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 NOTICE
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MCGH353-FM_pi-xvi.indd 2 30/07/15 4:49 PM

 ULTRASOUND OF THE FOOT AND ANKLE
EDITED BY

Nathan H. Schwartz, DPM

Private Practice
The Center for Foot and Ankle Care
Smyrna, Georgia

New York  Chicago  San Francisco  Athens  London  Madrid  Mexico City

New Delhi  San Juan  Singapore  Sydney  Toronto

MCGH353-FM_pi-xvi.indd 3 30/07/15 4:49 PM

Copyright © 2016 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be
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 DEDICATION

To my wife, Debbie

To my sister-in-law, Anita Schwartz, retired senior editor for National Geographic

School Publishing, for her invaluable assistance.

MCGH353-FM_pi-xvi.indd 5 30/07/15 4:49 PM

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 CONTENTS

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 6. Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Nathan Schwartz
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
7. Soft Tissue Masses and Foreign Bodies . . . 73
Nathan Schwartz

1. Basics of Ultrasound: Physics and Artifacts . . 1 8. Skin, Fat, and Bone . . . . . . . . . . . . . . . . . . . . . . 79

Janak R. Goyal Nathan Schwartz

2. Ultrasound Image Optimization . . . . . . . . . . . 9 9. Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Patrick Meyers Nathan Schwartz

3. Ergonomics and Probe Handling . . . . . . . . 17 10. Neovascularization . . . . . . . . . . . . . . . . . . . . . . 97

Nathan Schwartz Todd P. Stitik, Gloria Hwang, Varun Patibanda,
Nandkumar Rawool, and Bryan Kong
4. Muscles and Tendons . . . . . . . . . . . . . . . . . . . 23
Nathan Schwartz 11. Interventional Uses of Ultrasound
in the Foot and Ankle . . . . . . . . . . . . . . . . . . 109
5. Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Nathan Schwartz
Nathan Schwartz
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

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 CONTRIBUTORS

▶▶ Janak R. Goyal, MD ▶▶ Varun Patibanda, MD

Clinical Assistant, Professor of Medicine
Robert Wood Johnson Medical School
New Brunswick, New Jersey
Director Division of Rheumatology
Raritan Bay Medical Center
Perth Amboy, New Jersey
▶▶ Gloria Hwang, MD
Department of Physical Medicine and Rehabilitation
Medical School of New Jersey
Rutgers, New Jersey
▶▶ Bryan Kong
Department of Physical Medicine and Rehabilitation
Medical School of New Jersey
Rutgers, New Jersey
▶▶ Patrick Meyers, BS, RDMS, RVT
Clinical Science Specialist
Musculoskeletal Ultrasound, LLC
Aurora, Colorado
Radiology Imaging Associates
Denver, Colorado
Department of Physical Medicine and Rehabilitation
Medical School of New Jersey
Rutgers, New Jersey
▶▶ Nandkumar Rawool, MD, RDMS
Associate Professor
Department of Radiologic Science
Thomas Jefferson University
Philadelphia, Pennsylvania
▶▶ Nathan H. Schwartz, DPM
Private Practice
The Center for Foot and Ankle Care
Smyrna, Georgia
▶▶ Todd P. Stitik, MD, RMSK
Professor, Department of Physical Medicine and
Rehabilitation
Medical School of New Jersey
Rutgers, New Jersey

MCGH353-FM_pi-xvi.indd 9 30/07/15 4:49 PM

This page intentionally left blank

Diagnostic ultrasound has been my best teacher, allowing me
to better understand the mechanics and pathomechanics of
the foot and ankle. There are many observations I have made
with this technology that have allowed an understanding of
pathology that was not previously recognized. Diagnostic
ultrasound takes the guesswork out of diagnosis and treat-
ment. No longer is it acceptable to diagnose a condition purely
by location, as ultrasound allows the clinician to actually see
the pathology and its implications. Utilizing ultrasound inter-
ventionally is equally valuable. The procedure, whether injec-
tion or surgical, is observed non-invasively, verifying accuracy.
The foot and ankle is probably the most challenging ana-
tomical area for ultrasound examination. I have addressed
MCGH353-FM_pi-xvi.indd 11
PREFACE
this subject from a clinical standpoint, which relies on an
understanding of the anatomy from multiple perspectives.
My goal in this text is to show the value of diagnostic and
interventional ultrasound in the foot and ankle and pres-
ent the information in a comprehensible format.
The greater the understanding of ultrasound’s capa-
bilities the more valuable it will become in your practice.
I know that this tool will continue to develop, and its
clinical applications will multiply. I consider this the
beginning of an exciting future in ultrasound of the foot
and ankle. This text will provide the tools for the devel-
opment of your skills. Your imagination will provide the
journey.
30/07/15 4:49 PM
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A comprehensive book on ultrasound of the foot from the
viewpoint of the podiatrist is overdue. Nathan Schwartz,
DPM, fills that void with this newly edited tome. This work
places accepted concepts in text next to superb images.
Richly illustrated and neatly organized in 11 chapters,
“Ultrasound of the Foot and Ankle” lifts the reader to a level
of higher understanding in this complex region of the anat-
omy. The initial few chapters introduce the necessary con-
cepts of physics, image optimization, ergonomics, and probe
handling. The different histologic layers of tissues, which
play a role in the pathology of the foot, are each discussed
separately in a methodical approach of detecting disease.
MCGH353-FM_pi-xvi.indd 13
FOREWORD
Ultrasound’s unique capability in detecting neovasculariza-
tion requires its own chapter and so does intervention, as it
is an ever-growing field of our practice. Annotated videos
prompt the reader to try these techniques out unabashedly.
After all, ultrasound of all imaging appeals as the more play-
ful one. Dr. Schwartz convinces us that once you get access
to the tissues under the skin a new world surfaces, a world
you can search without endangering the patient’s cells and
your own life by radiation. Nathan Schwartz, DPM, who
practices magic when he is away from the office shows with
this work that he can set a podiatry office on fire by using
the ultrasound transducer as his magic wand.
Marnix van Holsbeeck, MD
Head, Division of Musculoskeletal Radiology
Professor of Radiology
Wayne State University School of Medicine
Henry Ford Hospital, Detroit, Michigan
30/07/15 4:49 PM

