
recesses (between liver and diaphragm) IMAGING ANATOMY
– Marks plane separating medial and lateral segments
of left hepatic lobe
Internal Contents
– Carries round ligament (ligamentum teres), fibrous • Capsule
remnant of umbilical vein ○ Reflective Glisson capsule making borders of liver well
○ Ligamentum venosum defined
– Remnant of ductus venosus • Left lobe
– Separates caudate from left hepatic lobe ○ Contains segments 2, 3, 4a, and 4b
• Vascular anatomy (unique dual afferent blood supply) ○ Longitudinal scan
○ Portal vein – Triangular in shape
– Formed by confluence of superior mesenteric and – Rounded upper surface
splenic veins and receives blood from inferior – Sharp inferior border
mesenteric, left and right gastric, and cystic veins ○ Transverse scan
– Carries nutrients from gut and hepatotrophic – Wedge-shaped tapering to left
hormones from pancreas to liver along with oxygen • Right lobe
□ Contains 40% more oxygen than systemic venous ○ Contains segments 5, 6, 7, and 8
blood ○ Sections of right lobe show same basic shape, though
– 75-80% of blood supply to liver right lobe usually larger than left
○ Hepatic artery • Caudate lobe
– Supplies 20-25% of blood ○ Longitudinal scan
– Liver less dependent than biliary tree on hepatic – Almond-shaped structure posterior to left lobe
arterial blood supply ○ Transverse scan
– Usually arises from celiac artery – Seen as extension of right lobe
□ Variations common, including arteries arising from • Portal veins
superior mesenteric artery ○ Have thicker reflective walls than hepatic veins; portal
○ Hepatic veins veins have fibromuscular walls
– Usually 3 (right, middle, and left) – In hepatic steatosis portal triads often less well
– Many variations and accessory veins visualized
– Deoxygenated blood from liver returned to IVC ○ Wall reflectivity also depends on angle of interrogation;
– Confluence of hepatic veins just below diaphragm and portal veins cut at more oblique angle, may have less
entrance of IVC into right atrium apparent wall
○ Portal triad ○ Normal portal flow is hepatopetal on color Doppler;
– At all levels of size and subdivision, branches of absent or reversal of flow may be seen in portal
hepatic artery, portal vein, and bile ducts travel hypertension
together ○ Normal velocity: 13-55 cm/s
– Blood flows into hepatic sinusoids from interlobular ○ Normal diameter: < 13 mm
branches of hepatic artery and portal vein →
hepatocytes, which detoxify blood and produce bile
4
 Liver
○ Portal waveform has undulating appearance due to
variations with cardiac activity and respiration
○ Branches run in transverse plane
○ Hepatic portal vein anatomy is variable
• Hepatic veins
○ Appear as echolucent tubular structures within liver
parenchyma with no reflective wall: Large sinusoids with
thin or absent wall
– In hepatic steatosis, hepatic vein walls may appear
blurry
○ Branches enlarge and can be traced toward IVC
○ Flow pattern has triphasic waveform
– Resulting from transmission of right atrial pulsations
into veins
□ A wave: Atrial contraction
□ S wave: Systole (tricuspid valve moves toward
cardiac apex)
□ D wave: Diastole
○ Right hepatic vein
– Runs in coronal plane between anterior and posterior
segments of right hepatic lobe
○ Middle hepatic vein
– Lies in sagittal or parasagittal plane between right and
left hepatic lobe
○ Left hepatic vein
– Runs between medial and lateral segments of left
hepatic lobe
– Frequently duplicated
○ 1 of 3 major branches of hepatic veins may be absent
– Absent right hepatic vein: ~ 6%
– Less commonly middle and left hepatic vein
• Hepatic artery
○ Flow pattern has low-resistance characteristics with large
amount of continuous forward flow throughout diastole
– Normal proper hepatic artery velocity: < 100 cm/s
(mean: 40-80 cm/s)
– Resistive index ranges 0.5-0.8, increases after meal
○ Common hepatic artery usually arises from celiac axis
○ Classic configuration: 75%
– Celiac axis → common hepatic artery →
gastroduodenal artery and proper hepatic artery →
latter gives rise to right and left hepatic artery
○ Variations from classic configuration
– Common hepatic artery arising from superior
mesenteric artery (replaced hepatic artery): 4%
– Right hepatic artery arising from superior mesenteric
artery (replaced right hepatic artery): 11%
– Left hepatic artery arising from left gastric artery
(replaced left hepatic artery): 10%
• Bile ducts
○ Normal peripheral intrahepatic bile ducts too small to be
demonstrated
○ Normal right and left hepatic ducts measuring few mm
usually visible
○ Normal common duct
– Most visible in its proximal portion just caudal to porta
hepatis: < 5 mm
□ Should be measured from inner wall to inner wall
□ CT unable to visualize inner wall and thus may
overestimate caliber
Anatomy: Abdomen
– Distal common duct should typically measure < 5-7
mm
– In elderly, generalized loss of tissue elasticity with
advancing age leads to increase in bile duct diameter
but should still remain < 8.5 mm (somewhat
controversial)
– Post cholecystectomy, slight increase in caliber may be
seen: 1- to 2-mm increase
ANATOMY IMAGING ISSUES
Imaging Recommendations
• Transducer
○ 2.5- to 6.0-MHz curvilinear or vector transducer
○ Higher frequency linear transducer (i.e., 7-12 MHz) useful
for evaluation of liver capsule and superficial portions of
liver
• Left lobe
○ Subcostal window with full inspiration generally most
suitable
• Right lobe
○ Subcostal window
– Cranial and rightward angulation useful for
visualization of right lobe below dome of
hemidiaphragm
– Can sometimes be obscured by bowel gas
○ Intercostal window
– Usually gives better resolution for parenchyma
without influence from bowel gas
– Right lobe just below hemidiaphragm may not be
visible due to obscuration from lung bases
– Important to tilt transducer parallel to intercostal
space to minimize shadowing from ribs
CLINICAL IMPLICATIONS
Clinical Importance
• Liver ultrasound often 1st-line imaging modality in
evaluation for elevated liver enzymes
○ Diffuse liver disease, such as hepatic steatosis, cirrhosis,
hepatomegaly, hepatitis, and biliary ductal dilatation,
well visualized on ultrasound
○ Documentation of patency of portal vein, hepatic vein
waveforms, and hepatic arterial velocities helpful in
evaluation for etiologies of elevated liver function tests
○ Shear wave elastography can characterize liver fibrosis
with high degree of accuracy
• Liver metastases common
○ Primary carcinomas of colon, pancreas, and stomach
commonly metastasize to liver
– Portal venous drainage usually results in liver being
initial site of metastatic spread from these tumors
○ Metastases from other non-GI primaries (breast, lung,
etc.) commonly spread to liver hematogenously
• Primary hepatocellular carcinoma
○ Ultrasound commonly used for screening and
surveillance in patients at risk for developing
hepatocellular carcinoma typically at 6-month intervals
○ Risk factors include cirrhosis of any etiology and chronic
viral hepatitis B in certain populations
5
 Liver
Anatomy: Abdomen

HEPATIC VISCERAL SURFACE

Coronary l. Diaphragm

Left triangular l.
Right triangular l.

Falciform l.

Ligamentum teres

Gallbladder

Gallbladder

Falciform l.

Porta hepatis

Gastric impression

Right renal impression

Bare area
Fissure for ligamentum
venosum

Inferior vena cava

(Top) The anterior surface of the liver is smooth and molds to the diaphragm and anterior abdominal wall. Generally, only the
anterior/inferior edge of the liver is palpable on a physical exam. The liver is covered with peritoneum, except for the gallbladder bed,
porta hepatis, and bare area. Peritoneal reflections form various ligaments that connect the liver to the diaphragm and abdominal wall,
including the falciform ligament, the inferior edge that contains the ligamentum teres, and the obliterated remnant of the umbilical
vein. (Bottom) Graphic shows the liver inverted, which is somewhat similar to the surgeon's view of the upwardly retracted liver. The
structures in the porta hepatis include the portal vein (blue), hepatic artery (red), and the bile ducts (green). The visceral surface of the
liver is indented by adjacent viscera. The bare area is not easily accessible.

6
 Liver

Anatomy: Abdomen
HEPATIC ATTACHMENTS AND RELATIONS

Falciform l.

Coronary l.
Left triangular l.

Adrenal gland

Right triangular l. Lesser omentum

Falciform l.
Coronary l.

Left triangular l.
Sulcus for inferior vena cava

Ligamentum venosum Right triangular l.

Lateral segment (left lobe)

Falciform l.

