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LWBK505-FM_i-x.qxd 09/07/2010 07:00 PM Page i Aptara
Pediatric Sonography
FOURTH EDITION
Editor
Marilyn J. Siegel
Professor of Radiology and Pediatrics
The Edward Mallinckrodt Institute of Radiology
Washington University School of Medicine
St. Louis, Missouri
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Acknowledgments
riting a book is a task that requires time and commitment remain dedicated to performing high-quality examinations on
W from many people. As editor, it would not have been pos-

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

lie on the Atlantic Coast between our own state of Maine and the
mouth of the St. Lawrence. The Provinces are Nova Scotia, New
Brunswick, and Prince Edward Island. Their area is almost equal to
that of our six New England states, and in climate and scenery they
are much the same. Their population, however, is only about one
million, or little more than one fourth as many as the number of
people living in Massachusetts. These provinces were the first British
possessions in Canada, and like New England they have seen the
centre of population and progress move ever westward.
Nova Scotia is the easternmost province of the Dominion of
Canada. Its capital and chief city is Halifax, situated on the Atlantic
on one of the world’s best natural harbours. This is a deep water
inlet ten miles in length, which is open all the year round. Montreal
and Quebec are closed to navigation during the winter months on
account of the freezing of the St. Lawrence.
Halifax is six hundred miles closer to Europe than is New York,
and nearer Rio de Janeiro than is New Orleans. As the eastern
terminus of the Canadian National Railways, it has direct
connections with all Canada. With these advantages, the city hopes
to become one of the great shipping centres on the North Atlantic.
Halifax has long been noted as the most English city in Canada.
It was once the military, naval, and political centre of British North
America, and gay with the social life of British officers and their
ladies. Now, both the warships and the soldiers are gone, and the
city is devoting itself to commercial activities.
As we steamed past the lighthouses and the hidden guns on the
headlands guarding the entrance, I was reminded of all that this
harbour has meant to America. The city was founded by Lord
Cornwallis in 1749 at the suggestion of Boston merchants who
complained that the French were using these waters as a base for
their sea raiders. Less than thirty years later it provided a haven for
Lord Howe when he was driven out of Boston by our soldiers of the
Revolution, and became the headquarters for the British operations
against the struggling colonies. In the war of 1812, the American
warship Chesapeake was brought here after her defeat by the British
frigate Shannon. During our Civil War Halifax served as a base for
blockade runners, and the fortunes of some of its wealthy citizens of
to-day were founded on the profits of this dangerous trade. No one
dreamed then that within two generations England and America
would be fighting side by side in a World War, that thousands of
United States soldiers would sail from Halifax for the battlefields of
Europe, or that an American admiral, commanding a fleet of
destroyers, would establish his headquarters here. Yet that is what
happened in 1917–18. All that now remains of the former duels on
the sea is the annual sailing race between the fastest schooners of
the Gloucester and the Nova Scotia fishing fleets.
Halifax is built on a hillside that rises steeply from the water-front
to a height of two hundred and sixty feet above the harbour. The city
extends about halfway up the hill, and reaches around on both sides
of it. The top is a bare, grassy mound, surmounted by an ancient
citadel.
Stand with me on the edge of the old moat, and look down upon
Halifax and its harbour. Far to our left is the anchorage where
occurred one of the greatest explosions the world ever knew. Just as
the city was eating breakfast on the morning of December 6, 1917, a
French munitions ship, loaded with benzol and TNT, collided with
another vessel leaving the harbour, and her cargo of explosives blew
up in a mighty blast. Nearly two thousand people were killed, six
thousand were injured, and eleven thousand were made homeless.
Hardly a pane of glass was left in a window, and acres of houses
were levelled to the ground. A deck gun was found three miles from
the water, and the anchor of one of the vessels lies in the woods six
miles away, where it was thrown by the explosion. A street-car
conductor was blown through a second-story window, and a sailor
hurled from his ship far up the hillside. Since then much of the
devastated area has been rebuilt along approved town-planning
lines, but the scars of the disaster are still visible. For a long time
after the explosion, the local institution for the blind was filled to
capacity, and one saw on the streets many persons wearing patches
over one eye.
Standing on the hill across the harbour one sees the town of
Dartmouth, where much of the industrial activity of the Halifax district
is centred. There are the largest oil works, chocolate factories, and
sugar refineries of Canada. Vessels from Mexico, South America,
and the British West Indies land their cargoes of tropical products at
the doors of the works. Fringing the water-front are the masts of
sailing vessels and the smokestacks of steamers. Among the latter is
a cable repair ship, just in from mending a break in one of the many
submarine telegraph lines that land on this coast. Next to her is a
giant new liner, making her first stop here to add to her cargo some
twenty-five thousand barrels of apples from the Annapolis Valley.