I would like to give tribute to the deceased who have
donated their bodies for the furthering of medical edu-
cation. On the accompanying website there are cadaveric
demonstrations of the ankle’s lateral, collateral ligaments.
These videos clearly show the dynamics and pathome-
chanics of these structures. I would also like to thank
MCGH353-FM_pi-xvi.indd 14
ACKNOWLEDGMENTS
the ­University of Irvine’s medical school, department of
anatomy, where the dissection was performed and videos
were taken.
I also thank Sound Consulting and Esaote of North
America for their diagnostic ultrasounds, which yield
incredible images.
30/07/15 4:49 PM
 BASICS OF ULTRASOUND:
PHYSICS AND ARTIFACTS
JANAK R. GOYAL
SOUND
Sound waves are mechanical waves and are generated only
by movements. There is no sound in vacuum because there
is nothing to move. Everything around us, including air,
is made of small particles. Sound waves are created by the
movements of these particles and travel in straight lines.
They are transmitted by the waves of compression and rar-
efaction of these particles.
▶▶ Sound Waves
Many different parameters are used to describe the various
aspects of a sound wave. Amplitude, power, and intensity
measure a sound wave’s strength. Parameters associated
with the speed of sound are wavelength, period, and fre-
quency. Changing these parameters affects the quality of an
ultrasound study. We now consider these parameters and
their importance in such studies.
For a proper understanding of the most of the param-
eters of sound waves, consider the sound wave as a sort of a
footstep of the sound. Sound wave parameters include the
following (Figure 1-1):
• Wavelength
• Period/frequency
• Speed
• Amplitude
• Power/intensity
The period is the time taken by sound to travel though
a cycle of compression and rarefaction. It is measured in
microseconds. Period can be compared to the time needed
to take one step during walking.
Frequency is the number of cycles or waves per sec-
ond, a unit known as hertz (Hz). One hertz is one cycle
per second; 1000 cycles per second is one kilohertz (kHz).
MCGH353-Ch01_p1-8.indd 1
1
One megahertz (MHz) is 1 million cycles per second.
Medical diagnostic sonography uses sound of very high
frequency, in the range of 1 to 30 MHz. The frequency
can be compared to the number of steps taken in 1 second
while walking.
Period and frequency have a reciprocal relationship.
The number of waves per second decreases as the time for
a wave to pass increases; hence, with an increased period,
there is a decreased frequency.
Compare it to the walking example again If the time
taken for one step is half a second, then the frequency is two
steps per second. If the time taken to take a step increases to
1 second, there will be only one step in a second.
1
Period ∝
frequency
The choice of proper frequency is important for imag-
ing tissues at different depths. High-frequency sound gives
better resolution but lacks penetration. On the other hand,
low-frequency sound penetrates more deeply but has less
resolution.
WHAT IS ULTRASOUND?
Sound is classified based on the range of frequencies audible
to humans: between 20 Hz and 20 kHz. Any sound above
20 kHz is called ultrasound. Medical diagnostic ultrasound
uses frequencies of 1 to 30 MHz.
The speed of sound, or propagation velocity, is the dis-
tance sound travels in 1 second. Although the speed of
sound varies in different tissues, for the purpose of calcula-
tions the speed of sound in soft tissues is presumed to be
1540 meters (1.54 km) per second.
The wavelength (k) is the physical length of a sound
wave measured in millimeters. It is the distance traveled
23/07/15 12:11 AM
 2 CHAPTER 1
Power/intensity/
amplitude
Wavelength/period
Figure 1-1 Diagram of a sound wave.
by sound during a single cycle of compression and rar-
efaction. Wavelength can be compared to the distance
traveled by taking one step while walking. The wavelength
equation is:
c other and all describe the strength of a sound wave. Ampli-
λ∝ (λ : wave length , c : speed of sound , f : frequency )
f
Wavelength is inversely proportional to frequency. When
the speed of sound remains constant, its wavelength
decreases with increased frequency and vice versa. If a
person is walking at a speed of 1 meter per second (m/
sec) and taking only one step per second, the length of
the step must be 1 m. If two steps are taken per second
to travel a distance of 1 m, the length of the step will be
0.5 m.
1 focus. Beyond the focus, the beam progressively widens as
Wavelength ∝
Frequency
Wavelength is directly proportional to the speed of
sound. When the frequency remains unchanged, the
wavelength increases with an increased speed of sound
and vice versa. While traveling with a speed of 1 m/sec,
taking two steps per second, the length of the step will be
0.5 m. If the speed of walking is increased to 2 m/sec but
still taking two steps per second, the length of the step
must increase to 1 m.
Power is the energy in watts, and intensity is the power
per square centimeter of the beam area. Output power is
the energy generated by the machine to drive the trans-
ducer. Power output is adjusted by the sonographer. The
lowest possible power output should be used, to minimize
the biologic effects of sound.
Returning echoes are very small; amplification is used
to increase the overall strength of returning echoes.
Both output power and amplification (gain) can be used
to adjust the brightness of the image. Gain should be
increased before increasing power output when the image
is too dark; power output should be decreased before
decreasing gain when the image is too bright to minimize
biologic effects.
MCGH353-Ch01_p1-8.indd 2
Speed
Wavelength =
Frequency
▶▶ Amplitude/Voltage
Amplitude is a measure of the peaks and troughs of the
sound wave. Voltage is the electrical equivalent of amplitude.
Power, intensity, and amplitude are directly related to each
tude describes the strength in terms of the physical height
and depth of sound waves, and voltage is the electrical rep-
resentation of that physical parameter. Power is directly pro-
portional to the square of the amplitude (power ∝ voltage2).
▶▶ Sound Beam
Waves of sound generated by the transducer travel in the
tissues in the form of a beam that varies in shape as it trav-
els (Figure 1-2). The sound beam narrows progressively
like a funnel until it reaches its smallest diameter at the
it travels.
Narrow beams give better lateral resolution. The focus or
focal point, the point of narrowest beam diameter, is thus
the point of best lateral resolution.
The part of the sound beam from the transducer face to
the focus is known as the near zone or Fresnel zone. The
part of the sound beam that extends deeper from the focus
is called the far zone or Fraunhofer zone.
The focal length is the distance from the transducer face
to the focus. It is also called focal depth or near-zone length.
The focal zone is the region around the focus where the
beam is relatively narrow. Half of the focal zone is in the
near zone and half in the far zone.
Modern transducers are capable of creating multiple
areas of focus electronically at different imaging depths
surrounded by focal zones that can be adjusted by the
sonographer.
RESOLUTION
Resolution is the ability to resolve the difference between
two objects or signals. Resolution is better when the resolved
difference is smaller. The difference may be defined as the
23/07/15 12:11 AM

Fresnel zone (Near zone)
Focal zone Focus
Fraunhofer zone (Far zone)
Figure 1-2 Fresnel and Fraunhofer zones of a sound beam.
distance separating the objects, the difference in the sig-
nal strength (voltage), or the separation by time of occur-
rence, as seen in a heart rhythm with one beat coming after
another. If the heart rhythm becomes too fast, as in ven-
tricular fibrillation, it becomes hard to appreciate individual
beats as separate beats.
▶▶ Spatial Resolution
There are two aspects of spatial resolution:
1. Resolution of the screen in terms of pixel density, and
2. Resolution of the signal within the pixel.
More pixels with a smaller distance between individual pix-
els define better screen resolution.
The number of gray shades within the individual pixel
defines the gray-scale resolution of the signal. Different
terms are used to define the three-dimensional aspects of
gray-scale resolution.
Resolution along the depth of the tissue is known as axial
resolution. It depends on the transducer frequency. High-
frequency sound gives better axial resolution but poor pen-
etration to deeper tissues.
Lateral resolution is the resolution from left to right
of the image, along the long axis of the transducer. L­ ateral
resolution depends on the beam width. Narrow beams
provide better lateral resolution. Focusing decreases the
side-to-side dimensions of the sound beam and improves
lateral resolution. Focus is the narrowest area of the beam.
MCGH353-Ch01_p1-8.indd 3
BASICS OF ULTRASOUND: PHYSICS AND ARTIFACTS 3
The beam area just before and after the focus (the focal
zone) is relatively narrower than the rest of the beam.
Modern ultrasound machines are capable of making mul-
tiple areas of focus and hence multiple focal zones by elec-
tronic focusing.
Elevational resolution is the resolution from front to
back along the imaging plane, which is not seen on two-
dimensional (2D) imaging.
▶▶ Temporal Resolution
Temporal resolution is accuracy in time. It is the ability to
accurately locate moving structures at any particular instant
in time. Temporal resolution is determined by frame rate
(Figures 1-3 and 1-4).
A frame is an image generated by sending sound pulses
into the tissues. The number of frames per second depends
on the depth of imaging and the number of focal zones.
Increased depth of imaging requires more time to create an
image because it takes longer for the echoes to return from
deeper tissues. Multiple focal zones require more pulses, a
pulse for every focal zone. For a particular depth of imag-
ing, two focal zones will require twice as much time as sin-
gle focal zone, and so on.
To increase the number of frames per second for best
temporal resolution, the depth of imaging should be as
shallow as possible and the number of focal zones as low
as possible.
▶▶ Contrast Resolution
Contrast resolution is the ability to distinguish the differ-
ence in brightness of various parts of an image. It defines
Transducer crystals
Frame
Figure 1-3 One focal zone. A frame created by 8 echoes and
8 sound pulses. Each double arrow represents a pulse echo.
23/07/15 12:11 AM
 4 CHAPTER 1
Transducer crystals
Frame
Figure 1-4 Two focal zones. There are two pulses per scan
line, corresponding to two focal zones. This frame takes twice as
much time as the frame in Figure 1-3, thus decreasing the frame
rate and temporal resolution.
the difference between the echo strengths represented by
varying degrees of gray shading in the image. Contrast res-
olution is used to describe the image quality in terms of
both image contrast and resolution.
Resolution is better when a greater number of gray
shades are visible, with smaller differences between them.
On the other hand, the image looks sharper when the dif-
ference between the signals is larger, as in a high-contrast
image.
Log compression or dynamic range compression is used
to control contrast and resolution. A high-contrast image
has a low dynamic range and low resolution.
DYNAMIC RANGE
Returning echoes are converted to gray shades of varying
brightness. Each range of echo amplitudes, for instance 0–1
microvolt, is assigned a different gray shade.
Dynamic range is the logarithmic ratio of the maxi-
mum to the minimum echo amplitudes. In gray-scale
imaging, it is the ratio of the signal strength of the bright-
est and the darkest signals converted to a logarithmic
scale.
The dynamic range of echoes coming from tissues is
very large: Typically, for gray-scale imaging, the largest
echo ­signal is 10,000 times larger than the smallest echo
signal, with a dynamic range of 80 decibels. Dynamic range
compression decreases the ratio between the largest and the
smallest signal voltage, improves contrast, and decreases
resolution.
MCGH353-Ch01_p1-8.indd 4
DOPPLER ULTRASOUND
Doppler sonography is used to image blood flow. A gray-
scale signal is caused by reflection from tissue interfaces,
whereas a Doppler signal is caused by blood flow and tissue
movements. The best gray-scale image is obtained when
the sound beam hits the interface at 90 degrees, but the best
Doppler signal is obtained when the sound beam is parallel
to the blood flow.
The Doppler effect is a change in frequency of a sound
beam due to relative motion between a sound source and
a receiver. In diagnostic medical sonography, the sound
source is the ultrasound transducer, and the receiver is the
flowing blood. The change in frequency is known as the
Doppler shift or Doppler frequency:
Doppler shift = Received frequency – transmitted frequency
The Doppler equation states the relationship between
different variables that affect the Doppler shift, including
the transducer frequency or operating frequency, the veloc-
ity of the blood, and the angle between the sound beam and
blood flow:
Doppler Shift = 2 F0V cos θ/c
where F0 is the transducer frequency, V the velocity of
blood, c the speed of sound, and θ the angle between the
sound beam and the direction of flow.
▶▶ Common Modes of Doppler
Sonography
Spectral Doppler (Figure 1-5) records the tissue movements
in the form of a graphic recording, whereas color Doppler
records tissue movements as a visual display of colors.
Spectral Doppler is not discussed in detail here, because it
is not used in musculoskeletal sonography.
Color flow and color power Doppler (Figures 1-6 and
1-7) is useful in musculoskeletal sonography to look for
low-velocity flow in inflammatory conditions such as gout
Figure 1-5 Spectral/pulse Doppler.
23/07/15 12:11 AM