Medial segment (left lobe)

Right lobe

(Top) The liver is attached to the posterior abdominal wall and diaphragm by the left and right triangular and coronary ligaments. The
falciform ligament attaches the liver to the anterior abdominal wall. The bare area is in direct contact with the right adrenal gland,
kidney, and inferior vena cava (IVC). (Bottom) Posterior view of the liver shows the ligamentous attachments. While these may help to
fix the liver in position, abdominal pressure alone is sufficient, as evidenced by orthotopic liver transplantation, after which the
ligamentous attachments are lost without the liver shifting position. The diaphragmatic peritoneal reflection is the coronary ligament
whose lateral extensions are the right and left triangular ligaments. The falciform ligament separates the medial and lateral segments
of the left lobe.

7
 Liver
Anatomy: Abdomen

HEPATIC VESSELS AND BILE DUCTS

Right hepatic v.
(separates anterior and
posterior segments of Left hepatic v. (separates
right lobe of liver) medial and lateral
segments of left lobe of
liver)

Right hepatic duct

Middle hepatic v.
(separates right and left
lobes of liver)
Right hepatic a. Left hepatic duct

Left portal v.
Right portal v.
Left hepatic a.

Common hepatic duct Proper hepatic a.

Cystic duct
Inferior vena cava

Gallbladder Main portal v.

Common bile duct

Graphic emphasizes that at every level of branching and subdivision, the portal veins, hepatic arteries, and bile ducts course together,
constituting the portal triad. Each segment of the liver is supplied by branches of these vessels. Conversely, hepatic venous branches lie
between hepatic segments and interdigitate with the portal triads but never run parallel to them.

8
 Liver

Anatomy: Abdomen
HEPATIC ARTERIAL ANATOMY

Segment 1 (caudate lobe)

Segment 4

Segment 8 Segment 2

Left hepatic a.
Segment 7

Segment 3

Left gastric a.
Segment 5

Splenic a.

Segment 6 Celiac trunk

Common hepatic a.

Gastroduodenal a.
Cystic a.

Right hepatic a.
Right gastroepiploic a.

Proper hepatic a.

Graphic demonstrates the conventional hepatic arterial supply to the liver. The celiac artery arises at ~ T12 level before dividing into
the common hepatic artery, left gastric artery, and splenic artery. The common hepatic artery gives off the gastroduodenal artery
inferiorly and becomes the proper hepatic artery, which then divides into the right and left hepatic arteries at the liver hilum. The left
hepatic artery courses superiorly and slightly to the left before giving off branches to segments 2-4. In some instances, the segment 4
artery may arise directly from the proper hepatic artery and is then termed the middle hepatic artery. The right hepatic artery divides
into anterior and posterior branches, which take an upward vertical course and horizontal course, respectively. The anterior branch
gives off arteries supplying segments 5 and 8, while the posterior branches supply segments 6 and 7. Segment 1 (caudate lobe) is
typically supplied by small branches of either the right or left hepatic arteries (or both).

9
 Liver
Anatomy: Abdomen

LEFT LOBE OF LIVER: LEFT HEPATIC VEIN

Left rectus abdominis m.

Right rectus abdominis m.

Middle hepatic v.
Left hepatic v.
Right hepatic v.

Left rectus abdominis m.

Segment 2
Segment 4a
Left hepatic v.
Segment 8

Middle hepatic v.

Inferior vena cava

Left rectus abdominis m.

Left hepatic v.
Middle hepatic v.
Right hepatic v.
A wave

D wave
S wave

(Top) Transverse grayscale ultrasound centered at the left hepatic lobe shows the right, middle, and left hepatic veins as they join into
the intrahepatic IVC. (Middle) Transverse color Doppler ultrasound centered at the confluence of the hepatic veins shows that the flow
direction is away from the transducer, directed toward the IVC. (Bottom) Spectral tracing of the left hepatic vein near the confluence
with the IVC shows a characteristic triphasic waveform pattern, which represents reflection of cardiac motion.

10
 Liver

Anatomy: Abdomen
LONGITUDINAL LEFT LOBE OF LIVER

Abdominal m.

Diaphragm
Heart
Left lateral liver

Stomach

Heart Superior mesenteric a.

Celiac a.

Aorta

Left portal v.

Portal v.
Heart
Hepatic a.

Left hepatic v.
Falciform l.
Junction of inferior vena cava and right
atrium

(Top) Longitudinal grayscale ultrasound of the left lobe of the liver shows a triangular-shaped cross section. The heart is partially
visualized above the diaphragm. (Middle) Longitudinal grayscale ultrasound view of the left lobe of the liver at the level of the aorta
shows the aorta posterior to the liver, the celiac artery, and the superior mesenteric artery arising from the aorta. (Bottom)
Longitudinal grayscale ultrasound of the left lobe of the liver shows the left hepatic vein and left portal vein in cross section.

11
 Liver
Anatomy: Abdomen

TRANSVERSE RIGHT LOBE OF LIVER

Middle hepatic v.

Left hepatic v.
Anterior branch right portal v.

Right hepatic v.
Inferior vena cava

Diaphragm

Middle hepatic v.

Anterior right portal v. branch

Right hepatic v. branch
Right hepatic v. branch
Inferior vena cava

Diaphragm

Right portal v.
Posterior branch of right portal v.

Inferior vena cava

Diaphragmatic crus

(Top) Transverse grayscale ultrasound at the level of the hepatic vein confluence shows the right, middle, and left hepatic veins as they
join with the IVC posteriorly. (Middle) Transverse grayscale ultrasound of the liver just below the confluence of the hepatic veins shows
the IVC and more peripheral portions of the right and left hepatic veins. (Bottom) Transverse grayscale ultrasound of the right lobe of
the liver, centered at the right portal vein, shows the posterior branch of the right portal vein, which is typically directed away from the
transducer.

12
 Liver

Anatomy: Abdomen
RIGHT LOBE OF LIVER: RIGHT HEPATIC VEIN

Anterior right portal v.

Middle hepatic v.

Right hepatic v.

Diaphragm

Middle hepatic v.

Right hepatic v.

A wave

D wave
S wave

Middle hepatic v.

Left hepatic v.
Right hepatic v.

A wave

D wave
S wave

(Top) Transverse color Doppler ultrasound of the right lobe of the liver shows that the right and middle hepatic veins are directed away
from the transducer and flowing toward the IVC. (Middle) Spectral tracing of the right hepatic vein shows a typical triphasic waveform
with A, S, and D waves representing reflection of cardiac motion in the hepatic veins. (Bottom) Spectral tracing of the middle hepatic
vein shows a typical triphasic waveform with A, S, and D waves representing reflection of cardiac motion in the hepatic veins.

13
 Liver
Anatomy: Abdomen

TRANSVERSE LEFT LOBE OF LIVER

Subcutaneous fat

Segment 3

Rectus abdominis m. Pancreas

Segment 4b
Splenic v.
Falciform l. Left renal a.
Portal v.
Aorta
Inferior vena cava
Spine

Ligamentum venosum
Rectus abdominis m.
Falciform l. Pancreas
Left portal v.

Inferior vena cava Aorta

Middle hepatic v.

Rectus abdominis m.

Portal v. branch

Left hepatic v.
Middle hepatic v.
Right hepatic v.

(Top) Transverse grayscale ultrasound of the left lobe of the liver is shown centered at the level of the falciform ligament and pancreas.
(Middle) Transverse grayscale ultrasound of the left lobe of the liver is shown. (Bottom) Transverse grayscale ultrasound of the left lobe
of the liver is shown centered at the level of the left hepatic vein.

14
 Liver

Anatomy: Abdomen
MAIN PORTAL VEIN

Right portal v.

Main portal v.
Hepatic v. branch

Inferior vena cava

Right portal v.

Main portal v.

Inferior vena cava

Main portal v.

Inferior vena cava

Main portal v. spectral tracing

(Top) Longitudinal oblique grayscale ultrasound is shown centered at the level of the main and right portal veins. (Middle) Longitudinal
oblique color Doppler ultrasound, centered at the level of the main and right portal veins, shows that flow in the portal vein is directed
toward the liver (hepatopetal). (Bottom) Longitudinal oblique spectral Doppler ultrasound of the main portal vein shows that the flow
is hepatopetal with gentle undulation reflecting the cardiac and respiratory cycles.

15
 Liver
Anatomy: Abdomen

PORTA HEPATIS

Hepatic a.

Systolic peak

End diastole

Common duct

Right hepatic a.
Main portal v.
Inferior vena cava

Right hepatic a.
Common duct

Main portal v.