This valley, on the western side of Nova Scotia, is known also as
“Evangeline Land.” It was made famous by Longfellow’s poem based
on the expulsion of the French Acadians by the English because
they insisted on being neutral in the French-British wars. It is one of
the finest apple-growing districts in the world, and sends annually to
Europe nearly two million barrels. Many descendants of the former
French inhabitants have now returned to the land of their ancestors.
Looking toward the mouth of the harbour, we see the new
terminal, a twenty-five million dollar project that has for some years
stood half completed. Here are miles and miles of railroad tracks,
and giant piers equipped with modern machinery, a part of the
investment the Dominion and its government-owned railway system
have made to establish Halifax as a first-class port. Beyond the port
works another inlet, Northwest Arm, makes its way in between the
hills. I have motored out to its wooded shores, which in summer time
are crowded with the young people of Halifax, bathing and boating. It
is the city’s chief playground and a beautiful spot.
But now take a look at the city itself, stretching along the water-
front below where we stand. The big red brick building just under our
feet is the municipal market. There, on Saturdays, one may see an
occasional Indian, survivor of the ancient Micmacs, and Negroes
who are descendants of slaves captured by the British in Maryland
when they sailed up the Potomac and burned our Capitol. Farther
down the hillside are the business buildings of the city, none of them
more than five stories high, and all somewhat weatherbeaten. I have
seen no new construction under way in downtown Halifax; the city
seems to have missed the building booms of recent years. Most of
the older houses are of stone or brick. Outside the business district
the people live in wooden frame houses, each with its bit of yard
around it. One would know Halifax for an English town by its
chimney pots. Some of the houses have batteries of six or eight of
these tiles set on end sticking out of their chimneys.
The streets are built on terraces cut in the hillside, or plunging
down toward the water. Some of them are so narrow that they have
room for only a single trolley track, on which are operated little one-
man cars. I stepped for a moment into St. Paul’s Church, the first
English house of worship in Canada. Its front pew, to the left of the
centre aisle, is reserved for the use of royal visitors. Passing one of
the local newspaper offices, I noticed a big crowd that filled the
street, watching an electric score board that registered, play by play,
a World Series baseball game going on in New York. The papers are
full of baseball talk, and the people of this Canadian province seem
to follow the game as enthusiastically as our fans at home.
My nose will long remember Halifax. In lower Hollis Street, just
back from the water-front, and not far from the low gray stone
buildings that once quartered British officers, I smelled a most
delicious aroma. It was from a group of importing houses, where
cinnamon, cloves, and all the products of the East Indies are ground
up and packed for the market. If I were His Worship, the Mayor of
Halifax, I should propose that Hollis street be renamed and called
the Street of the Spices. Just below this sweet-scented district, I
came to a tiny brick building, with a sign in faded letters reading “S.
Cunard & Co., Coal Merchants.” This firm is the corporate lineal
descendant of Samuel Cunard, who, with his partners, established
the first transatlantic steamship service nearly a century ago, and
whose name is now carried all over the world by some of the
greatest liners afloat.
Another odour of the water-front is not so sweet as the spices. It
is the smell of salt fish, which here are dried on frames built on the
roofs near the docks. Nova Scotia is second only to Newfoundland in
her exports of dried cod, and all her fisheries combined earn more
than twelve million dollars a year. They include cod, haddock,
mackerel, herring, halibut, pollock, and salmon. Lunenburg, down
the coast toward Boston, is one of the centres of the deep-sea
fishing industry, and its schooners compete on the Grand Banks with
those from Newfoundland, Gloucester, and Portugal.
I talked in Halifax with the manager of a million-dollar corporation
that deals in fresh fish. He was a Gloucester man who, as he put it,
“has had fish scales on his boots” ever since he could remember.
“We operate from Canso, the easternmost tip of Nova Scotia,” he
said. “Our steamers make weekly trips to the fishing grounds, where
they take the fish with nets. They are equipped with wireless, and we
direct their operations from shore in accordance with market
conditions. While the price of salt fish is fairly steady, fresh fish
fluctuates from day to day, depending on the quantities caught and
the public taste. Such fish as we cannot sell immediately, we cure in
our smoking and drying plants.