Figure 1-6 Color Doppler.
and rheumatoid arthritis. Color flow Doppler provides
information about the direction of flow, whereas power
Doppler provides visual information about the strength of
blood flow and gives no information about the speed and
direction of flow.
Optimum settings for a good-quality Doppler image
include the following:
• Maximize power output
• Increase the gain until random noise appears, and then
lower it until the noise just disappears
• Try different frequencies until the best signal is obtained
(higher frequencies are more sensitive to flow but are
subject to attenuation).
• Use a low number of pulses per second (the pulse
repetition frequency or PRF (0.5–1 kHz)
• Use the smallest color box
• Avoid pressing the transducer into the tissue during
scanning to maintain blood flow
Figure 1-7 Power Doppler of an inflamed talonavicular joint.
MCGH353-Ch01_p1-8.indd 5
BASICS OF ULTRASOUND: PHYSICS AND ARTIFACTS 5
THE ULTRASOUND TRANSDUCER
An ultrasound transducer contains an array of piezoelec-
tric crystals. These crystals vibrate to produce sound when
an electric voltage is applied across them. They generate
electrical energy when they are mechanically deformed by
sound.
Depending on the clinical situation, transducers are
operated to produce a continuous or a pulsatile sound.
Continuous sound cannot produce anatomical images. Pul-
satile sound is used to create gray-scale anatomical images.
Short pulses of sound are transmitted to create an anatomi-
cal image
An ultrasound image is created by processing echoes
received from the body tissues. Echoes are generated by the
reflection of sound from the tissue boundaries (interfaces).
The most important factors that determine the amount
of reflection (echoes) are the strength of the transmitted
signal, the angle of incidence of the sound beam, and the
difference in the impedance of the tissues at the interface.
Impedance is the product of the density of the medium
and the speed of sound in that medium. A greater differ-
ence in impedance generates a greater reflection.
Air has very low density (1.25 kg/m3) as compared to soft
tissue (1060 kg/m3). The speed of sound in air is approxi-
mately 340 m/sec, and the speed of sound in soft tissue on
average is 1540 m/sec. Thus there is a huge difference in the
calculated impedance of air and soft tissues This huge dif-
ference creates a highly reflective air and soft tissue inter-
face—99% of sound is reflected at the interface. The use of
acoustic gel eliminates air from the interface, dramatically
decreasing reflection and ­increasing t­ ransmission.
Most body tissues are made of a specific tissue paren-
chyma and supporting connective tissue framework, creat-
ing multiple connective tissue and parenchyma boundaries
(interfaces). Tissues have different histological and sono-
graphic characteristics based on the arrangement of con-
nective tissue framework and parenchyma. For example,
tendons appear bright because they have densely packed
fibers and multiple interfaces to reflect sound. Body fluids
appear dark because they have no connective tissue frame-
work and hence no interfaces to reflect sound.
The arrangement of different tissues in the body creates
tissue boundaries (interfaces). The reflection of sound dif-
fers based on the difference of impedance of two tissues at
the interface. The greater the difference in impedance, the
greater the reflection. Normally, for most tissue interfaces,
less than 1% of sound is reflected, and the rest is transmit-
ted for imaging of deeper tissues. However, 99% of sound
is reflected from a tissue-air interface and about 50% from
a soft tissue–bone interface because of larger differences in
impedance.
The strength of the reflected echo also depends on the
strength of the original signal from the machine and the
attenuation of sound as it travels through the tissues. Attenu-
ation is progressive weakening of the signal as it travels to the
deeper tissues. Attenuation depends on the type of tissue, the
frequency of the sound, and the depth of the target tissue.
23/07/15 12:11 AM
 6 CHAPTER 1

A B

Figure 1-8 (A) Short-axis view of the tarsal tunnel with speckle reduction. (B) Same view as Figure 1-8A without speckle reduction.

Different tissues attenuate sound at different rates, but Speckle is a grainy appearance of the image. It is a form
for the purpose of calculation and machine standard- of noise that results from constructive and destructive
ization, the attenuation in soft tissue is assumed to be interference of small-amplitude reflections from many tis-
0.5 decibel (dB)/MHz/cm. sue reflectors (Figure 1-8A and B). Speckle appears as a tis-
Biologic fluids attenuate sound far less than soft tissues, sue texture close to the transducer.
which results in enhancement of tissues deep to fluid-filled Shadow is a lack of echoes from structures deep to an
structures because of the compensation applied to the object with a high attenuation rate (Figure 1-9). It is a
returning echoes based on the assumed attenuation. hypoechoic or anechoic region extending downward par-
Bone has a high attenuation rate due to absorption. allel to the sound beam deep to a structure such as calci-
Sound has very poor penetration to structures deep to bone fication. Anatomic details are missing in the region of the
because of attenuation by reflection at the highly reflective shadow because nothing is visible within it.
soft tissue–bone interface and because of the high rate of
absorption of sound by the bone.
Compensation is variable amplification to compen-
sate for the increased attenuation of sound with increased
depth. Echoes returning from superficial tissues undergo
less attenuation compared to echoes returning from deeper
tissues because one of the key factors that determine atten-
uation is the depth of the target tissue.
The ultrasound system calculates the attenuation based
on the depth of origin of the echo and applies amplification
based on calculated attenuation; echoes from deeper tissues
are amplified more than the echoes from superficial tissues
to compensate for their loss.
Compensation is also known as time gain compensation
(TGC) or depth gain compensation (DGC) or swept gain.
Although the machine automatically applies compensation
to the returning echoes, there are also TGC controls on the
machine for the sonographer to further adjust compensa-
tion if needed.

SONOGRAPHIC ARTIFACTS
Many different types of artifacts have been described in
gray-scale and Doppler imaging. Here we discuss only the
artifacts that are commonly encountered in the everyday
practice of musculoskeletal sonography.
Figure 1-9 Short-axis view posterior to the calcaneus
demonstrating the Achilles tendon with calcifications. Note
the anechoic area (acoustic artifact) deep to the calcifications,
which have a high attenuation rate.

MCGH353-Ch01_p1-8.indd 6 23/07/15 12:11 AM

 BASICS OF ULTRASOUND: PHYSICS AND ARTIFACTS 7

Figure 1-10 Short-axis view of the Achilles tendon revealing an

edge artifact (arrow).
Figure 1-12 Reverberation artifact.

Characteristics of shadows include the following: deeper tissues (Figure 1-11) due to lack of attenuation
by fluid media.
• Hypoechoic or anechoic
Reverberation is caused by bouncing of a sound beam
• Deep to a structure with abnormally high attenuation rate between two strong specular reflectors positioned parallel
• Prevents visualization of true anatomy deep to the to the beam axis (Figure 1-12). Multiple echoes result in
shadow-producing object multiple equally spaced artificial reflectors on the display at
increasing depths parallel to the main axis of the beam. All
Edge shadow (Figure 1-10) is created by refraction of
tissues between the reverberating specular reflectors can
sound from the edges of a curved structure commonly seen
be replicated. The first of the two reflectors is usually the
at the edges of superficial subcutaneous veins and torn
transducer face.
edges of tendons. The edge shadow disappears with the
Comet-tail artifact is a reverberation artifact with the
change in the direction of ultrasound beam.
spaces squeezed out (Figure 1-13). It appears as a solid
Enhancement is a hyperechoic appearance of tis-
hyperechoic line directed downward and parallel to the
sues due to lack of attenuation of the sound beam dur-
sound beam’s main axis. The vibrations are caused by the
ing propagation. It is the reciprocal of shadowing. More
bouncing of the sound beam between two closely spaced,
sound energy returns to the transducer from tissues
highly reflective interfaces. The sequential echoes are so
deep to a low-attenuation medium. Returning echoes
are amplified based on depth assuming a constant rate
of attenuation. Structures such as a full bladder, cyst,
abscess, or joint effusion result in ­ enhancement of

Figure 1-11 Through transmission enhancement of a ganglion. Figure 1-13 Comet-tail artifact.

MCGH353-Ch01_p1-8.indd 7 23/07/15 12:11 AM

 8 CHAPTER 1

Figure 1-14 Ring-down artifact that also displays some comet-

tail artifact. Ring-down looks like a solid line with no spaces; in a Figure 1-15 Double imaging of the calcaneus.
comet tail, the spaces are very small.

close together that individual signals do not appear sepa-
rate. The width and strength of echoes diminishes in the
deeper tissues, resulting in a triangular conical artifact.
The phenomenon is caused by the sound beam reflect-
ing from metal objects such as a prosthesis or needles,
or from highly reflective foreign bodies and tissue
­calcifications.
Ring-down artifact is considered a variant of comet-tail
artifact because of its similar appearance (Figure 1-14). It
appears as a continuous echo deep to a highly reflective
interface mostly due to gas.
In a mirror-image artifact, a highly reflective interface
can act as a mirror and create a virtual image of the super-
ficial reflectors deep to it, just like an actual mirror (Figure
1-15). A mirror-image artifact is a virtual copy of the true
reflector deep to the highly reflective interface acting as a
mirror. The true reflector and the artifact are at equal dis-
tance from the highly reflective interface (mirror).
Anisotropy is an angle-dependent artifact of a specu-
lar structure (Figure 1-16A and B). For example, fibers
are echogenic when perpendicular to the sound beam, but
hypoechoic or anechoic when oriented obliquely, giving a
false impression of pathology.
Tendons are strongly anisotropic. Anisotropy of tendons
helps differentiate tendons from surrounding fat when
echogenicity of fat approximates that of the tendons.