Inferior vena cava

(Top) Longitudinal oblique spectral tracing of the main hepatic artery shows a typical low-resistance waveform with brisk upstroke and
forward diastolic flow. In this case, the hepatic artery velocity is 44 cm/s, which is within normal limits (normal range is < 100 cm/s).
When measuring velocity, proper angle correction is the key to obtaining accurate velocities. (Middle) Oblique grayscale ultrasound of
the liver, centered at the porta hepatis, shows the common duct anterior to the right hepatic artery and portal vein. Measurement of
the hepatic duct should be from inner wall to inner wall. The IVC is seen posterior to the portal vein. (Bottom) Oblique color Doppler
ultrasound of the liver, centered at the porta hepatis, shows the common duct is anterior to the portal vein, and the right hepatic artery
is between these 2 structures. This is the typical anatomy in this location, although anatomic variants of the right hepatic artery may
occur in which the hepatic artery may be located anterior to the common duct.

16
 Liver

Anatomy: Abdomen
LEFT LOBE OF LIVER: LEFT PORTAL VEIN

Rectus abdominis m.

Left portal v.

Middle hepatic v.

Inferior vena cava

RIght hepatic v.

Rectus abdominis m.

Left portal v.

Inferior vena cava

Rectus abdominis m.

Left portal v.

Middle hepatic v.
Right portal v. Left lobe lateral segment
Ligamentum venosum
Right hepatic v. Segment 1 (caudate lobe)
Inferior vena cava
Spectral tracing of left portal v.

(Top) Transverse grayscale ultrasound of the left lobe of the liver is shown centered at the left portal vein. (Middle) Transverse color
Doppler ultrasound of the left lobe of the liver is shown centered at the level of the left portal vein. Flow in the left portal vein is
directed toward the transducer, indicating that the flow is hepatopetal and therefore normal. (Bottom) Spectral tracing of the left
portal vein on this transverse pulsed Doppler ultrasound shows that the flow is monophasic, directed toward the transducer, with a
mildly undulating waveform related to slight transmission of the cardiac cycle, which is a normal appearance for the portal vein.

17
 Liver
Anatomy: Abdomen

LIVER SEGMENTS

Plane of middle hepatic v.

Segment 4a
Left hepatic v.
Segment 8

Plane of right hepatic v.

Segment 7

Diaphragm

Falciform l.

Segment 4b
Plane of middle hepatic v. Segment 5

Plane of right hepatic v.

Segment 6

Diaphragm

(Top) Graphic demonstrates the division of the Couinaud segments of the liver at 4 different levels. The Couinaud segments are defined
by the hepatic veins (hepatic vein plane) and the portal veins (portal vein plane). (Middle) Transverse ultrasound of the right lobe of
liver at the level of the confluence of the hepatic veins shows the right hepatic vein separates segment 7 (superior posterior segment of
the right lobe) from segment 8 (superior anterior segment of the right lobe), and the middle hepatic vein separates segment 8 from
segment 4a (superior medial segment of the left lobe). (Bottom) Transverse ultrasound of the right lobe of the liver just below the level
of the portal vein shows the right hepatic vein, which demarcates the anterior from posterior segments of the right lobe of the liver.
The plane of the middle hepatic vein separates the left lobe from the right lobe. A horizontal plane in line with the main portal vein
demarcates the upper from lower liver segments.

18
 Liver

Anatomy: Abdomen
LIVER SEGMENTS

Plane of middle hepatic v.

Segment 4b
Plane of right hepatic v.
Gallbladder
Segment 6
Segment 5

Right kidney

Plane of left hepatic v.

Segment 4a Segment 2

Plane of middle hepatic v.

Segment 8
Inferior vena cava

Segment 3

Plane of left hepatic v. and falciform l.

Ligamentum venosum
Segment 4b
Segment 1 (caudate lobe)
Inferior vena cava
Plane of middle hepatic v.
Aorta
Segment 5

(Top) Transverse ultrasound of the right lobe of the liver inferiorly at the level of the gallbladder shows segment 5 (inferior anterior
segment of the right lobe) and segment 6 (inferior posterior segment of the right lobe). The demarcation between the 2 segments is
created by drawing a plane vertically from the right hepatic vein. A vertically oriented plane at the level of the gallbladder and middle
hepatic vein separates the right and left lobe of the liver. (Middle) Transverse grayscale ultrasound of the left lobe of the liver at the
level of the confluence of the hepatic veins and IVC shows the left hepatic vein separates segment 2 (superior lateral segment of the
left lobe) from segment 4a (superior medial segment of the left lobe). (Bottom) Transverse grayscale ultrasound shows the left lobe of
the liver at a level just inferior to the left portal vein. Segment 1 (caudate lobe) abuts the ligamentum venosum, IVC, and left portal
vein. The falciform ligament separates segment 3 (inferior lateral segment of the left lobe) from segment 4b (inferior medial segment
of the left lobe).
19
 Biliary System
Anatomy: Abdomen
TERMINOLOGY
Abbreviations
• Extrahepatic biliary structures
○ Gallbladder (GB)
○ Cystic duct (CD)
○ Right hepatic (RH) and left hepatic (LH) ducts
○ Common hepatic duct (CHD)
○ Common bile duct (CBD)
Definitions
• Proximal/distal biliary tree
○ Proximal refers to portion of biliary tree that is closer in
proximity to liver and hepatocytes
○ Distal refers to caudal end closer to ampulla and bowel
• Central/peripheral
○ Central refers to biliary ducts close to porta hepatis
○ Peripheral refers to higher order branches of
intrahepatic biliary tree extending into hepatic
parenchyma
IMAGING ANATOMY
Overview
• Bile ducts carry bile from liver to duodenum
○ Bile is produced continuously by liver, stored and
concentrated by GB, and released intermittently by GB
contraction in response to presence of fat in duodenum
○ Hepatocytes form bile → bile canaliculi → interlobular
biliary ducts → collecting bile ducts → RH and LH ducts →
CHD → CBD → duodenum → intestines
• Variant biliary ductal anatomy is present in up to 20% of
population
• CBD forms in free edge of lesser omentum by union of CD
and CHD
○ Length of duct: 5-15 cm, depending on point of junction
of CD and CHD
○ Descends posterior and medial to duodenum, lying on
dorsal surface of pancreatic head
○ Joins with pancreatic duct to form hepaticopancreatic
ampulla of Vater
○ Ampulla opens into duodenum through major duodenal
(hepaticopancreatic) papilla
○ Distal CBD is thickened into sphincter of Boyden and
hepaticopancreatic segment is thickened into sphincter
of Oddi
– Contraction of these sphincters prevents bile from
entering duodenum; forces it to collect in GB
– Relaxation of sphincters in response to
parasympathetic stimulation and cholecystokinin
(released by duodenum in response to fatty meal)
• Vessels, nerves, and lymphatics
○ Arteries
– Hepatic arteries supply intrahepatic ducts
– Cystic artery supplies proximal common duct
– RH artery supplies middle part of common duct
– Gastroduodenal and pancreaticoduodenal arcade
supply distal common duct
– Cystic artery supplies GB (usually from RH artery;
variable)
○ Veins
20
– From intrahepatic ducts → hepatic veins
– From common duct → portal vein (in tributaries)
– From GB directly into liver sinusoids, bypassing portal
vein
○ Nerves
– Sensory: Right phrenic nerve
– Parasympathetic and sympathetic: Celiac ganglion and
plexus; contraction of GB and relaxation of biliary
sphincters is caused by parasympathetic stimulation,
but more important stimulus is from hormone
cholecystokinin
○ Lymphatics
– Same course and name as arterial branches
– Collect at celiac lymph nodes and node of omental
foramen
– Nodes draining GB are prominent in porta hepatis and
around pancreatic head
• GB
○ ~ 7-10 cm long, holds up to 50 mL of bile
○ Lies in shallow fossa on visceral surface of liver
○ Vertical plane through GB fossa and middle hepatic vein
divides LH and RH lobes
○ May touch and indent duodenum
○ Fundus is covered with peritoneum and relatively
mobile; body and neck attached to liver and covered by
hepatic capsule
○ Fundus: Wide tip of GB, projects below liver edge
(usually)
○ Body: Contacts liver, duodenum, and transverse colon
○ Neck: Narrowed, tapered, and tortuous; joins CD
○ CD: 3-4 cm long, connects GB to CHD; marked by spiral
folds of Heister; helps to regulate bile flow to and from
GB
• Normal measurement limits of bile ducts
○ CBD/CHD
– < 6-7 mm in patients without history of biliary disease
in most studies
– Controversy about dilatation related to previous
cholecystectomy and old age
○ Intrahepatic ducts
– Normal diameter of 1st-order and higher order
branches < 2 mm or < 40% of diameter of adjacent
portal vein
– 1st- (i.e., LH duct and RH duct) and 2nd-order branches
are normally visualized
– Visualization of 3rd-order and higher order branches is
often abnormal and indicates dilatation
ANATOMY IMAGING ISSUES
Imaging Recommendations
• Patient should fast for at least 4 hours prior to US
examination to ensure GB is not contracted after meal,
ideally fasting for 8-12 hours (overnight)
• Complete assessment includes scanning liver, porta hepatis
region, and pancreas in sagittal, transverse, and oblique
views
• Subcostal and right intercostal transverse views help align
bile ducts and GB along imaging plane for optimal
visualization
 Biliary System
• Structures are usually better assessed and imaged with
patient in full suspended inspiration and in left lateral
oblique position
• Harmonic imaging provides improved contrast between
bile ducts and adjacent tissues, leading to improved
visualization of bile ducts, luminal content, and wall
• For imaging of gallstone disease, special maneuvers are
recommended
○ Move patient from supine to left lateral decubitus
position
– Demonstrates mobility of gallstones
– Gravitates small gallstones together to appreciate
posterior acoustic shadowing
○ Set focal zone at level of posterior acoustic shadowing;
maximizes effect
Imaging Approaches
• Transabdominal US is ideal initial investigation for
suspected biliary tree or GB pathology
○ Cystic nature of bile ducts and GB (especially if these are
dilated) provides inherently high-contrast resolution
○ Acoustic window provided by liver and modern US
technology provides good spatial resolution
○ Common indications of US for biliary and GB disease
include
– Right upper quadrant/epigastric pain
– Abnormal liver function test or jaundice
– Suspected gallstone disease
– Pancreatitis
○ US plays key role in multimodality evaluation of complex
biliary problems
• Supplemented by various imaging modalities, including
MR/MRCP and CT
Imaging Pitfalls
• Common pitfalls in evaluation of GB
○ Posterior shadowing may arise from GB neck, Heister
valves of CD, or adjacent gas-filled bowel loops
– Mimics cholelithiasis
– Scan after repositioning patient in prone or left lateral
decubitus positions
○ Food material within gastric antrum/duodenum
– Mimics GB filled with gallstones or GB containing milk
of calcium
– During real-time scanning, carefully evaluate
peristaltic activity of involved bowel with oral
administration of water
• Common pitfalls in US evaluation of biliary tree
○ Redundancy, elongation, or folding of GB neck on itself
– Mimics dilatation of CHD or proximal CBD
– Avoided by scanning patient in full suspended
inspiration
– Careful real-time scanning allows separate
visualization of CHD/CBD medial to GB neck
○ Presence of gas-filled bowel loops adjacent to distal
extrahepatic bile ducts
– Obscure distal biliary tree and render detection of
choledocholithiasis difficult
– Scan with patient in decubitus positions or after oral
intake of water
○ Gas/particulate material in adjacent duodenum and
pancreatic calcification
Anatomy: Abdomen
– Mimic choledocholithiasis within CBD
○ Presence of gas within biliary tree
– May mimic choledocholithiasis, differentiated by
presence of reverberation artifacts
– Limits US detection of biliary calculus
Key Concepts
• Direct venous drainage of GB into liver bypasses portal
venous system, often results in sparing of adjacent liver
from generalized steatosis (fatty liver)
• Nodal metastasis from GB carcinoma to peripancreatic
nodes may simulate primary pancreatic tumor
• Sonography: Optimal means of evaluating GB for stones
and inflammation (acute cholecystitis); best done in fasting
state (distends GB)
• Intrahepatic bile ducts follow branching pattern of portal
veins
○ Usually lie immediately anterior to portal vein branch;
confluence of hepatic ducts just anterior to bifurcation
of right and main portal veins
CLINICAL IMPLICATIONS
Clinical Importance
• In patients with obstructive jaundice, US plays key role
○ Differentiates biliary obstruction from liver parenchymal
disease
○ Determines presence, level, and cause of biliary
obstruction
• Common variations of biliary arterial and ductal anatomy
result in challenges to avoid injury at surgery
○ CD may run in common sheath with bile duct
○ Anomalous RH ducts may be severed at cholecystectomy
• Close apposition of GB to duodenum can result in fistulous
connection with chronic cholecystitis and erosion of
gallstone into duodenum
Function & Dysfunction
• Obstruction of CBD is common
○ Gallstones in distal bile duct
○ Carcinoma arising in pancreatic head or bile duct
○ Result is jaundice due to backup of bile salts into
bloodstream
Embryologic Events
• Abnormal embryologic development of fetal ductal plate
can lead to spectrum of liver and biliary abnormalities,
including
○ Polycystic liver disease
○ Congenital hepatic fibrosis
○ Biliary hamartomas
○ Caroli disease
○ Choledochal cysts
SELECTED REFERENCES
1 Fujimoto N et al Clinical investigation of the cystic duct variation based on
the anatomy of the hepatic vasculature Surg Today 50(4) 396-401, 2020
2 Shackelford RT Shackelford's Surgery of the Alimentary Tract 7th edition
Elsevier/Saunders, 2013
3 Standring S et al Gray's Anatomy The Anatomical Basis of Clinical Practice
40th ed Churchill Livingstone/Elsevier, 2008
4 Mortelé KJ et al Anatomic variants of the biliary tree MR cholangiographic
findings and clinical applications AJR Am J Roentgenol 177(2) 389-94, 2001
21
 Biliary System
Anatomy: Abdomen