“All our crews share in the proceeds of their catch, and the
captains get no fixed wages at all. We could neither catch the fish
nor sell them at a profit without the fullest coöperation on the part of
our men, most of whom come from across the Atlantic, from
Denmark, Norway, and Sweden, and also from Iceland. Next to the
captain, the most important man on our ships is the cook. Few fish
are caught unless the fishermen are well fed. The ‘cook’s locker’ is
always full of pies, cakes, and cookies, to which the men help
themselves, and the coffee-pot must be kept hot for all hands to
‘mug up.’”
From Halifax I crossed Nova Scotia by rail into the adjoining
province of New Brunswick. Nova Scotia is a peninsula that seems
to have been tacked on to the east coast of Canada. It is three
hundred and seventy-four miles long, and so narrow that no point in
it is more than thirty miles from the sea. The coast does not run due
north and south, but more east and west, so that its southernmost tip
points toward Boston. The Bay of Fundy separates it from the coasts
of Maine and New Brunswick, and leaves only an isthmus, in places
not more than twenty miles wide, connecting Nova Scotia with the
mainland. The lower or westernmost half of the province is encircled
with railroads, which carry every year increasing thousands of
tourists and hunters from the United States. The summer
vacationists and the artists go chiefly to the picturesque shore towns,
while those who come up for hunting and fishing strike inland to the
lakes and woods. Deer and moose are still so plentiful in Nova
Scotia that their meat is served at Halifax hotels during the season.
The scenery is much like that of Maine. Rolling hills alternate
with ledges of gray rock, while at every few miles there are lakes and
ponds. Much of the country is covered with spruce, and many of the
farms have hedges and tall windbreaks of those trees. The
farmhouses are large and well built; they are usually situated on high
ground and surrounded by sloping fields and pastures considerably
larger than the farm lots of New England. In some places the broad
hills are shaped like the sand dunes of Cape Cod. At nearly every
station freshly cut lumber was piled up, awaiting shipment, while one
of the little rivers our train crossed was filled with birch logs floating
down to a spool factory.
Some two hours from Halifax we came to Truro at the head of
Cobequid Bay, the easternmost arm of the Bay of Fundy. Scientists
who have studied the forty-foot Fundy tides attribute them to its
pocket-like shape. The tides are highest in the numerous deep inlets
at the head of the Bay. In the Petitcodiac River, which forms the
northernmost arm, as the tide comes in a wall of water two or three
feet high rushes upstream. These tides are felt far back from the
coast. The rivers and streams have deep-cut banks on account of
the daily inrush and outflow of waters and are bordered with
marshes through which run irrigation ditches dug by the farmers.
With his poem of Evangeline, Longfellow made

famous the old well at Grand Pré, the scene of the
expulsion of the Acadians because they wanted to
remain neutral in the French-British wars.
When the tide goes out at Digby, vessels tied to
the docks are left high and dry. At some points on the
Bay of Fundy the rise and fall of the water exceeds
forty feet.
Truro is a turning-off point for the rail journey down the Bay side
of Nova Scotia through “Evangeline Land” and the Annapolis Valley,
and also for the trip north and east up to Cape Breton Island. This
island is part of the province of Nova Scotia. It is separated from the
mainland only by the mile-wide Strait of Canso, across which railroad
trains are carried on ferries. In the southern part of the Island is the
Bras d’Or Lake, an inland sea covering two hundred and forty square
miles.
Because of the deep snows in winter the Quebec
farmhouse usually has high porches and often a
bridge from the rear leading to the upper floor of the
barn. The older houses are built of stone.
Spinning wheels and hand looms are still in use
among the French Canadian farm women. Besides
supplying clothes for their families, they make also
homespuns and rugs for sale.
Though Cabot landed on the coast of Cape Breton Island after
his discovery of the Newfoundland shore, it later fell into the hands of
the French. They found its fisheries worth more than all the gold of
Peru or Mexico. To protect the sea route to their St. Lawrence
territories, they built at Louisburg a great fortress that cost a sum
equal to twenty-five million dollars in our money. To-day, hardly one
stone remains upon another, as the works were destroyed by the
British in 1758. Not far from Louisburg is Glace Bay, where Marconi
continued the wireless experiments begun in Newfoundland, and it
was on this coast, also, that the first transatlantic cable was landed.