A B

Figure 1-16 (A) Plantar aspect of the flexor hallucis longus tendon with the hallux plantar flexed, placing the flexor hallucis longus
tendon almost parallel with the probe and showing the fibular pattern of the tendon. (B) Same location as Figure 1-16A, but the hallux
is dorsiflexed, creating an angle between the probe head and tendon. The ultrasound waves now ricochet off the tendon and do not
contribute to the image. The location of the tendon is still visible, but it is dark (arrow).

MCGH353-Ch01_p1-8.indd 8 23/07/15 12:11 AM

 ULTRASOUND IMAGE
OPTIMIZATION
PATRICK MEYERS
There are few published data on the qualities that make an
acceptable image. However, there are basics of image pre-
sentation and quality that are essential to get a diagnostic
quality image. This chapter discusses image presentation
and basic image quality components.
IMAGE PRESENTATION
Regardless of the appearance of the image or the ultra-
sound system manufacturer, there are defined items that
are fundamental to all ultrasound systems. The most basic
and fundamental is that the ultrasound system begins with
the conversion of electrical energy to acoustic energy. The
electrical pulse excites the crystals in the transducer, which
emits sound waves from the transducer face that are trans-
mitted into the body. The waves strike different tissue inter-
faces with varying tissue density and are reflected back to
the surface of the transducer. The energy returning to the
transducer is converted back to electrical energy and is sent
to the system display to be viewed. A way to think of the dis-
played image is from the top of the image to the bottom in a
temporal sense. Structures that are closest to the transducer
surface, which is where the beam originates and terminates,
are displayed at the top of the screen. Regardless of where
the transducer is placed on the body, whatever structure is
first encountered and reflected back to the transducer will
be at the top of the display (Figure 2-1).
As the sound travels through the body and returns, it loses
energy as a result of multiple factors. Some of the reasons for
loss of return signal are compensated for by controls avail-
able to the imager. Today’s modern ultrasound equipment
has made intricate and time-consuming image-quality
tweaking obsolete. Largely because of automated image
optimization controls, increases in computational power
of modern computer chips, and knowledge of ultrasound,
image optimization has become decidedly easier. However,
MCGH353-Ch02_p09-16.indd 9
21
a basic understanding of sound interaction with tissue and
the controls most systems provide to improve the diagnostic
quality of the image is provided here.
The first rule to understand is that ultrasound is energy,
and care should be taken to limit the amount of energy
directed into the body. The U.S. Food and Drug Administra-
tion (FDA) has strict thermal and mechanical indices that
all companies must abide by. As recommended by guide-
lines established by the U.S. Nuclear Regulatory Commis-
sion (U.S. NRC), the lowest amount of energy should be used
during any study. This is referred to as ALARA, an acronym
for “as low as (is) reasonably possible.”
The acoustic output control (AO) controls the amount
of energy released from the transducer into the body. For
musculoskeletal imaging, acoustic output is seldom if ever
adjusted.
GAIN CONTROL
In contrast, the most common control adjusted in image
optimization is the gain control. The gain control is an
amplifier of the returning signal from the body and makes
the overall image brighter or darker (Figure 2-2). The gain
control is analogous to the volume control on audio devices.
The gain control amplifies all returning signals, but does
not increase the amount of energy emitted into the body.
TGC CONTROL
A secondary control, not found on all equipment, is the TGC
or “time gain compensation” control. This control allows for
horizontal gain control that increases or decreases gain in
segmented parts of the image (Figures 2-3 and 2-4). Con-
sidered a second-level control, the TGC allows the user to
“balance” the image brightness from top to bottom. The TGC
23/07/15 12:12 AM
 10 CHAPTER 2
Figure 2-1 An ultrasound system with an image displayed. The
yellow-brown arrow at left shows the direction of the ultrasound
beam and how anatomy that is closest to the transducer is
displayed at the top of the screen. The yellow and orange arrows
at right indicate the direction of the original pulse and the
direction of the returning pulse.
C
MCGH353-Ch02_p09-16.indd 10
controls are generally represented as a series of slide pods or
digital controls that can be individually adjusted. They are
similar in fashion to the rear speaker controls on an audio
system, allowing for increases in segmental brightness.
PRESETS
A common question for new users to ultrasound is, “Where
do I start in optimizing my image?” With advances in auto-
mated controls on modern equipment, a user can start by
selecting an imaging preset. Presets can be thought of as
shortcuts to first-level image optimization. The presets
may be grouped by specialty, location, or patient/joint size.
Presets act like station selection controls on audio systems.
The preset controls will automatically set a predetermined
gain and a number of imaging options. It is one of the first
controls that a user should become accustomed to selecting
(Figure 2-5).
Figure 2-2 (A) Long axis of muscle with gain control set too
high. (B) Long axis of gastrocnemius muscle with correct gain.
(C) Long axis of gastrocnemius muscle with overall gain too low.
23/07/15 12:12 AM

A B
Figure 2-3 (A) Mechanical TGC (time gain compensation control) pods seen inside yellow oval. (B) Electronic TGC pods on a tablet
system (yellow oval).
The general purpose of the preset control is to set your
system in a “ballpark” state for imaging. It will be the quick-
est route to initial system optimization. Adjustments to the
preset can be made based on user tastes and tissue sub-
stance after it is selected. Imaging presets in many newer
systems allow for users to build user-defined presets that
allow for customization of specific tasks.
The ultimate goal of image optimization is to achieve the
best diagnostic-quality image with the system as quickly as
possible. Many more controls may be available for optimi-
zation, but they are beyond the scope of this chapter.
DEPTH OF FIELD
The top-level controls just discussed—gain, TGC, and
presets—are the most important first-level parameters in
image quality. Preset values are, as stated earlier, ballpark
parameters. Because body habitus can be significantly
different within a preset parameter (for example, “knee”
would include an elite athlete as well as a morbidly obese
patient) the ability to adjust these factors is essential. We
begin with depth of field or viewing area. Think of depth
of field over (FOV) as the area that will be displayed on the
monitor. Remember, once the sound leaves the transducer,
MCGH353-Ch02_p09-16.indd 11
ULTRASOUND IMAGE OPTIMIZATION 11
it continues in the body until all energy is used. Adjust-
ing the viewable area on the machine is a function of the
depth control and has two main functions. The first is to
set the depth to include targeted anatomy and sufficient
surrounding structures. Second, proper depth adjust-
ment helps the machine work more efficiently. The system
pulses a signal and waits for all returning echoes before a
second pulse can be sent. If the system pulses before the
vast majority of energy from the previous pulse is com-
pleted, negative artifacts may be encountered. Therefore,
a depth set improperly deep will unnecessarily slow down
the image refresh rate, otherwise known as frame rate. A
frame rate that is too slow results in the image refreshing
too slowly, with image lag or what is known as a “wind-
shield wiper” effect. Setting the depth too shallow will
result in the full range of target anatomy not being dis-
played (Figure 2-6A and B).
A good rule of thumb is to adjust image depth such that
target anatomy fills two thirds of the display area and, if
appropriate, include osseous (bone) anatomy for orienta-
tion. Remember that the depth of field is an adjustable wall
that can be moved either way with the depth control button.
Once proper depth is selected, adjustments in overall gain
and TGC can be made.
23/07/15 12:12 AM
 12 CHAPTER 2

B
A

Figure 2-4 (A) Properly balanced image brightness with overall

brightness equal from top to bottom. (B) Far field too bright
compared to near field. (C) Far field gain too low compared to
C
near field.

A B

Figure 2-5 (A) Electronic preset showing application and depth of target anatomy (upper left side of display, “MUSCULOSKELETAL”,
“VERY SUPERFICIAL” inside yellow oval). (B) Selection for preset button is located on the lower left side of the keyboard (yellow circle).

MCGH353-Ch02_p09-16.indd 12 23/07/15 12:12 AM

 ULTRASOUND IMAGE OPTIMIZATION 13

A B

Figure 2-6 (A) Depth of field is set too shallow and not enough anatomy is seen to properly identify location in this long-axis (LAX)
view of the flexor tendon of the finger. (B) Depth of field is set correctly, and adequate anatomy is seen to identify bone and soft tissue
structure of the flexor tendons in the finger.