GALLBLADDER IN SITU

Right hepatic lobe Left hepatic lobe

Extrahepatic bile duct

Peritoneal reflection
Proper hepatic artery
Main portal vein
Gallbladder (body)

Lesser omentum (cut edge,

anterior)
Gallbladder (fundus)

Duodenum
Colon (hepatic flexure)

Pancreas

Cystic duct
Common hepatic duct

Gallbladder (neck)

Gallbladder (body)

Gallbladder (fundus) Common bile duct

Pancreatic duct

Superior mesenteric artery

Ampulla
Superior mesenteric vein

(Top) Graphic shows that the gallbladder is covered with peritoneum, except where it is attached to the liver. The extrahepatic bile
duct, hepatic artery, and portal vein run in the lesser omentum. The fundus of the gallbladder extends beyond the anterior-inferior edge
of the liver and can be in contact with the hepatic flexure of the colon. The body (main portion of the gallbladder) is in contact with the
duodenum. (Bottom) The neck of the gallbladder narrows before entering the cystic duct, which is distinguished by its tortuous course
and irregular lumen. The duct lumen is irregular due to redundant folds of mucosa, called the spiral folds of Heister, which are believed
to regulate the rate of filling and emptying of the gallbladder. The cystic duct joins the common hepatic duct to form the common bile
duct, which passes behind the duodenum and through the pancreas to enter the duodenum.

22
Another random document with
no related content on Scribd:
 On Saturday, the 21st August, 1802, we went
with the General,[182] Ld. Robert,[183] and ST. CLOUD
Frederick,[184] and we took Charles to St. Cloud. It
was a palace belonging formerly to the Dukes of Orleans, but poor
Marie Antoinette liked it, and is accused of having exerted her royal
influence to compel the late Duke to sell it, which he did most
reluctantly. She was so partial to its beauties that she was profuse in
her expense to decorate it. In each taste the First Consul imitates
her, as he is so impatient to take possession that the surveyors are
obliged to make the men work all night; and he likes it so much that
no expense is spared to render it a fit residence for the Sovereign of
France. The gallery remains as it was finished by Gaston, Duke of
Orleans, Louis XIII’s brother; only on the panels some of the plunder
of Italy, which was in the Museum of the Louvre, has been placed,
much to their disadvantage, as the gaudy ceiling and rich gilding kills
the colouring of the pictures. They are capital; some of my old
acquaintances out of the Palais Pitti. The apartments that are fitted
up are done in le goût sévère, which, in other words, means a dark
and dingy style. The walls are hung with cloth, and draperies of cloth
edged with magnificent deep parti-coloured fringes are festooned
over it. The colours being generally dark green and brown produce a
solemn effect, and the whole has a sombre military appearance; the
rods of the curtains are finely polished spears. Where the Queen’s
apartments have been preserved, I admire them far beyond those in
the goût sévère, and prefer bright gilding to the heavy mahogany,
and a well-stuffed sofa to a small, hard one. In short, the exchange is
a bad one, les ris et les amours please me, broad cloth and sphinxes
do not. The Library is very pretty, and the books placed in very
appropriate cases, plain and simple, but at the same time rich and
decorated. The gardens are insignificant, but if the Consul continues
to like living there, I doubt not he will find means to extend them, tho’
as yet I only look upon St. Cloud as a halt on the road to Versailles.
On Sunday, ye next day, we went with a large party to Versailles,
where we expected to see the Eaux play, but we had been misled.
We dined at Le petit Trianon, formerly a favourite little palace of the
Queen’s, with a garden à l’Anglaise; but what I did admire indeed is
Le grand Trianon, a most noble palace. The centre, instead of a
corps-de-logis, is a peristyle composed of a double row of large
marble columns; the front to the garden is very large and grand, only
a rez-de-chaussée. The garden is thoroughly in the French style,
broad and spacious walks, fountains, alleys, cabinets de verdure; in
short, just what a garden should be near a large house.
We went from thence to Versailles. What a change from former
days! We walked along the Terrace, and so to the Orangerie, where
there are trees in tubs as large as any I ever saw growing either at
Nice or Naples in the common ground. One old tree they call
François Premier, and they add that it is 400 years old. It is
satisfactorily proved by a procès verbal that it belonged to the
Constable of Bourbon, and was confiscated with the rest of his
property, and so came to François I. Our party was numerous: Mr.
and Mrs. Fox, Ld. Robert, the General, Mr. Allen, Frederick
Ponsonby, Miss Adair, Heathcote, St. John, Trotter,[185] Smith (the
Petrarch of Carolina’s brother), Green.