Cape Breton Island was settled mostly by Scotch, and even to-
day sermons in the churches are often delivered in Gaelic. As a
result of intermarriage sometimes half the people of a village bear
the same family name. For generations these people lived mostly by
fishing, but the opening of coal mines in the Sydney district brought
many of them into that industry. The Sydney mines, which normally
employ about ten thousand men, are the only coal deposits on the
continent of North America lying directly on the Atlantic Coast. They
are an asset of immense value to Canada, yielding more than one
third of her total coal production. One of the mines at North Sydney
has the largest coal shaft in the world. Because of these enormous
deposits of bituminous coal, and the presence near by of dolomite,
or limestone, steel industries have been developed in the Sydney
district. Ownership of most of the coal and steel properties has been
merged in the British Empire Steel Corporation, one of the largest
single industrial enterprises in all Canada. It is this corporation, you
will remember, that owns the Wabana iron mines in Newfoundland.
In the Gulf of St. Lawrence, and north of the isthmus connecting
Nova Scotia with the mainland, is Prince Edward Island, the
smallest, but proportionately the richest province in the Dominion of
Canada. It is not quite twice the size of Rhode Island, and has less
than one hundred thousand people, but every acre of its land is
tillable and most of it is cultivated. The island is sometimes called the
“Garden of the Gulf.”
Prince Edward Island is a favourite resort of Americans on
vacation. It leaped into fame as the scene of the first successful
experiments in raising foxes for their furs, and now has more than
half of the fox farms in Canada. The business of selling fox skins and
breeding stock is worth nearly two million dollars a year to the Prince
Edward Islanders. The greatest profits are from the sales of fine
breeding animals.
Most of the west shore of the Bay of Fundy and many of its
northern reaches are in the third and westernmost of the three
Maritime Provinces. This is the province of New Brunswick. It is
Maine’s next-door neighbour, and almost as large, but it has less
than half as many people. The wealth of New Brunswick, like that of
Maine, comes chiefly from the farms, the fisheries, and the great
forests that are fast being converted into lumber and paper. Its game
and fresh-water fishing attract a great many sportsmen from both the
United States and Canada.
St. John, the chief city of New Brunswick at the mouth of the St.
John River, used to be a centre of anti-American sentiment in
Canada. This was because the city was founded by the Tories, who
left the United States after we won our independence. St. John to-
day is a busy commercial centre competing with Halifax for first
place as Canada’s all-year Atlantic port. It is the eastern terminal of
the Canadian Pacific Railroad, whose transatlantic liners use the port
during the winter. It enjoys the advantage over Halifax of being some
two hundred miles nearer Montreal, but, like Halifax, suffers on
account of the long railway haul and high freight rates to central
Canada. As a matter of fact, New England, and not Canada, is the
natural market for the Maritime Provinces, and every few years the
proposal that this part of Canada form a separate Dominion comes
up for discussion. Such talk is not taken seriously by the well
informed, but it provides a good safety valve for local irritation.
CHAPTER VII
IN FRENCH CANADA
Come with me for a ride about Quebec, the oldest city in

Canada, the ancient capital of France in America, and a stronghold
of the Catholic Church. We go from the water-front through the
Lower Town, up the heights, and out to where the modern city eats
into the countryside. The Lower Town is largely French. The main
part of the Upper Town used to be enclosed by walls and stone
gates, parts of which are still standing. The dull gray buildings are of
stone, with only shelf-like sidewalks between them and the street.
Most of the streets are narrow. The heights are ascended by stairs,
by a winding street, and in one place by an elevator. The old French
caleche, a two-wheeled vehicle between a jinrikisha and a dog-cart,
has been largely displaced by motor-cars, which can climb the steep
grades in a jiffy. Even the ancient buildings are giving way to modern
necessities, and every year some are torn down.
As a city, Quebec is unique on this continent. It fairly drips with
“atmosphere,” and is concentrated romance and history. You know
the story, of course, of how Champlain founded it in 1608, on a
narrow shelf of land under the rocky bluff that rises nearly three
hundred and fifty feet above the St. Lawrence. Here brave French
noblemen and priests started what they hoped would be a new
empire for France. Between explorations, fights with the Indians, and
frequent British attacks, they lived an exciting life. Finally, General
Wolfe in 1759 succeeded in capturing for the British this Gibraltar of
the New World. Landing his men by night, at dawn he was in position
on the Plains of Abraham behind the fort. In the fight that followed
Wolfe was killed, Montcalm, the French commander, was mortally
wounded, and the city passed into the hands of the English. If
General Montgomery and Benedict Arnold had succeeded in their
attack on Quebec on New Year’s Eve, sixteen years later, the history
of all Canada would have been different, and the United States flag
might be flying over the city to-day.