FOCAL ZONES OTHER PARAMETERS

Some machines have the ability to increase the resolution
of the image in a specific horizontal aspect of the image.
These controls, much like focusing light with a lens, pro-
vide the ability to focus the energy from side to side for
increased image resolution at a specific depth. Figure 2-7
is an illustration of what happens when focus depth is not
adjusted properly. Adjusting the focal zones in the image
increases resolution as well as brightness of the image at
the level of the focal zones. Proper focal zone adjustment
should be made by placing the focal zones at the level of the
target anatomy or just below.
One may wonder why the machine does not have focal
zones cover the entire image instead of a specific area. The rea-
son is that adding more focal zones slows down the frame rate.
The next line of image parameters that can be adjusted
are available on some but not all systems. These features
include imaging maps, frame averaging, and reject. These
three controls are often adjusted to user tastes and seldom
have dramatic effects on the diagnostic quality of the image
unless used at extreme ranges of selection. Map selection
may produce an image emphasizing the black or bright
reflections. Map selection is primarily a visual prefer-
ence for display. Only the extreme ends of map selection
may affect diagnostic image quality. Frame averaging is a
method to remove speckle artifact, the salt and pepper foci
in an image. Frame averaging is more of an obsolete con-
trol and should not be considered a primary image adjust-
ment option.

A B

Figure 2-7 (A) Correct focal zone position across from patellar tendon (yellow hourglass). Tendon fibers are seen as discrete
structures (blue arrow). (B) Incorrect focal zone position. Focal zone set too deep (yellow hourglass). Tendon fibers are blurry and blend
in with other fibers (blue arrow).

MCGH353-Ch02_p09-16.indd 13 23/07/15 12:12 AM

 14 CHAPTER 2

A B C D

Figure 2-8 Common form factors for transducers. A, curved Figure 2-10 LAX view of the anterior adult hip illustrating the
linear array; B, sector/phased array; C, micro linear array; D, typical trapezoidal wide-format image display of a curved linear
50-mm linear array. array transducer.

FREQUENCY transducer and operating frequency are often considered

A primary imaging control that is a combination of machine
and transducer is imaging frequency. The higher the fre-
quency, the better the spatial resolution. Modern machine/
transducer combinations accommodate multiple frequency
selections for each transducer. The trade-off in frequency
is the higher the frequency, the greater the spatial resolu-
tion, to the detriment of penetration. In other words, tissue
structure will be sharper at the expense of seeing deeper into
the body. During imaging, it is not unusual to change fre-
quencies to observe the benefits. Presets for each area gen-
erally provide the best compromise.
TRANSDUCERS
There are two final factors regarding image optimization,
transducer selection and operating frequency of trans-
ducer. Up to this point, methods to optimize the image
have focused on the displayed image. Choosing the correct
first steps, but transducer selection and operating frequency
can be changed during the examination to help improve the
diagnostic quality of the image. The format, or form factor,
of the transducer selection is discussed first.
Figure 2-8 illustrates the common form factors of trans-
ducers. Commonly used transducers come in three basic
formats: linear array, curved linear array, and sector array.
Linear array transducers, those with flat faces, come in for-
mats with small contact surfaces, often referred as micro
linear or “hockey stick” form factor. The micro linear arrays
are generally employed in evaluations of the hands, feet, and
wrist. The small footprint or face allows for easy placement
of the transducer in small spaces such as between fingers
and toes and while working around protruding bone sur-
faces such as the malleoli. This form factor is often used in
ultrasound guidance in the joints of the fingers and toes.
Its small footprint allows for easy manipulation. Although
it is not required for evaluation of any particular joint, its
light weight and easy maneuverability make it ideal for

A B

Figure 2-9 (A) LAX view of the flexor tendon in the hand at the metacarpal-phalangeal joint space with micro linear array transducer.
(B) Larger linear format demonstrates a larger side-to-side format, and more anatomy can be seen.

MCGH353-Ch02_p09-16.indd 14 23/07/15 12:12 AM


A B
Figure 2-11 (A) Flexor tendons in the finger showing indistinct tendon fibers (blue arrows). (B) Same image as Figure 2-11A, but with
spatial compounding activated. Greater distinction of tendon fibers in the flexor tendons is seen.
providers focused on the hands, feet, and wrist. Because of
the superficial nature of anatomy in this area, the operat-
ing frequency of this transducer ranges from 8 to 30 MHz
and beyond. Although ideal for getting into tight places, the
small footprint of the transducer provides a small field of
view and, with the higher frequency range, limits the depth
of penetration.
The second and most common form factor is the stan-
dard linear array format. The footprint of linear array in
general is between 29 and 50 mm. The footprint, although
slightly larger than the micro linear, can be used in prac-
tically all the same applications as the micro linear. The
larger footprint has the advantage of a wider field of view
for display (Figure 2-9A and B).
Depending on the study being performed, the curved lin-
ear array may be the transducer of choice when larger field
of view is needed, both in deep anatomy and in some situ-
ations where the anatomy is close to the transducer, such as
the sacroiliac (SI) joint, where the curved linear array would
have advantages. In general, the curved linear array trans-
ducers have a lower operating frequency band and will have
less spatial resolution when compared to the linear array
(Figure 2-10).
The operating frequency or frequencies is referred to
as the bandwidth of the transducer. Modern transducers
are broadband—in other words, they have a good range
of operating frequencies that a user can select. Although
there is a relationship between the ultrasound machine and
the frequency range of the transducers, that relationship is
beyond the scope of this chapter.
The key element of operating frequency of a transducer
is that the higher the frequency, the better the spatial reso-
lution (axial and lateral resolution) of the image. The nega-
tive of high-frequency imaging is that as frequency goes
higher, the penetration of the ultrasound waves decreases.
The best rule of thumb is to use the highest frequency
available to adequately image the target anatomy. In gen-
eral, high frequency is considered to be a range greater
than 7 MHz and low frequency lower in the 1- to 6-MHz
range.
MCGH353-Ch02_p09-16.indd 15
ULTRASOUND IMAGE OPTIMIZATION 15
SPATIAL COMPOUNDING
One other technology that has a direct effect on image
quality is spatial compounding. Spatial compounding is
an image acquisition technique—in other words, when the
system is sending the wave into the body. What is unique
about spatial compounding is that the system sends waves
from different angles and combines them into a single dis-
played image (Figure 2-11).
The value of this technique is that it improves the defini-
tion of the borders of structures, improves contrast resolu-
tion, and has the added benefit of minimizing anisotropy
encountered in tendons and other anatomy. The aniso-
tropic effect is discussed in detail in other chapters of this
book.
SUMMARY
In summary, the optimization of the ultrasound image
requires the user to have a basic understanding of how the
controls on the ultrasound system work. A practical algo-
rithm for beginning an exam would be the following:
1. Enter patient information
2. Select the closest available preset that matches the body
part being examined
3. Choose an appropriate transducer type and operating
frequency
4. Adjust the depth control, if needed, over preset to image
slightly deeper than the target anatomy
5. Use the gain control, and TGC controls if available,
to adjust the brightness of the image and good image
brightness balance
Although this chapter has not provided exhaustive coverage
of image optimization, the most basic concepts and most
common image controls have been explained. Importantly,
developing a consistent method to achieve a diagnostic-
quality image will increase efficiency and consistency in
scanning.
23/07/15 12:12 AM
Another random document with
no related content on Scribd:
 A complete list of the plays, with their dates, will be found in the
Bibliography at the end of this book. There are, as I said, twenty-seven of
them; and they were wrought between the years 1881 and 1911. The last
four were not published until after the poet’s death; but of these In the
Name of Time, which did not appear until 1919, was being written so long
before as 1890; and A Question of Memory was first printed for the actors
when the play was performed at the Independent Theatre in October 1893.
Besides complete plays, however, there is a masque called Noontide
Branches (printed at Oxford by the Daniel Press in 1899), which has
charming associations with the late Provost of Worcester and Mrs Daniel.
And there is a trialogue called Stephania which was published in 1892.
Indeed, the bibliographical interest of this poet’s work is very great, and
would touch the history of several private printing-presses during the last
quarter of the nineteenth century. Thus Fair Rosamund and the poet’s
Roman trilogy (The Race of Leaves, The World at Auction, and Julia
Domna) were issued from the Vale Press of Mr Charles Ricketts, and nobly
decorated by him. His border for Fair Rosamund is more than a lovely
symbol; it expresses with the last fine touch of perception the wild-rose
exquisiteness of the spirit of the play. The Tragic Mary was printed at the
Chiswick Press in 1890: its binding was designed by Professor Selwyn
Image, as also was the frontispiece of Stephania. Whym Chow, the rarest of
the Michael Field books and the most curious in content, can hardly be said
to have been published at all. It was printed in 1914 at the Eragny Press of
Mr and Mrs Lucien Pissarro. Only twenty-seven copies were printed, and of
these perhaps not more than half a dozen were given to intimate friends
who might be trusted, if not to understand the poems (for they are
extravagant and obscure), at least to sympathize with the occasion of them.
For all of their books, with one exception, the poets took pains to secure
a comely form and adequate binding, often of white vellum. Even the group
which appeared anonymously and in temporary covers between 1905 and
1911 (Borgia, A Question of Memory, The Tragedy of Pardon, Diane, The
Accuser, A Messiah, Tristan) were printed with distinction on good paper.
That the poets had sufficient means and leisure to indulge their taste may
rejoice the bibliophile; but there is no doubt that the cost of books so
produced was too high to gain them a large public. At one time they
themselves suspected this, and experimented with a cheaper form. Hence
the one exception (Brutus Ultor) to their practice. This work was published
in 1886 as a small paper-covered booklet at the price of ninepence. Michael
wanted, in her own phrase, “to reach the Demos”; and it is possible that she
did so. But the Demos did not respond sufficiently to cause her to break her
rule a second time.
Here, then, is a very large body of poetic drama, engaged upon subjects
drawn from the literature and the history of many countries and many
epochs. How to arrive at the significance of a total so extensive and
various? A coherent impression of it would be difficult in any case; and
within these narrow limits it may well be impossible. There is, however,
one helpful fact, for the tragedies divide themselves almost automatically
into three groups. The division is, indeed, so simple as almost to be suspect,
and so definite as almost to be mechanical. It corresponds, too, in the most
approved manner, with the early, middle, and later periods of the poet’s life.
Thus there are, in progressive order from the beginning of her career, her
English, Latin, and Eastern periods. The first deals with themes from
Scottish chronicles and English history, and extends from 1881 to about
1890. In the second group, published from 1892 to 1903, the subjects are
mainly drawn from Roman history; and the third, published from 1905 until
the end, has for its outstanding features two plays of a projected trilogy
from Josephus, another called A Messiah, and one which handles an
Abyssinian love-tragedy.
Yet these categories are not quite so clear-cut, after all. One soon finds
plays which do not correspond to the order to which they are supposed to
belong, and discovers, on investigation, that they were not written in that
order. But one makes at the same time the much more satisfying discovery
that there are, within each group, affinities which hold the plays by a
stronger bond than the arbitrary likeness of theme. Thus in the English
period, the stage of the poet’s grave and strenuous youth, ideas are a motive
force. This body of drama, if too dynamic to be ‘high-brow,’ may be justly
defined as ‘intellectual,’ with a strange pouring of the new wine of modern
thought into the old bottles of Elizabethan form. But with the approach of
the Latin period the centre of power shifts from ideas to art. Form is now as
important as, or more so than matter; and the two cannot be separated. The
value of the work now is in its unity of beauty and truth. But when the last
phase has come, and tragic vision has ranged far enough among the
elements of its universe to make a final synthesis, it wheels back to close
the cycle upon the idea of destiny. Vast passions are now the poet’s theme.
Destiny, consisting in some overmastering elemental force, is now her
inspiration. But it is no external, supernatural, or superhuman force. It
subsists in nature, and resides within humanity: it belongs inalienably to the
stuff of which man is made: it is the tragic shadow of life itself.
Coming at once to the English group, it is amusing to find that this starts
off with a Greek play! That is to say, the earliest work published by the
poets as Michael Field, Callirrhoë, has a Greek theme. It is a fact which at
first glance threatens to embarrass our nice clear categories; but we
remember in time that there is something almost absurdly native in the
familiar spectacle of a Greek subject in the hands of a young English poet.
Of course! What else, what other, could one expect?—;at least down to the
epoch of yesterday to which our poet belonged. Was not this dependence
upon the classics largely responsible for the revolt of contemporary poets
—;as witness Anna Wickham:

We are outwearied with Persephone,

Rather than her, we’ll sing Reality.

The story of Callirrhoë comes from Pausanias; but our poet has modified
the original by basing the motive of the plot upon the origin of the worship
of Dionysos, which, as she admits, must have been much earlier. The
anachronism is deliberate, however, and does not vitiate the theme, which is
already un-Greek in its preoccupation with romantic passion. For
Callirrhoë, a maiden of Calydon, is beloved to distraction by the Dionysiac
priest Coresus. She loves him in return (or at least our poet makes us
suspect so), but will not marry him because she cannot worship the new
god. He thereupon calls down a curse upon her city, and the people begin to
sicken and die of the plague. They send to consult the oracle at Dodona, and
it is decreed that Callirrhoë must be sacrificed to Dionysos unless some one
else will die in her stead. No one offers, however, and she goes to the altar
prepared to die. Coresus makes ready to slay her, but when the moment
comes to strike he kills himself instead of her. His sacrifice convinces
Callirrhoë of the truth of his religion. Now that he is dead she realizes that
she had loved him, and she kills herself as an offering to his god.
The play is a living work despite its ancient theme, its rather cumbrous
machinery, and its mixed elements. But apart from certain passages of great
imaginative beauty, its chief interest lies in the fact that its motives—;love,
self-sacrifice, enthusiasm—;were the ruling motives of the poets’ lives and
a frequent theme of their art. Therein, of course, lies the significance of
their modification of the old story. Love they always saw as the greatest
good of life, self-sacrifice as the dearest end of life, and enthusiasm (here
enters Dionysos) as the means to life’s noblest expression. In this last
element the work remains Greek, though Englished in so much else.
Michael was, in that sense, a Thracian born, and she had compelled a peace
with Apollo. She infused the play with the spirit of Dionysiac worship
because that spirit was her own. And when one remembers the spiritual
truth that was implicit in the cult of Dionysos, its contribution to the world’s
growing belief in immortality, and its connexion with the origins of tragedy,
there is peculiar appropriateness in such a subject for Michael Field’s first
essay in drama. Thus the key-pieces to the poet’s meaning are found where
Coresus is pleading with Callirrhoë for his love and his religion. He has
begged her to join the Maenads’ revel, and so set her spirit free; and he
declares of his god:
 He came to bring
Life, more abundant life, into a world
That doled its joys as a starved city doles
Its miserable scraps of mummying bread.
He came to gladden and exalt, all such
Must suffer....
Callirrhoë. ... Of old the gods
Gave culture by the harp, the helm, the plough,
Not by the ivy-wand.
Coresus. Seems it so strange
That Semele’s sublime audacity
Should be the origin of life urbane?
We must be fools; all art is ecstasy,
All literature expression of intense
Enthusiasm: be beside yourself.
If a god violate your shrinking soul,
Suffer sublimely.
Callirrhoë. Yet I hold it true,
Divinity oft comes with quiet foot.
Coresus. To give a moment’s counsel or to guard
From instant peril. When a god forsakes
Olympus to infuse divinity
In man’s mean soul, he must confound, incite,
O’erwhelm, intoxicate, break up fresh paths
To unremembered sympathies. Nay, more,
Accompany me further in my thought—;
Callirrhoë, I tell you there are hours
When the Hereafter comes and touches me
O’ the cheek.

. . . . .

Callirrhoë. I tremble at your god, for terrible

In wrath I fear him; though you speak him fair.

. . . . .
 Coresus. Turn not away, Callirrhoë; by goads
The ox-souled must be driven; yield response
To Heaven’s desire of thee; love humanly.
Love is the frenzy that unfolds ourselves;
Before it seize us we are ignorant
Of our own power as reed-bed of the pipe.
The rushes sang not; from Pan’s burning lips
Syrinx sucked music. Wert thou lute to love,
There were a new song of the heaven and earth.
Callirrhoë. ... I will not yield my love
To Bacchic priest....
Coresus. ... As unseasoned wood
That smokes and will not kindle is flung by
For any refuse purpose, while the train
Of torchlight sinuous winds among the hills,
A starry serpent, so art thou cast out,
An apathetic slave of commonplace,
Sluggish and irreceptive of true life,
From all high company of heavenly things.
Go to your home.

Callirrhoë. O, Heaven shelter it!

Act I, Scene 3

There is much that one would like to quote from this play, including the
faun scenes (written by Henry) that have already been adopted into certain
anthologies. Machaon, too, sceptic and humorist, might be used to
confound the dullards who said that Michael Field had no humour. There is
salt enough in him to give the whole tragedy another flavour, and he breaks
at least one of the precious unities. His rationalism is away in a much colder
region (he usually speaks in prose); and his conversion to the cult at the end
is out of character. But though one may not linger on him, one must stop for
a moment at Henry’s faun song. For here, very delicately and quietly, a
greater theme is stated. And if we seek in this first work for an early
glimpse of the larger vision which the poets attained at last, seeing the
tragic element of life as life’s inescapable shadow, it will be found, quite
unself-conscious, in this playful song.

I dance and dance! Another faun,

A black one, dances on the lawn.
He moves with me, and when I lift
My heels, his feet directly shift.
I can’t out-dance him, though I try;
He dances nimbler than I.
I toss my head, and so does he;
What tricks he dares to play on me!
I touch the ivy in my hair;
Ivy he has and finger there.
The spiteful thing to mock me so!
I will out-dance him! Ho! Ho! Ho!
Act III, Scene 6

Fair Rosamund, which appeared in the same volume with Callirrhoë,

possesses equal dramatic power with greater control and a clearer sense of
direction. The play is built with more economy; the movement is quicker,
and the lyrical passages really belong to the setting and are not simply
interludes to provide relief. Of the works of the first group, Fair Rosamund
is perhaps the most perfect artistically, which may have been the reason
why the poets chose it for reproduction in the Vale Press. But just because it
is so balanced, and entirely free from afterthought, it is not fully typical of
this group. We pass it, therefore, with two short quotations, and in addition
only this fragment from Rosamund’s farewell to the King, to illustrate how
our poet will sometimes gather infinity into a gem-like phrase:

Dear, my lord,
There are some thoughts
That through this stormy weather of my soul
Cannot now travel toward you.
Act II, Scene 5

In Act I, Scene 3, spies have just informed Queen Elinor of the King’s
love for Rosamund, and of the place where he has hidden her:
 Q. Elinor. Thank God for boys!
To have reared a treasonous brood from his own blood,
To have it at my call!