The following is a list of those who dined with us at Paris in July,

August, and part of September, 1802.
 La Fayette, who is indebted to Bonaparte for his
liberty, has, since his return to his native country, LA FAYETTE
resided chiefly upon the small estate the
Revolution has not deprived him of at La Grange. Bonaparte affected
to consult the nation whether he should be Consul for life; was
answered by La Fayette, who wrote a gentle but able remonstrance
upon the subject. Bonaparte was little enough, when an army
promotion took place, to pass over La Fayette’s son and nephew; he
has, however, promoted them since. His son was educated in
Washington’s house, appears very amiable; he was just married.[186]
Andréossy[187] is the son of an obscure man of Italian origin,
employed by Riquet in the Languedoc Canal. He was born at
Castelnaudary, educated at Sorèze, and served under the ancien
régime as an engineer. He made some campaigns in Italy, went to
Egypt, was there employed upon an expedition to ye Lake
Menzalah, and returned in the vessel which brought the First Consul
to France. He has since been named to ye Embassy of England. He
lived very much with us. He is a plain Militaire in his manner, and if
he offends it will be unintentional, as he is disposed to maintain
peace and amity between the two countries.
Caffarelli,[188] brother of a general of the same name killed before
Acre. He is a fellow townsman and school companion of Andréossy,
and like him descended from an Italian family brought by Riquet to
work at the Canal. He is a remarkably displeasing person in his
manner, a sycophant and court echo of the ante-chamber of
Bonaparte; from love of order and morality always proclaiming that
the First Consul and his wife sleep in the same bed, and that the
domestic virtues of a warrior are more important than his heroic
deeds. In short, from him one collects the disgusting cant which is to
be employed by the present Governt. as a counterpoise to the wild
extravagant opinions of atheism and immorality set afloat under the
first constitution of the Republic.
Valence,[189] a general who served in the first campaigns under
Dumouriez, a good-humoured, boasting, bluff Papa.
 Mde. de V., daughter of Mde. de Sillery, a beauty on the wane,
pleasing and clever.
Abbé St. Fard, a son of the Duke of Orleans, father to the
unfortunate Égalité; remarkably obliging, and, tho’ not distinguished
for talents, very popular, and a person one cannot but like.
Duc de Duras,[190] a ci-devant Duc returned, but not reconciled to
the changes in his country.
Lally Tollendal,[191] the epitome of sentiment. By
some inconceivable freak imagined himself to be LALLY
the son of Count Lally, executed for the surrender TOLLENDAL
of Pondicherry. Whilst at college he heard the
story; his birth was obscure and even mysterious. A flight into the
region of fancy made him imagine himself the son of the state culprit
(but not till after his execution); he then pleaded for him. He is
returned to France after an absence of many years, but, like many
who were distinguished at first, he returns but to see his
insignificance and the indifference of the Governt. to these, many of
whom conceived themselves to be of the utmost importance.
Psse. d’Hesnin [sic], an excellent woman, formerly about the
Queen, attached for many years to Lally.
Mde. Flahaut.[192] A volume would not suffice. An agreeable
adventuress, who after failing in various projects, both upon English
and French, at last has closed her tempestuous career by marrying
Souza, ye Portuguese Minister. She has written some pretty novels;
her conversation consists more in a narrative of the good things she
has said than in those she actually does say. Her son, a fine, open
young man. He is handsome and uncommonly engaging in his
manners and countenance.
Girardin,[193] an élève of Jean Jacques, and proprietor of
Ermenonville. He was eager in the beginning of Revolution;
emigrated for a short time; is now a Tribune, and intimate friend of
Joseph Bonaparte’s. He is not an Emile, but good-natured. His love
of independence and the naked truth for the sake of truth will never
expose him to the straits a patriot must undergo. He will shift in time.
 Gallois,[194] a Tribune, uncommonly interesting in his manner, with
a countenance that proclaims his talents and gentle, amiable heart.
Abbé Morellet,[195] an old économiste. Sprightly, altho’ he is
turned of eighty.
Molé,[196] a descendant of the great President of that name. We
knew him well in England; a mild, gentlemanlike young man, very
unlike a young Frenchman.
Chevalier Acerbi,[197] an Italian Cisalpine. He travelled to North
Cape, and has published two 4to. vols. of his journey; a clever man,
great facility of languages.
Le Chevalier de la Bintinaye, nephew of the ci-devant Archbishop
of Bordeaux.
Marquise de Coigny, celebrated for her wit. Her daughter, a
charming girl.
Narbonne.[198] The scandalous chronicles of the
old Court report that he is the son of Mde. M. DE
Adélaïde of France. He is strikingly like the NARBONNE
Bourbons, but depraved as were the manners, it is
too repugnant to nature to credit the whole story. His conversation is
brilliant, full of lively sallies, and, upon the whole, he is one of the
most agreeable persons in society I ever met with. He was Minister
of War for a moment just after the King accepted the Constitution. He
is attached to Mde. de Staël, who has the most uncontrolled
dominion over his opinions and conduct. His person is a more
divided property. He used to be Talleyrand’s intimate friend, but Mde.
Grand, finding him averse to her elevation, by degrees broke the
friendship.
Ségur,[199] son of the Comte, a promising, rising young man,
married to Mde. d’Aguesseau’s daughter.
Young Ségur, a flippant lad, vain of having made under McDonald
a campaign, which he has written, and of having gone, by order of
Bonaparte, with more celerity than was ever done, from Paris to
Madrid and back again. Age and some well-directed rebuffs will be of
infinite service to him.
Mde. d’Aguesseau.
Jaucourt,[200] a Tribune. Under the days of the Court he was
distinguished for his galanterie and dévouement in affairs of intrigue.
There is a famous anecdote of his losing his thumb not to betray a
lady whose house he quitted by stealth at daybreak. The Swiss
heard a noise at the gate, and shut it with violence; Jaucourt’s thumb
was crushed, but he made no noise, and for many years the
adventure was secret. He is now married, according to the licence
allowed by the Revolution, to Mde. de la Châtre. He is an agreeable
man, she is clever.
Abbé Casti.[201] I will not do to him what an injudicious panegyrist
has done to Ariosto, whose epitaph is laden with an enumeration of
his works. Suffice it to say that his last work is inferior to all his
others—Gli animali parlanti, a poem as dull and as ill-conceived as
Dryden’s Hind and Panther. Those discuss polemical questions, and
Casti’s reason upon the abstract principles of Governt. He is very
old, and worn out by every species of debauchery and excess; his
eyes twinkle at times, and show a trace of his former life, but they
are but rare scintillations.
Rumford, ye Yankee philanthropist. I have often named him
elsewhere.
Le Chevalier,[202] a most cordial, warm-hearted,
zealous man. He travelled to the plain of Troy with M. LE
Sir Francis Burdett, and has written upon it, which CHEVALIER
has given rise to a fresh controversy. He is
employed au Bureau des relations extérieures, merely from
Talleyrand’s friendship for him. His language is not calculated to
obtain him promotion in his career, nor is he trusted with anything,
his place being a sinecure and more a pension than an employment.
Monteron,[203] [sic] one of the unfortunate Duke of Orléans’ set, a
complete mauvais sujet, but an agreeable vaurien. He was one of
the Dsse. de Fleury’s husbands, but has regained his liberty.
 Markoff,[204] the Russian Ambassador, a rusé diplomat, scurvily
treated by Bonaparte, who seems to make a point of saying
offensive things before him.
M. de Grave,[205] an obliging driveller.
Abbé Dillon, brother of the Beau Dillon,[206] &c. Knew him in Paris
in 1790, afterwards in Italy and England. A conceited bel esprit, with
too much pretensions.
Calonne. One may say of him as Johnson did of Garrick, that his
loss has removed a stock of harmless amusement from society. He
was delightful; with all the freshness and vivacity of youth, he had
the taste and refinement of riper years. Tho’ he allowed himself to
range in the regions of fancy, when he ought to have been restrained
by the strictness of veracity, yet he did it with such liveliness and wit
that one compounded for the lost fact in hearing the facetious story.
He was murdered by an unskilful physician a very short time after we
quitted Paris.
Talma,[207] the celebrated tragedian. His voice is bad, nor is his
conception of his part always correct. He is the person who has
introduced the severity and perfection of costume in the theatre. He
is not clever and not well informed.
Abbé Sicard,[208] the successor of Abbé de L’Épée. He brought
with him his most intelligent pupil Massieu. The pains he bestows
upon the unhappy objects confided to his care entitle him to much
praise; the lectures are worth seeing once, but to those who stand
not in need of this assistance are soon tedious.