The British built in the rock on top of the bluff a great fort and
citadel covering about forty acres. It still bristles with cannon, but
most of them are harmless compared with modern big guns. The
works serve chiefly as a show place for visitors, and a summer
residence for dukes and lords sent out to be governors-general of
Canada. The fortification is like a mediæval castle, with subterranean
chambers and passages, and cannon balls heaped around the
battlements. Below the old gun embrasures is a broad terrace, a
quarter of a mile long. This furnishes the people of Quebec a
beautiful promenade that overlooks the harbour and commands a
fine view of Levis and the numerous villages on the other shore.
The Parliament building stands a little beyond the entrance to
the citadel. As we go on the architecture reflects the transition from
French to British domination. The houses begin to move back from
the sidewalk, and to take on front porches. I saw workmen putting in
double windows, in preparation for winter, and noticed that the sides
of many of the brick houses are clapboarded to keep the frost out of
the mortar. Still farther out apartments appear, while a little beyond
are all the marks of a suburban real estate boom. Most of the “for
sale” signs are in both French and English.
Now come with me and look at another Quebec, of which you
probably have never heard. The city is built, as you know, where the
St. Charles River flows into the St. Lawrence. The valley of the St.
Charles has become a great hive of industry, and contains the
homes of thousands of French workers. Looking down upon it from
the ancient Martello Tower on the heights of the Upper Town, we see
a wilderness of factory walls, church spires, and the roofs of homes.
Beyond them great fields slope upward, finally losing themselves in
the wooded foothills of the Laurentian Mountains. Cotton goods,
boots and shoes, tobacco, and clothing are manufactured here. It
was from this valley that workers for the textile and shoe industries of
New England were recruited by thousands. A few miles upstream is
the village of Indian Lorette, where descendants of a Huron tribe,
Christianized by the French centuries ago, make leather moccasins
for lumberjacks and slippers for American souvenir buyers. A big fur
company also has a fox farm near Indian Lorette.
Quebec was once the chief port of Canada, but when the river
was dredged up to Montreal it fell far behind. All but the largest
transatlantic liners can now sail for Europe from Montreal, though
they make Quebec a port of call. Quebec is five hundred miles
nearer Liverpool than is New York, and passengers using this route
have two days less in the open sea. The navigation season is about
eight months. The port has rail connections with all Canada and the
United States. Above the city is the world’s longest cantilever bridge,
on which trains cross the river. After two failures the great central
span, six hundred and forty feet long, was raised from floating
barges and put into place one hundred and fifty feet above the water.
In the English atmosphere of the Maritime Provinces I felt quite
at home, but here I seem to be in a foreign land, and time has been
pushed back a century or so. We think of Canada as British, and
assume that English is the national language. But in Quebec, its
largest province, containing about one fifth of the total area, nearly
nine tenths of the people are French and speak the French
language. They number almost one fourth of the population of the
Dominion.
Quebec is larger than Texas, New Mexico, Arizona, and
California combined; it is nearly as big as all our states east of the
Mississippi River put together. Covering an area of seven hundred
thousand square miles, it reaches from the northern borders of New
York and New England to the Arctic Ocean; from the Gulf of St.
Lawrence and Labrador westward to Hudson Bay and the Ottawa
River. Most Americans see that part of Quebec along the St.
Lawrence between the capital and Montreal, but only one fourteenth
of the total area of the province lies south of the river. The St.
Lawrence is more than nineteen hundred miles long, and Quebec
extends along its north bank for almost the entire distance.
Jacques Cartier sailed up the St. Lawrence in 1535 and claimed
possession of the new land in the name of “Christ and France.”
Later, French soldiers and priests pushed their way up the river,
explored the Great Lakes, and went down the Mississippi. It was
French fur traders, fishermen, and farmers who opened up and
populated eastern Canada. With no immigration from France since
British rule began, the population of the province of Quebec has had
a natural increase from about sixty thousand to more than two
millions. The average family numbers from six to eight persons,
while families of twelve and fourteen children are common. Quebec
maintains the highest birth rate of any province in Canada. It has
also the highest death rate, but there is a large net gain every year.
Quebec is one of the chief reservoirs of Canada’s natural wealth.
It leads all other provinces in its production of pulpwood, and
contributes more than one half the Dominion’s output of pulp and
paper. It is second only to British Columbia and Ontario in lumber
production, while its northern reaches contain the last storehouse of
natural furs left on our continent.