[To the King, who has entered.

I tell you to your face, that boy of ours,

Crowned Henry, has my love, because he has
My bridegroom’s eyes; but for the rest, my lord,
You’re old to think of love: when you were young
You thought not of it.

K. Henry. I embraced your lands,

Not you.

Q. Elinor. Plantagenet, you wronged yourself

As you had made the day and night your foe,
And roused
The violated seasons to confer
Each his peculiar catastrophe
Of death or pestilence.—;Embraced my lands!
I’ll shatter you
As Nature shatters—;you as impotent
As the uprooted tree to lash the earth....
Embraced my lands.—;Ah, I forget myself,
The loveless are insensate to presage;
’Tis in calamity’s harsh stubble-field
They learn to suffer. I’ll be harvester,
And sickle your ripe joys.

The last scene is in Rosamund’s room at Woodstock. It is night, and she

is waiting for the King. But Queen Elinor has found the clue to the
labyrinth, and is at this moment approaching the secret bower, intent upon
killing her rival:
 Rosamund. White moon, art thou the only visitant?
Thou lookst like death!
Dost glisten through the trees
My Henry bows his plumes to in the gloom?
He comes to-night; for good Sir Topaz said,
“My lady, put you on the crimson gown
The King had wrought for you, and ask no more,
But trust an old man’s word.
And be you ready.” It’s a silver night;
I’ll put me out apparel. How blood red
Burn the dark folds! I cannot put it on;
And yet I will. My lute; what is’t I want—;
God, or the King?

[Sings.

Love doth never know

Why it is beloved,
And to ask were treason;
Let the wonder grow!
Were its hopes removed,
Were itself disproved
By cold reason,
In its happy season,
Love would be beloved.

No; it hurts sharper. I must just sit down

On the edge of the bed, and comb my hair and wait—;

. . . . .
 I cannot think at all. How beautiful
This gold made silver in the moonlight! What!
Would Heaven age me for my Love? Let’s look
In the mirror. Rosamund, you’re worshipful.
[Starting back.] ’Tis thus,
Even thus, he swore that he should come to me.
His very words! The prophecy’s fulfilled,—;
I’ll comb my hair down to my very feet.
A step!—;my heart, some patience. Henry, speak;
Bid it take courage! [Enter Elinor.] God! the Queen!

Q. Elinor. The Queen, who’ll give you access to your God;

The wife, who’ll doom the leman.
Act II, Scene 8

But coming now to the plays which are completely representative of the
poets in this period, we may glance at The Father’s Tragedy, William Rufus,
Canute the Great, The Cup of Water, and The Tragic Mary. These, with
three others, appeared within the dates 1885 and 1890—;not a poor record
of five years’ work, and one which reminds us that our poets laboured at
their art as only the genuine artist does. They drew the themes of these
plays mainly from English history and Scottish chronicles; and they
selected them, all except that of The Tragic Mary, ultimately for an idea that
lay behind them. Obviously, therefore, this work is not entirely disinterested
art: it anticipates, to that extent, the problem-play, the intellectual drama,
and even (so far as concerns his influence in this country) Ibsen. Indeed, a
remarkable aspect of the group is the way in which, despite its romantic
tone and its Elizabethan form, it yet foreshadows the movement that
English drama was about to make toward a ‘realistic’ presentment of life.
There may be a piquancy in thinking of Michael Field the romantic as the
forerunner of Mr Bernard Shaw and Mr John Galsworthy: and it is not
certain which would be the less pleased at the comparison, ancestress or
descendants. The latter, following a poetic age with inevitable comedy
—;inevitable if only from reaction—;were compelled to decline upon prose
as their medium; and the great merit of Michael Field is that, belonging to
the poetic age and possessed of the poet’s ardour and imagination, she yet
kept near enough to the actual world to see the evils that existed there.
Happily removed from them by circumstance and temperament, she yet
kept her eyes clear and her sympathies alert. Her prologue to The Father’s
Tragedy is apt to this point, for there she warns

the light and easy-souled

Who shun the joyless truth in human things

to turn to more congenial pages than her tragedies. It is evident that she was
concerned, thus early, with the joyless truth which was to take possession
—;absolute and somewhat depressing possession—;of the dramatists who
came after her. Unlike them, however, by giving her truth the form of
poetry she endowed it with the joyousness of art. She saw it, too, in the
round: there is a largeness in her conception of it which gives her
‘intellectual drama’ greater dignity, and one would suppose greater
permanence, than later ‘realistic’ work. Yet when one observes the ideas
that govern some of her plays in this kind—;parental tyranny, the land
question, marriage, or the conflict between an older and a newer order of
civilization—;one recognizes at once the likeness to the motives of much
more recent drama. Indeed, we might go further and demonstrate a rather
later play—;Attila—;as an anticipation of Freud and the psycho-analysts.
The Father’s Tragedy, a play in five acts and a great many scenes, was
written almost entirely by the younger of the two poets. Some parts of it
were composed by her at the age of sixteen, and were in fact the means by
which Michael discovered her dramatic talent. At the date of its publication
(1885) Henry was only twenty-three, and it had been completed some
months before. The play is, therefore, the work of a very young mind, and
one is not surprised that its main feature is a vigorous and sympathetic
study of youth. What does surprise one, however, is that the study of age in
this struggle between a father and a son is also sympathetic; and although it
is the son who is the victim of the father, the play is called, significantly, the
father’s tragedy. Which is to say that the profoundest depth of the tragedy is
seen to be the moral defeat (one ought rather to say the moral annihilation)
of the father. That is a conception not so youthful, perhaps, as the age of the
author; just as the fierce dark strength of the drama would not appear to
accord with her sex. There is something Brontesque in the sombre power of
this tragedy; something too much of horror, barely relieved by two or three
short scenes of hectic gaiety when the young prince has escaped
temporarily to his boon companions. But only imagination of the highest
kind could have conceived it.
The plot comes from Scotichronicon and the old chronicler Wyntoun,
whose words are in one place almost exactly quoted. Robert III is shown to
be pious, weak, superstitious, affectionate, desiring only the ‘good’ of his
heir, the young Prince David, Duke of Rothsay. But David, intensely alive
in his buoyant young manhood, loathes the dour ‘good’ that is forced upon
him, and combats it. He has, in fact, more strength than his father, and the
struggle becomes bitter and tragic only when Albany, the King’s brother,
backs the King with a strength equal to David’s own, overbears the father’s
weakness and perverts his affection, and eventually compasses the Prince’s
death. The crisis is the enforced marriage of David to a bride whom he
detests, he having been literally sold to her father as the highest bidder for a
great match. He breaks into the council-chamber at the moment when the
King and Albany are settling the price that the bride is to pay for him.
Albany bids him be seated.

Rothsay. In the market-place

Slaves stand for sale. I will not sit; I’ll stand
In purchasable shame before you all
Who bargain for my manhood; stand and watch
My father sell the birthright of my flesh;
Yea, stand and bear a sacrilege my youth
Must damn itself to credit.

King. David, peace!

. . . . .
 Rothsay. Nothing glorious
Is marketable—;fame, nor love, nor deeds
Of any virtue, youth nor happiness;
Nothing, oh nothing, but the meanest things,
Of which I am the meanest. On my soul,
You drag me in the dirt, and there I’ll lie
And dash it in your faces....

Albany. Wherefore all this noise

And rampant passion? We would understand
The tossing cause thereof.

Rothsay. Speak it! Oh no!

’Twould want an old and worldly merchant, one
Who has a counting-house. I’m still a prince
About the lips, nor know your tricks with coin,
Your sales of man for woman, your low truck
And miserable frauds. You’ve ruined me,
And thrown my youth down to the bottom step
Of Pride’s high stairs. I’ll never climb again.

. . . . .

Oh, write your contract, for it joins my life

To snaky-headed Sin, in whose hot breast
I’ll know what pleasure is. Call forth your priest—;
He’s but a pander in the guise of Heaven.
Let Hymen’s torches flare—;they smell of pitch
And sulph’rous fever of contemn’d desire;
Ring from your steeples—;’tis the curfew-bell;
Prepare your bridal-veil—;’tis hiding night;
Present your hateful bride to pulseless arms—;
And Lust receives the harlot in its clasp.
Act I, Scene 3
 Rothsay. Oh, all the shame
You’ve struck into my being will be there,
When it is opened to its secret depth
Before the Judgment seat, and lo! old men
Will answer for the sins that they have done
Across the years to those in backward Time’s
Most lovely season.
Act II, Scene 2

The scenes in Act IV, when Rothsay is starving to death in Falkland

Castle, are vividly imagined:

Rothsay. I can only think

Of bread, bread, bread!...
... Oh, without
Are many cornfields—;and the river! God!
I scarcely can remember anything
But the white floods, and the last scrap of meat
I emptied from my wallet.

. . . . .