Bertrand.[209] I knew him in Italy. He is a friend of Mde. d’Albany’s,
and belongs to the society of Mde. de Souza, Morellet, &c., &c. He is
declining fast; he was a lively man.
Charles de Noailles,[210] an uncommonly handsome man, son of
the Prince de Poix. He lived very much in England, and at one time
with the Prince, who grew jealous at Mrs. Fitzherbert’s partiality to
him, which occasioned their rupture. He has much more sense and
useful knowledge than one might suppose from a slight
acquaintance with him he possessed.
The English who dined with us were Mr. and
Mrs. Fox, Ld. Robert Adair, St. John, Mr. Trotter, ENGLISH IN
Mr. Clarke, Green, Heathcote, Kemble, Pinkerton, PARIS
Fitzpatrick, 2 Erskines, Mr. Merry, Lens, Abbé
Roberts, Banks, Mrs. H. Fox, Mr. Neave, Miss Townshend, Mr.
Parish, St. Leger, Tuyle, Warner, Francis, A. St. Leger, Capt. Jones,
Jerningham. We dined twice at Sieyès; once at Cambacères’s and
Lucchesini’s; often at Talleyrand’s; once at Versailles with the
Caumonts and Andréossys.
The Hollands left Paris on September 20, 1802, for a tour in the
South of France and Spain. They did not return to England till April
1805. The Journal continues until April 8, but is omitted from these
pages.
July 24th, 1806.—The Russians have made a separate peace.
[211] The Cabinet have determined upon sending a person upon an
extraordinary Mission to Portugal, and have chosen Lauderdale for
that purpose, and he has accepted. Ld. St. Vincent is to follow with
the fleet, and be joined in the Commission; the nature of the
appointment to be the same as Ld. Minto and Ld. Hood were at
Toulon. It is proposed, if Portugal be invaded, that we should carry
off (vi et armis) the Royal family, and such as choose to follow their
fortunes, and establish them at Brésil. A French army of 90,000 men
is assembled at Bayonne for the invasion of Portugal. Eugène
Beauharnais, the Viceroy of Italy, is to have the command of it; the
attack is to be made by Galicia.
25th.—The preliminaries of peace between
France and Russia have been signed by d’Oubril, NEGOTIATION
though he knew at the time that Basilico was on S FOR PEACE
his road to Paris with dispatches from our Governt.
He signed three hours after he knew of his landing at Boulogne. The
following stipulations form the basis of the peace. The Russians are
to return Corfu, but they are not to keep more than 4000 men in
garrison there. Dalmatia and Ragusa are left to the French. The
Montenegrins are not to be punished for the successful resistance
which, in conjunction with the Russians, they have opposed to the
French arms, but this amnesty does not extend to any offences
which they may have committed against their lawful Sovereign. Sicily
is left exposed to the French without a stipulation in its favour. No
provision of any sort is made for the ex-King of Naples, nor is there
any allusion to him in the Treaty, except a declaration on the part of
the French that they have no objection to the King of Sicily et sa
femme (they will not call her Queen) finding an asylum wherever
they can. By a secret article, Minorca, Majorca, and Iviza are to be
transferred from Spain to the D. of Calabria, on condition that the
ports of these islands shall be shut against the English. The
Russians agree to exclude the English from all their ports in the
Mediterranean. The French are to be allowed six months[212] to
evacuate Germany. The present Treaty must be ratified within
twenty-five days.
On the day following this extraordinary transaction, Ld.
Yarmouth[213] presented his credentials to the F. Governt., though
his instructions were not to present them at all, till the basis of the
pacification was settled. This step of Ld. Y.’s is very reprehensible,
as it may give d’Oubril a pretext to justify his conduct.
The terms of peace originally offered by
Talleyrand and conveyed to Mr. Fox by Ld. Y. were NEGOTIATION
very advantageous to this country; indeed, so S FOR PEACE
extremely so, that as the proposals were verbally
made, much doubt was entertained of Ld. Y.’s accuracy in reporting
them, and he owed entirely his being employed in the negotiation to
the doubts of his veracity. The uti possidetis on both sides was to be
the basis of the treaty. Hanover was to be restored to the K. of E., in
return for our acknowledgment of Bonaparte’s newly-created Kings.
No further changes were to be made in Germany or Switzerland.
The integrity of Spain and Portugal was to be guaranteed in both
Hemispheres. We were not to interfere with the settlement of Italy or
Holland. Upon a distant hint being thrown out about commercial
arrangements, ‘Nous voulons être maîtres chez nous’ was the reply.
When Sicily was mentioned, Talleyrand, who had spoken the above,
exclaimed, ‘Mais que voulez vous? Vous l’avez.’ Our Cabinet readily
assented to these terms (in addition to which it was hinted that
Bonaparte was disposed to concur with Mr. F. in taking measures for
the general abolition of the Slave Trade, but this was intended as a
sneer. When Talleyrand read the resolutions of the H. of Commons
upon the subject of the S. Trade, he said there was another Act of
Parliament much more necessary, one for which the Spaniards,
Portuguese, and Germans called out most loudly, ‘Et cette acte du
Parlement, c’est la paix’), and Ld. Y. was sent back to Paris with full
assent to his message. But when he arrived there he found the
views of the French Governt. materially changed in the most
important point. They now demanded that Sicily should be ceded to
them in order to be re-annexed to the kingdom of Naples. Joseph,
the new King, had represented that his kingdom of Naples would not
be secure without the possession of Sicily, and the French engineers
had given in a report that Sicily could be subdued with much more
ease than they had at first supposed. On these grounds, which the
French have the assurance to represent as new occurrences since
their first overtures to Ld. Y., they pretend to justify their deviation
from their original proposals, and they offered to the King of Sicily, in
exchange for that island, to make him King of Dalmatia and Albania.
[214] D’Oubril, the Russian negotiator, who was by this time at Paris,
and who had been privy to everything done by our Cabinet, was
caught by this last proposal, and expressed his opinion decidedly in
favour of it. In the cession of Dalmatia to the King of Sicily, he
fancied that he saw the elevation of power which would remove the
French to a greater distance from the frontiers of Turkey, and prove
in future a bulwark against the extension of their empire in that
quarter. He was ready, as Mr. Fox observed, to sacrifice a well-
understood English object to an ill-defined Russian one. This
modification of the original project was received here with great
disappointment and ill-humour, and was considered as a breach of
faith on the part of the French. We contended that no event had
happened which could justify any departure from the first proposals.
We could not consent to transfer Albania from its present
possessors, who were the friends and allies of England, in order to
make compensation to the K. of Sicily for the loss of his dominions,
which it was equally our interest and our duty to defend. Dalmatia
alone was not to be mentioned as an equivalent for Sicily. But to
show our disposition to accommodate matters, it was at length
proposed as a compromise, that Dalmatia should be given to the
King of Sardinia, with the title of King; and since the new K. of
Naples was desirous to have a greater extent of sea-coast, that
Sardinia, together with the other Spanish Islands of Majorca, &c.,
should be added to his kingdom; Sicily on no account could we yield.
The Minute which Mr. Fox drew up for the Cabinet, in which he
states his reasons compressed into 8 or 10 sentences, is the most
able summary ever penned.
In this state of the negotiation, d’Oubril, who a few days before
had reminded Mr. Fox of the expression of ‘piano piano,’ which he
had used in his letter to Czartorisky upon the Grand Confederacy
forming last year, signed the peace, the outline of which I have just
noted. His excuse for this conduct is said to be the danger to which
Russia would be exposed, if they were to persuade Turkey and
compel Austria to join in a coalition against her. Austria is so much
reduced that she must comply with whatever France demands, and
French influence domineers at Constantinople. But these are not
supposed to be the true reasons for his conduct. The late changes in
the private councils of St. Petersburg are suspected to have had a
greater share in determining him, and it is even said that, on the
strength of those, he has ventured to take this important step without
instructions from his Court. He says, ‘He is gone back to lay his
Treaty and head at the feet of his Master.’
Czartorisky,[215] the late Minister of Russia, is a Pole of great
consideration and high rank in Poland. He owed his elevation to the
partiality of the Empress, who was passionately in love with him. He
afterwards became a favourite with Alexander; he played the truant
to his mistress, who was for a length of time quite inconsolable at his
infidelities. The Empress is with child at present.
26th.—It is determined to send a military man to
Portugal, and Ld. Rosslyn[216] has been fixed upon MISSION TO
for the mission. Ld. H. immediately proposed to PORTUGAL
him to take Brougham, if he had any person in a
civil capacity. He promised to propose him to Ld. Grenville. There is
an idea of employing Dumouriez.
Sr. Sidney Smith has taken the Isle of Capri, and the French have
been worsted in several encounters in Calabria. Hopes are
entertained that we shall be able to defend Sicily against the French,
with the aid alone of the Sicilians. The Queen and Duke of Calabria,
who are surrounded by persons suspected of being secretly in the
French interest, are eager for carrying the war into Calabria.
Great dissatisfaction at Ld. Yarmouth’s conduct, and another
negotiator must go. Ld. Holland not being able to leave his uncle,
Lauderdale, as the next best person, is to go. It is a sad mortification,
as it has long been the darling hope of uncle and nephew; but it
would be impossible to go, as Ld. H., besides being useful, is also
one of the greatest comforts to Mr. Fox. Mr. F. so ill that none of the
last transactions of the preceding three days have been
communicated to him.
27th July.—Mr. Fox stronger, and in better spirits to-day, but there
is no material change in his complaint. The news of the Russian
Treaty, and the determination of sending Lauderdale to Paris, were
communicated to him by Ld. Howick. Upon hearing that L. was to go
to Paris, he exclaimed, ‘Why does not Holland go?’ Ld. Howick was
perplexed, and stammered by way of excuse the ‘suddenness of the
departure’; upon which Fox said, ‘Oh, I understand you!’ and
immediately changed the subject. When he saw Ld. Holland about
an hour afterwards, he began with saying, ‘So, young one, you won’t
go to Paris’; on Ld. Holland’s answering that he preferred staying, as
he thought he was a comfort to him, he caught his hand and said,
with great emotion, ‘Yes, a comfort indeed,’ and was for several
minutes quite overcome and shedding tears. This circumstance is
the first event which has given him any apprehension about his own
danger.
D’Oubril has written to Stroganoff[217] that he
signed the preliminaries with Ld. Yarmouth’s LORD
approbation. Ld. Yarmouth in his dispatches says YARMOUTH’S
CONDUCT
quite the contrary. Copies of the letters have been
sent to St. Petersburg. Our Ministers are greatly displeased with Ld.
Yarmouth for having presented his credentials the very day after
d’Oubril signed, and are not without fear that he may be bullied or
won into signing the preliminaries without further instructions. There
are some unpleasant suspicions afloat about Ld. Y., especially upon
the score of stock-jobbing.[218] General Clarke[219] is the person
named to negotiate with him; he was employed upon d’Oubril’s
business. The French already show a disposition since the signature
of the Russian Treaty, to rise in their demands. They have thrown out
hints that they expect St. Lucia and Tobago to be restored to them,
and Ld. Y. has of his own head suggested that Cuba should be
ceded to the King of Naples, who cannot be reduced to live as a
fugitive or subject in the dominions of his son. Ld. Y. is suspected of
concealments in his report of his negotiations. A messenger went off
instructing him not to proceed in any way, but wait L.’s arrival.
Notwithstanding their displeasure, Ld. Y. has been joined in the
Commission with Ld. Lauderdale.
28th.—Mr. Fox nearly in the same state; his spirits are good, and
he has still great hopes of recovery. He said this morning, ‘I hope my
recovery is not so desperate as peace.’ The news from Paris is
every day less favourable, so much that hints have been thrown out
to Ld. Yarmouth about the restitution of Pondicheri and Surinam, and
the other Dutch colonies in S. America, about the expulsion of the
French Princes from England, and a restraint upon the licence of the
journals. Ministers are much more discontented with Ld. Y. L. has
been told in the most explicit manner by the Cabinet, that if he finds
anything in Ld. Y.’s conduct to disapprove of, he has only to give a
hint, and he shall be recalled.
Bonaparte is elated beyond his usual tone of insolence since he
procured the Russian Treaty; he sent for the Austrian Chargé
d’Affaires, and ordered him to signify to his master that he must lay
aside the title of Emperor of Germany, and yield the precedence to
France, and that he must assent to and recommend the alterations
in the constitution of the Empire, which were proposed to be held at
Frankfort on the 10th August. The Chargé d’Affaires pleaded that he
durst not convey such a message to his Sovereign. ‘Pourquoi votre
maître ne m’envoye-t’-il pas un ambassadeur, et pas un misérable
parlementaire?’
29th.—Professor Dugald Stewart, who has just arrived from
Edinburgh, is to go with L. to Paris. Gaeta is taken, and Sr. Sidney
has met with some check in the kingdom of Naples.[220] L. had a
conversation alone with Mr. F., in which he opened himself freely. He
said he wished to retire from office till he got better, and to have Ld.
H., whom he had always destined ultimately to succeed him,
appointed to fill his place pro tempore, adding that he had been
thinking of this for some time, but that he had put it off in the hope of
being able to sign the peace before he retired. He bid L. ‘open the
matter to Ld. Grenville,’ and added that he ‘would talk further on the
subject to Ld. Grenville in 8 or 10 days.’ In a conversation which L.
had with Ld. Grenville some time ago, during which they talked of Mr.
Fox’s situation and of the small prospect of any amendment in his
health, Ld. Grenville said, ‘That he hoped his own conduct had been
such as to satisfy Mr. Fox’s friends since the period of their being
connected together, and if that disastrous calamity should happen,
and most disastrous indeed would it be for the country, he trusted,
they would have no reason to be dissatisfied with any future
arrangements that might take place.’
Sheridan, who dined here to-day, begged to talk to me privately.
He said that it was the wish of many of Fox’s friends, whenever the
state of his health should make it impossible for him to attend to the
duties of his office, that Ld. H. should be appointed his successor;
that such an appointment would be regarded by them as a pledge
that the Whig Party was still to be kept up, and its principles
maintained; that the Prince was very eager to have them carried into
effect; that he had spoken to Windham, who seemed to listen with
satisfaction. That he, ‘from delicacy, spoke to me instead of to Ld. H.,
and begged I would communicate the substance of them to him,’ He
told me that George Byng and the second-rate sort of politicians
were very eager upon the subject.
Cline, the surgeon, has seen Mr. Fox, and declares himself ready
to perform the operation whenever the physicians shall judge it
expedient, as he does not see any reason to think the result more
formidable to Mr. F. than to any other person.
Ld. Howick is full of plans for an Administration,
in the event of Mr. Fox’s retirement, or worse. He A SUCCESSOR
takes for granted that neither the General or Ld. TO FOX
Fitzwilliam would choose to remain in office if F.
were away. He would, in that case, make Whitbread Secretary at
War, himself S. for the Home Department, Tom Grenville the
Admiralty, Tierney the Board of Control, Ld. H., of course, the
Foreign Office; and, said I, ‘Pray where do you put Lauderdale, ye
first, greatest, and best lord?’
31st.—Lauderdale had an interview with Ld. Grenville, and
repeated the substance of his late conversation with Mr. F.; Ld. G.
listened with great attention, but made no reply. Just as L. went out,
he called him back to beg that he would say to Ld. H. that, ‘He had
many times abstained from going to Stable Yard, from an
apprehension that if Mr. Fox should know he was there, he might
suppose he was come upon business and make an effort to see him,
which might do him harm; but that if he followed the dictates of his
own inclination, he should be there every day,’ Tierney and Ld.
Morpeth have both expressed to me very strongly their wishes and
the necessity that Ld. H. should be the locum tenens for his uncle.
1st August.—Ld. Rosslyn has written a letter on the subject of his
Mission to Portugal, from which it appears he is not inclined to
undertake the services assigned to him. When Admiral Markham
read it, he observed upon it that, ‘Ld. St. Vincent, when he sees this,
will say the fellow has got dung at his heart.’ Not a very elegant or
delicate mode of expression!
It is said that Spain is disposed to a war with France, in
consequence of their having discovered that a plan of partitioning
Spain is in agitation, by which Estremadura and Galicia are to be
annexed to Portugal, and made into a kingdom for the Prince of the
Peace,[221] while the rest of Spain is to be given to one of B.’s
brothers.
 Mr. Goddard (Ld. Henry Spencer’s friend) arrived this evening
from Paris with passports for Lauderdale. When the passport was
required, Bonaparte exclaimed, ‘What! another passport! Have they
not a blank one already? But this is of a piece with the whole of their
conduct during the negotiation; delay, delay is their object.’ ‘But will
you grant them the passport?’ ‘Yes, and for twenty more if they
choose.’
2nd.—Lauderdale set off for Paris this evening, with Professor
Stewart, and Mr. Maddison from the Post Office. Ld. H. gave him a
letter to Serra and Prince Masserano.[222]
Mr. Fox better; Vaughan said this morning that there was a greater
assemblage of favourable symptoms than there had been any day
since he attended.
Sheridan came here in the evening, and talked
over his schemes. He enlarged greatly upon the SHERIDAN’S
state in which the House of Commons would be INTRIGUES
left if Mr. Fox were removed from it; deplored the
unpopularity of Ld. Howick, and seemed to insinuate that Petty had
been tried and found unfit for the task.[223] He has some project, all
founded upon his enmity to Ld. Howick and hereditary suspicion of
Ld. Henry, to try and rouse Ld. H.’s old partiality for Canning, and get
him and Perceval into the Administration.
3rd.—Mr. Fox not quite so well.
4th.—Mr. Fox in high spirits, and talks confidently of meeting Parlt.
in October; approves of an early session in time of war. He has not
the slightest expectation of peace, and expects Lauderdale’s
immediate return.
5th.—When Bonaparte was told that L. was coming, he said,
‘Comment! on m’envoye un ancien Jacobin.’ D’Oubril had been shut
up for 14 hours with General Clarke, before he signed the
Preliminaries. It is a dexterous way of carrying a point, to weary out a
man’s physical strength, to tame him like a wild beast, to carry your
purpose. The pretext was to carry the business through rapidly.
 Ali Pacha[224] of Janina has sent a letter which he received from
Bonaparte, all written in his own hand, inviting him to form a
connection with France. Ali observed he had never received such a
mark of respect and confidence from the English. Bonaparte is
steady and indefatigable in all his undertakings.
6th.—Ld. Grenville has proposed to Ld. H. that he should be one
of the Commissioners for settling the points in dispute between this
country and the U. States of America.[225] Ld. Auckland, as
President of the Board of Trade, is to be the other Commissioner.
The Americans are Messrs. Monroe[226] and Pinckney.[227] Ld.
Howick and others consider this as a delicate opening on the part of
Ld. G. to show his readiness to comply with the intimation he had
recently had from Mr. F. through Lauderdale.
The operation is to be to-morrow.
7th.—The operation was performed this morn.; Cline and Hawkins
did it. Sixteen quarts of amber-coloured water was drawn off; he
bore the operation perfectly well, his pulse very little affected, and no
disposition to faintness.
8th.—Not so well from nausea and lowness.
Ld. H. has accepted the appointment of Commissioner. Mr. Eden
is the Secretary (by a shabby artifice of his father’s), Mr. Allen the
Assistant-Secretary.
It has been proposed to Tierney to go to Lisbon in the capacity in
which Ld. Rosslyn was to have gone. T.’s intimacy with Ld. St.
Vincent made him be thought of for the service. Ld. St. V. is to follow
with a squadron for carrying off, if necessary, the Portuguese fleet to
the Azores, and for transporting the Prince Regent and his friends to
Brazil. T. is disinclined, and has refused.
9th.—Ld. Grenville sent for Ld. Rosslyn late last
night and renewed his former proposal of sending LAUDERDALE’
him to Lisbon. Ld. R. has accepted, and is to set S MISSION
off to-night. The Commissioners are Lds. Rosslyn,
St. V., and General Simcoe;[228] and, to my great satisfaction, Mr.
Brougham.
10th.—Mr. Fox continues very low; a great flow from ye wound,
the anasarca diminishes fast.
12th.—No messenger from Paris. It is suspected that some
artifice is used to delay the messengers, in order to prolong the
negotiation, it being a matter of importance to France to keep up the
appearance of a negotiation with England till the changes she
meditates in Germany are completed.
14th.—Messengers in. Immediately on L.’s
arrival he presented to the F. Governt. a short NEGOTIATION
recapitulation of what had already passed during S FOR PEACE
the negotiation, recalling to their recollection that
the principle on which the E. Governt. had consented to treat was
the uti possidetis, and reminding them how much this had been
forgotten and departed from in their late demands, and concluding
with the alternative, either to resume the uti possidetis as the
principle of the Treaty, or to send him passports to return to England.
[229] Three days elapsed before any answer was given to this note.
General Clarke proposed that the business should be carried on by
conversations, and not by written notes, which was refused. He also
cavilled at some expressions in L.’s note, but at length presented a
note couched in rather a high tone, complaining that when the Treaty
was far advanced, and that Ld. Yarmouth was on the point of
signing, L. should have been sent over to make inadmissible
pretensions and to disappoint the hopes which all Europe had
conceived of peace. The uti possidetis could not be the basis of the
Treaty, unless the Emperor were to be replaced in the possession of
Fiume, Treviso, and of all the conquests which he had renounced by
the Peace of Presburg. Upon this L. sent for his passports. Three
days were employed in sending from one office to another to obtain
them, without success. M. de Lima (the Portuguese) called upon
him, and implored in the most earnest manner that he would not
break off the negotiation, as this would leave Portugal and Spain
exposed to certain and immediate destruction. No effect being
produced by this manœuvre, and L. persisting in his demand of
passports, a 2nd note was sent, expressed in much more civil and
moderate language, and tho’ denying that the uti possidetis had ever
been admitted as the basis of the Treaty, and declaring that without
great modifications it was inadmissible, but concluding with these
words, ‘Mais l’Empereur l’adopte puisqu’il le trouve.’ It is remarkable
that in this note the word adopte was substituted in the Emperor’s
own handwriting, in place of accepte or admet. And in the date, the
11th had been inserted instead of the 7th, which had been the
original date, so that the note had been detained some days, in
hopes of Lauderdale’s yielding. On receiving this, L. addressed a
note to the French Governt., in which, without taking any notice of
the contents of theirs, he declared he could not go on with the
negotiation, unless he had an explicit assurance from them that he
should have passports at any time within half an hour, for himself or
couriers, whenever he should chance to demand them. This note
produced a very civil answer from Talleyrand, ascribing to accident
entirely the blame of the former delay, and assuring him that it was in
no respect owing to any want of civility to him. Lauderdale returned a
second note, in answer to the former one, that he could not negotiate
further, unless the uti possidetis[230] was distinctly admitted to be the
basis of the Treaty, and that every deviation from it should be
considered as an exception from the general basis of the peace.
Things were in this state when Basilico was sent away.
Ministers, especially Ld. Grenville, are extremely pleased with L.’s
conduct, particularly in his note on the subject of passports, after he
received the second note from General Clarke. A Council was held
immediately, in which it was determined to recall Ld. Yarmouth, and
Basilico was sent back in the evening with an order to that effect.
The reason for this measure:—1st, d’Oubril’s account and Ld.
Yarmouth’s of the conclusion of the Russian Treaty are in flat
contradiction. D’Oubril has written to Stroganoff that he signed the
article with Ld. Yarmouth’s knowledge and approbation. 2ndly, Ld.
Yarmouth seems to have spent some weeks at Talleyrand’s country
house last autumn, tho’ he gave Ministry to understand that he was
hardly acquainted with him. 3rdly, Ly. Yarmouth is very much
connected with Monteron,[231] an agent of Talleyrand’s, and
employed in his office.
Favourable accounts of the disposition of the new Russian
Governt. towards this country; Stroganoff has received letters to that
effect from the new Prime Minister, Budberg,[232] in which he
expresses very strongly Alexander’s high opinion as well as his
confidence in Mr. Fox. Stroganoff thinks Russia will not ratify
d’Oubril’s preliminaries.
Ld. Granville Leveson arrived this day from Petersburg, dined
here, and is looking handsomer than ever. I have not seen him these
four years.[233]
American Commissioners very amicable; disposed to settle the
differences, and to conclude a Treaty of Commerce between the two
countries.
20th.—Ld. Howick dissatisfied with Sr. J. Borlase Warren, who
lost three days after he got orders to sail, and wasted three more at
Madeira, instead of going straight to ye W. Indies, by which Jerome
may escape.[234] Alderman Prinsep did not know how to open the
Stock Exchange.
Alas! Mr. Fox begins to fill again; they talk of another operation in
three weeks.
Lauderdale is abused at Paris, and represented as having
deserted Fox. Goldsmid is supposed to be Ld. Yarmouth’s agent in
the Stock Exchange, and to have transacted business for him to a
great amount. Narbonne was admonished not to visit L. so
frequently, Fouché sent for him to that purpose. Emperor gone to
hunt, his Ministers rejoice at his absence whilst in so violent a mood;
they call him bête féroce.
Second operation performed on Sunday. Bore
the operation extremely well; less water taken from FOX’S HEALTH
him than on the former occasion, but he was more
completely emptied. Some pints of water which had remained in ye
abdomen were drawn off; fell soon after into a state of languor and