Canada is one of the world’s great sources of water-power.
Nearly half of that already developed is in the province of Quebec,
and her falling waters are now yielding more than a million horse-
power. Tens of thousands of additional units are being put to work
every year, while some five million horse-power are in reserve. It
would take eight million tons of coal a year to supply as much power
as Quebec now gets from water.
The ancient citadel on the heights of Quebec is
now dwarfed by a giant castle-like hotel that helps
make the American Gibraltar a tourist resort. Its
windows command a magnificent view of the St.
Lawrence.
The St. Louis gate commemorates the days when
Quebec was a walled city and always well garrisoned
with troops. Just beyond is the building of the
provincial parliament, where most of the speeches are
in French.
At Three Rivers, about halfway between Montreal and Quebec,
the St. Maurice River empties into the St. Lawrence. Twenty miles
upstream are the Shawinigan Falls, the chief source of power of the
Shawinigan Company, which, with its subsidiaries, is now producing
in this district more than five hundred thousand horse-power. This is
nearly half the total power development in the province. Around the
power plant there have grown up electro-chemical industries that
support a town of twelve thousand people, while at Three Rivers
more paper is made than anywhere else in the world. Shawinigan
power runs the lighting plants and factories of Montreal and Quebec,
and also serves most of the towns south of the St. Lawrence. The
current is carried over the river in a thick cable, nearly a mile long,
suspended on high towers.
In the Thetford district of southern Quebec, power from
Shawinigan operates the machinery of the asbestos mines. Fifty
years ago, when these deposits were discovered, there was almost
no market for asbestos at ten dollars a ton. Nowadays, with its use in
theatre curtains, automobile brake linings, and coatings for furnaces
and steam pipes, the best grades bring two thousand dollars a ton,
and two hundred thousand tons are produced in a year. Quebec now
furnishes eighty-eight per cent. of the world’s annual supply of this
mineral.
The Quebec government controls all power sites, and leases
them to private interests for ninety-nine year terms. The province has
spent large sums in conserving its water-power resources. At the
headquarters of the St. Maurice River, it built the Gouin reservoir,
which floods an area of more than three hundred square miles, and
stores more water than the great Aswan Dam on the Nile.
Quebec is the third province in value of agricultural production.
What I have seen of its farms convinces me that the French
Canadian on the land is a conspicuous success. For a half day I
rode along the south shore of the St. Lawrence River through a
country like one great farm. Nearly every foot of it is occupied by
French farmers. Most of the time we were on high ground,
overlooking the river, which, where we first saw it, was forty miles
wide. It grew constantly narrower, until, where we crossed it on a
ferry to Quebec, its width was less than a mile. All the way we had
splendid views of the Laurentian Mountains, looming up on the north
shore of the river. Geologists say the Laurentians are the oldest rock
formation on our continent. They are not high, the peaks averaging
about sixteen hundred feet elevation, but they are one of the great
fish and game preserves of the world and are sprinkled with hunting
and fishing clubs.
In accordance with French law the Quebec farms have been
divided and sub-divided among so many succeeding generations
that the land is cut into narrow ribbons. Contrary to the custom in
France, however, every field is fenced in with rails. I am sure that the
fences I saw, if joined together, would easily reach from Quebec to
Washington and back. They did not zig-zag across the fields like
ours, thereby wasting both rails and land, but extended in a straight
line, up hill and down, sometimes for as much as a mile or more.
The standard French farm along the St. Lawrence used to be
“three acres wide and thirty acres long,” with a wood lot at the farther
end, and the house in the middle. As the river was the chief highway
of the country, it was essential that every farmer have water
frontage. With each division one or more new houses would be built,
and always in the middle of the strip. The result is that every farmer
has a near neighbour on each side of him, and the farmhouses form
an almost continuous settlement along the highway, much like the
homes on a suburban street. Each wood lot usually includes several
hundred maple trees, and the annual production of maple sugar and
syrup in Quebec is worth several hundred thousand dollars. The
maple leaf is the national emblem of Canada.
The houses are large and well built. They have narrow porches,
high above the ground, reached by steps from below. This
construction enables the occupants to gain access to their living
rooms in winter without so much snow shovelling as would otherwise
be necessary. For the same reason, most of the barns are entered
by inclines leading up to the second floor and some are connected
with the houses by bridges. The older houses are of stone, coated
with whitewashed cement. With their dormer windows and big,
square chimneys they look comfortable.

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