I ever thought
Death was a shadow.—;I myself am Death.
I fed and never knew it: now I starve.
Here is the skeleton I’ve seen in books!
’Tis I—;the knarled and empty bones. Here—;Here—;
The grinning dints! I thought Death anywhere
But near my life; and it is in the pith
And centre of my body. Horrible!
Act IV, Scene 2

King Robert does not know that David is dying, and the tragic irony of
Scene 5 of this act is masterly. It is a wild night, and the King, crouching
over the fire of a room high up in the castle, hears the wind shriek outside
and thinks of his boy, whom he believes to be merely shut up like a naughty
child to recover from his rage:

K. Robert. My poor lad,

My David, who is fearful of the dark,
Would he were here this bleak and scolding night!
He used to throw a cushion on the floor,
And lay him down as featly as the hound,
His foolish yellow head against my knee;
And so he’d laugh and chat and sing old songs,
Or gaily sneer at our last grave debate,
Drop sudden crude suggestions that anon
Our older counsel ripened into act;
Until for some light word I’d give rebuke,
When either with a peal of raillery
He’d toss me back a penitent bright face,
Or with a shaded humour spring apart,
No place from me too far. Good Albany,
You would not have our Rothsay longer shut
In such grim-tempered darkness?
Act IV, Scene 5

William Rufus (1885), a full-dress drama of five acts, is without a

woman character. It is based on Freeman’s history of Rufus, and was
suggested to the poet, as she explains in the preface, by a visit to the New
Forest. There she found the stone which marks the spot where Rufus fell,
pierced by an arrow glancing from an oak, “as if directed,” to use her own
phrase, “by Nature’s anger at the destruction of her food-bearing fields for
the insolence of pleasure.”
So there, again, peeps out the ulterior motive. The idea of the play is
explicitly to be the land question; and that it had, in fact, a political bearing
is confirmed by the poet’s letters on the subject. Yet one is glad to discover,
as we quickly do, that here as elsewhere in her intellectual drama Michael
Field has been better than her creed: her dramatic instinct has subdued the
idea to itself. So that, if we had no other evidence than that of the play, we
should be convinced that the idea grew out of the theme, and was not
imposed upon it. It was never a case of the poets’ exclaiming, “Go to, we
will write a problem-play!” but rather of a sudden perception, in their
travels or their reading, “What a subject for drama!” and then, as an
afterthought, “And see what profound significance!” But as a fact all the
evidence points in the same direction: a character would arrest them, they
would be attracted by its story, would absorb themselves in the study of it,
and become literally possessed by it—;working out the implicit idea as
something subsidiary.
In this play the idea is completely assimilated to imagination. There is no
bald presentation of it on the plane of everyday existence, for that surely is
a function of comedy. And though the King’s cruelty in appropriating the
peasants’ land is shown in its effect upon the lives of individuals, a larger
vision of the problem is presented in the figure of one old man, Beowulf,
who is, as it were, the wronged spirit of the Earth in human shape. In him
the idea is made both concrete and spiritual, as the genius of poetry can
make it. He is a very real, rough-hewn old countryman, with a vigorous part
in the movement of the drama; and yet there is a touch upon him that is
weird and supernatural, which relates him to fierce elemental forces and
makes him at one and the same time a rustic and an avenging deity. He is
blind; his eyes were put out long ago for trespass; and he feels his way to
the gallows where the body of his grandson has now been hanged for killing
a deer:
 Beowulf. I feel it’s here; I have no need to see.
I’m glad they murdered him, not made him dark;
For now he’s dead the Earth will think on him
As she unweaves his body bit by bit.
She’ll have time like the women-folk at work
To turn all over in her mind, and get
His wrongs by heart.
... Who is here?

Wilfrith. Wilfrith! I often come to pray for him!...

Beowulf. Pray! Pray! Are you a wench to chatter so?

Does not your tongue grow rigid in your head,
A corpse to bear that silence company?
Have you no death in you? Oh, say your prayers;
I will keep mourning in my ruined ears
The passing of his voice.
Act II, Scene 1

Beowulf. Do you think the Earth’s a thing that makes your flesh
Soft for the worms?—;the harvests lie asleep
Upon her bosom; she has reared the spring;
The seasons are her change of countenance;
She lives, and now for many thousand years
Hath ruled the toiling and the rest of men.
... She’ll judge.

Old Man. Do thou make known this matter to the Lord;

He will avenge.

Beowulf. The Lord! Oh, He’s above!

There’s something lying at the roots of things
I burrow for.
Act IV, Scene 1
 Beowulf [his last speech, after Rufus has been
killed]. Yea, bear him through the woods like a gashed boar,
Present him dripping to your angry God;
He may not be implacable. In haste
Cloak the foul thing beneath the minster tower;
Heap soil on him....
... There are worms
About his darkness; I am satisfied.
End of Act V

The people of this drama are vigorous creatures, as sharply drawn and
clear-cut as types, but very far from the merely typical. The poet has
created, and not constructed, them; and each one possesses his own soul.
Rufus is a credible villain, a man and not a monster. He can melt at the sight
of filial piety, unbend to a jest, warm to affection. Anselm may stand as a
figure which shall represent the insulted Church, but he is a very holy and
gentle old priest. Philosopher and saint, he was, of course, historically
studied; but he is, despite verisimilitude, an almost complete embodiment
of the two qualities of our poet’s mind which make so rare a combination
—;her religious temper and her philosophic intellect. Two short quotations
from him may help to illustrate this:

Anselm. God gives His bread to children who are sweet

With golden faith; to thinkers and to men
Of striving reason He presents a stone.
. . . . .
Faith is the child’s gift, and Philosophy
The man’s achievement. Blessèd toil, to walk
Where babes are carried past on angel-wings.
... It is Philosophy
That knocks at Heaven’s gate: Faith finds the door
Wide open.
Act II, Scene 2

But of all the characters, one supposes Leofric to have engaged the
poets’ affection most. He is a ‘mason’: which is to say he is the architect,
sculptor, and builder all in one who was the medieval artist. It is evident
that the poets had particular joy in imagining him, absorbed and happy in
his real world of art, with the actual world as mere stuff for his modelling.
If Leofric ever allows himself to be disturbed by the King’s greedy inroads,
it is from no ‘political’ reason, but simply that the noisy hunters make such
havoc of the woodland peace:

Leofric. ... A horn!

Methinks the forest hath another use
These precious hours of morning, when the world
Is at some process of its perfecting
’Twere well to learn the trick of. Wilfrith toils,
Tearing yon fibre from the ground a-sweat
With effort; while for me!—;my eyes are full;
I have no want; the world is excellent;
There is no prickle in the holly wrong.
How bossily it clusters!
... Oh do not think
We travel so untreasured in resource
We needs must earn the bread of every joy
By sweat of soul. If life’s a desert—;Ah!
There’s manna in the waste; it lies about,
And the wise idle soul is satisfied.
Act I, Scene 4

The motive of Canute the Great (1887) presents a curious difficulty. For
if we are to accept the poet’s own statement of what she meant by the play
(and it does seem as if she ought to have known), then we are forced to
conclude that she attempted the impossible, and therefore failed. But one
has the suspicion that she did not quite know what she meant by it—;which
is not so impertinent as it sounds, and only means that her artistic instinct
was stronger and truer in this case than her philosophy. For in the preface
she declares that she is here dealing with the theory of evolution; and she
elaborates an idea which, had it really operated as a motive force, would
surely have paralysed her Muse and struck it dumb. Canute, however, is no
paralytic: on the contrary, he has his creator’s vehement life and passion, at
least for the first half of the drama. But in those scenes he is far enough
from any abstract theory. Yet when his vitality flags, as it does sometimes,
and when the play becomes, as a consequence, to that extent unsuccessful,
the cause lies in a certain resemblance which the theme does bear to the
poet’s definition of it. For it is possible to regard the character of Canute in
the abstract as a transition between two ages and a link between two orders
of civilization. That is, of course, the meaning which the poet saw in it
—;when she was writing her preface. But in the process of making the
drama the wise æsthetic impulse seized and worked upon something
simpler, more definite, and more moving—;the potential conflict that exists
everywhere and always among human creatures between their instincts and
their reason. That, surely, is a tragic motive of universal validity; and it may
precipitate at any moment, and at any stage of civilization, the revolt of the
half-tamed instincts which is true stuff of tragedy, whether it be enacted
within the small orbit of an individual soul or in the insane immensity of a
world-war. So long as Canute is at grips with the rebel powers
—;dramatized in his struggle with Edmund—;he is a great dramatic figure;
but when his creator raises the conflict—;with his penitence for Edmund’s
death—;to the plane of pure thought, the life goes out of him and he
becomes but a type, though a very noble one, of spiritual struggle. Even at
those moments, however, one may find passages where the æsthetic sense
has subdued theory to itself with fine effect. Thus the poet has touched
Canute’s love for Emma with symbolism, seeing her as the gentler and riper
civilization into which Canute is adopted; and again, the wild Northern land
of his origin, the elements which went to the making of his race, the secret
compulsive urge of heredity, are embodied in the figure of a weird
prophetess who is to him his other self, the incarnate spirit of those ancient
forces. The speech which follows is made by Canute when he is recalling
his first meeting with Emma. There are passages with her, love-scenes
between the young sea-king and the mature queen, which are adroitly and
boldly handled, and are drama in essence and in fact. But here, in a reverie,
is the poet’s opportunity for putting her theory into a symbol: