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Wilhelm Schäberle

Ultrasonography in
Vascular Diagnosis
A Therapy-Oriented
Textbook and Atlas
Third Edition

123
Ultrasonography in Vascular Diagnosis
Wilhelm Schäberle

Ultrasonography in
Vascular Diagnosis
A Therapy-Oriented Textbook and Atlas

Third Edition
Wilhelm Schäberle
Department of Visceral, Vascular, Thoracic, and Pediatric Surgery
Alb Fils Kliniken
Göppingen, Germany

Translated by Bettina Herwig

Berlin, Germany

The Work was first pulished in 2016 by Springer-Verlag GmbH with the following title: Ultraschall in der
Gefäßdiagnostik, 4. Auflage. © Springer-Verlag Berlin Heidelberg 2016

ISBN 978-3-319-64996-2 ISBN 978-3-319-64997-9 (eBook)

https://doi.org/10.1007/978-3-319-64997-9

Library of Congress Control Number: 2018954360

© Springer International Publishing AG, part of Springer Nature 2005, 2011, 2018
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, com-
puter software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply,
even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations
and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to
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The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by the registered company Springer International Publishing AG part of Springer Nature
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
V

To my wife Solange and my children Jan and Philip

Preface to the Third English
and Fourth German Edition

The third English edition of this textbook continues captured in the Doppler waveform. New case
to promote the ultrasound philosophy already advo- examples and drawings have been added to teach
cated by its successful predecessors. A brief outline is readers how to interpret Doppler waveforms and
provided in the earlier prefaces, particularly that of make the most of what they can tell us about the
the second English edition (third German edition). underlying vascular disease.
This new edition discusses the latest scientific
insights, and the Atlas part has been supplemented Recent scientific study results are discussed paying
by new instructive teaching cases. As before, the special attention to their value for the clinician and
author attaches great importance to the therapeutic discussing differences among the various imaging
consequences that derive from abnormal ultrasound modalities used for vascular diagnosis and dis-
findings. The basic principle behind this approach is crepancies between the results of published ultra-
that the patient’s clinical findings, in conjunction sound studies. In his critical appraisal, the author
with the available therapeutic options, should guide points out the strengths and weaknesses of the dif-
the ultrasound examination. This principle also ferent methods, explaining discrepancies in terms
underlies the diagnostic algorithms proposed in this of different study designs, underlying physical
book and aims at providing detailed, highly resolved principles, and the laws of hemodynamics.
information on vascular pathology in a time-effi-
cient examination. Individual treatment can thus be The author wishes to thank Dr. Rupp-Heim and
planned on the basis of the sonographic findings, Dr. Knödler, who provided radiological images
and many patients do not need additional imaging for comparison with ultrasound findings, and
tests. Such algorithms are presented for the sonog Dr. Meinrenken for editorial assistance and other
raphic evaluation of patients with a hemodialysis support throughout this project. Many thanks are
access fistula, the diagnosis of PAOD, the ultrasound also due to Ms. Herwig for her expert translation
examination of the carotid arteries, sonographic fol- and tremendous support in preparing the new
low-up after stenting, and the diagnostic assessment English version. Last but not least, I would like to
and measurement of abdominal aortic aneurysm. express my thanks to the publishers, Springer-
Supplementary sonographic options such as con- Verlag, and in particular to Mr. Q uinones,
trast-enhanced ultrasound are discussed in greater Dr. Heilmann, Mr. Bachem, and Ms. Beisel, for
detail and illustrated with figures to show their their cooperation in preparing the new German
potential but also their limitations. and English editions of this textbook.

A patient’s clinical symptoms are not only due to A final word belongs to my family. A project of
morphologic vascular changes but are primarily this kind means less time spent as a family, and I
the consequence of pathological and in part intri- therefore dedicate this edition to my wife and
cate hemodynamic changes, which are best children.

Wilhelm Schäberle
Göppingen, Germany
November 2017
VII

Preface to the Second English

and Third German Edition

The longer and the more intensively one has been In terms of method and didactic approach this sec-
working with medical imaging, the more questions ond English edition continues in the tradition of
of a broader, more general kind one is confronted the earlier German editions and of the first English
with: How well does the image represent the truth? edition and emphasizes the therapeutic relevance
Can our interpretation of the imaging findings of the diagnostic measures being taken. For details
explain the patient’s disease? Which imaging appear- on this approach please refer to the earlier prefaces.
ances mean that the patient requires treatment, and Staying in the same pedagogical vein but seeking to
if so, which treatment? When does imaging (includ- advance this method further, this extensively
ing incidental findings) lead to unnecessary inter- revised edition incorporates even more diagrams
ventions – due to users not being aware of the and tables. The hope is that this will help make
intrinsic problems of a diagnostic method or failing examination protocols and complex diagnostic
to take its inherent limitations into account? These procedures even easier to visualize and understand.
issues are relevant for all diagnostic modalities, This new edition presents the most recent scientific
including the traditional gold standard of angiogra- insights as well as new developments in ultrasound
phy and more recent developments such as mag- technology, which are discussed with regard to
netic resonance and computed tomography their role in providing therapeutically relevant
angiography. Applied to diagnostic ultrasonography, diagnostic information for treating patients with
the more specific question that arises is how we mis- vascular disease. On points where there is no clear
interpret echo patterns or ultrasound features and consensus regarding the diagnostic status of cer-
consequently make erroneous treatment decisions. tain ultrasound features and findings, these contro-
These problems become particularly manifest when versies are discussed. The atlas sections of the
dealing with the morphology of internal carotid individual chapters have also been expanded to
artery plaque, where the sonographic appearance of include even more examples of ultrasound findings
the plaque may be used as a criterion for making obtained in the routine clinical setting, along with
treatment recommendations. In the name of scien- examples of less common vascular diseases. A
tific rigor investigators sometimes end up focusing focus here is on showing the reader how to inter-
too heavily on a single aspect of a complex problem, pret Doppler waveforms and how to use the hemo-
in turn giving rise to specific assumptions and dynamic information to help make a diagnosis. As
hypotheses that affect the study design and ulti- a little cultural aside, color flow ultrasound can also
mately lead to wrong, contradictory, and biased be counted on to produce images with highly artis-
results, as well as to the wrong therapeutic conclu- tic color compositions. My 4-year-old son’s com-
sions. Despite these cautionary remarks, however, ment, upon seeing the proofs of the book, was,
there is good scientific evidence that vascular duplex “Your new art book is really beautiful.”
ultrasonography – as long as both the morphologic
appearance and hemodynamic findings are taken The author would like to thank Ms Zorn, Ms
into account and as long as the examiner remains Rieker, Ms Mehlbeer, and Ms Lietz for secretarial
critically aware of the methodological basis – comes assistance. My thanks are also due to Ms Mütschele
very close to depicting the true clinical situation in for her support in preparing the diagrams and fig-
patients with vascular disease. Although somewhat ures. Thank you also to Ms Herwig for the transla-
neglected by some “schools of ultrasound,” where tion and excellent support through all stages of
color flow images (which are more angiography- preparing this English edition. Further, I would
like) are preferred, spectral Doppler analysis can like to thank the staff of Springer-Verlag for their
provide some very valuable information. In particu- excellent support in preparing this new edition,
lar it can depict the hemodynamic situation (in both particularly Ms Heilmann and Mr Bachem. Most
normal and diseased vessels) with excellent sensitiv- of all, however, I would like to thank my family for
ity, making it highly useful in the diagnostic assess- their patience and understanding and for the
ment of vascular disease and in solving problems of humor that is necessary and makes it easier to pull
differential diagnosis. off a project like this.

Wilhelm Schäberle
Göppingen, Germany
November 2010
Preface to the First English Edition

Vascular ultrasonography becomes increasingly the details of the surgical procedure, i.e., identifi-
valuable the more the diagnostic query to be cation of a suitable recipient vessel for a bypass
answered is based on the clinical findings and the graft. Some surgical procedures such as thrombo-
more the examination is performed with regard to endarterectomy of the carotid arteries or femoral
its therapeutic consequences. As with other spe- bifurcation can be performed without prior angi-
cialties that make use of ultrasound findings, the ography, which does not provide any additional
diagnostic yield of vascular ultrasound relies cru- information that would affect the surgical strategy.
cially on the close integration of the examination Duplex sonography has evolved into the gold stan-
into the routine of the clinician or physician treat- dard for answering most queries pertaining to
ing the patient. That is why in the German- venous conditions (therapeutic decision-making
speaking countries, vascular ultrasound is chiefly in thrombosis, planning of the surgical interven-
performed by angiologists and vascular surgeons. tion for varicosis, chronic venous insufficiency).
Duplex ultrasound can indeed be regarded as an
integral component of the angiologic examination Special emphasis is placed on the therapy-oriented
or an extension of the clinical examination by presentation of indications for vascular ultraso-
fairly simple technical means. Thus the sonog nography, including the sonographic differentia-
raphic findings do not simply supplement other tion of rare vascular pathology and the role of the
imaging modalities but, together with the clinical ultrasound examination in conjunction with the
findings, provide the basis for deciding whether patient’s clinical findings. The abundant images
medical therapy, a radiologic intervention, or sur- provided are intended to facilitate morphologic
gical reconstruction is the most suitable therapy and hemodynamic vascular evaluation and put the
for an individual patient. This means that in a reader in a position to become more confident in
patient with atherosclerotic occlusive disease of identifying rare conditions as well, which often
the leg arteries, the patient’s clinical presentation have a characteristic appearance and are thus rec-
determines whether or not surgical repair is neces- ognizable at a glance. The high acceptance of the
sary, while the duplex sonographic findings serve diagnostic concept advocated here as reflected in
to plan the kind of repair required and to confirm the success of the first two editions of the book in
the localization and extent of the vascular pathol- the German-speaking countries led to the decision
ogy suspected on clinical grounds. Up to this to have an English edition. I would like to thank
point, no invasive diagnostic tests are needed. Springer-Verlag, in particular Dr. Heilmann, for
Angiography continues to have a role in planning making this English edition possible.

Wilhelm Schäberle
Göppingen, Germany
August 2005
IX

Preface to the Second German Edition

Vascular duplex sonography is the continuation of invasive vascular reconstruction. Duplex sonogra-
the clinical examination of vascular disease by phy has replaced angiography in the localization of
fairly simple technical means. A sonographic a vascular obstruction and the evaluation of its
examination relies on interaction with the patient significance. The invasive radiologic modality is
and is guided by the clinical findings, therapeutic used only to identify a suitable recipient segment
relevance, and treatment options available. It is in patients scheduled for a bypass procedure or in
highly examiner-dependent and does not easily combination with a catheter-based intervention
lend itself to full documentation of the results, (PTA and stenting). The morphologic information
which are thus difficult to communicate and verify. provided on the vessel lumen and wall as well as on
For these reasons, sonographers require thorough perivascular structures makes nonatherosclerotic
training, both to avoid inaccurate findings with vascular disorders a domain of ultrasound.
disastrous consequences for patients and in order
not to discredit the method. Ultrasonography is the method of first choice in
evaluating carotid artery stenoses for stroke pre-
The format of the first edition with a text section vention by identifying those patients who would
and an atlas for each vascular territory has been benefit from surgical repair on the basis of hemo-
retained as has the subdivision of the individual dynamic parameters but also taking into account
chapters into sections on sonoanatomy, examina- morphologic information. Ultrasound can retain
tion technique, normal findings, abnormal ultra- its central role in therapeutic decision- making
sound findings, and diagnostic role of the only if its advantages are fully exploited, which
sonographic findings. Given the special focus of means that the examination should be performed
this textbook on clinically and therapeutically rel- by the angiologist or vascular surgeon who is also
evant aspects of vascular ultrasonography, each of treating the patient. This is why this second edition
the main chapters (peripheral arteries and veins, is again intended mainly for angiologists and vas-
extracranial arteries supplying the brain, hemodi- cular surgeons.
alysis shunts, and abdominal and retroperitoneal
vessels) has been supplemented with a section on The revised edition also describes recent develop-
the clinical significance of ultrasound examina- ments such as the use of ultrasound contrast
tions in the respective vascular territory. This addi- media, or echo enhancers, in angiology and the
tion was considered necessary in order to do B-flow mode although their role in the routine
justice to the expanding and changing role of diag- clinical setting is small from the angiologist’s and
nostic ultrasound since the first German edition 6 vascular surgeon’s perspective. The use of ultra-
years ago. While until only a few years ago vascular sound contrast media in differentiating liver
ultrasound was used for orientation or served as a tumors is not dealt with in detail since it is mainly
supplementary diagnostic test only, it has since of interest to gastroenterologists and visceral sur-
evolved into a key modality in this field. It has geons and would therefore go beyond the scope of
since even become a kind of gold standard in the this textbook.
diagnostic evaluation of veins, in particular in
patients with thrombosis and varicosis. In this set- As in the first edition, great care was taken in
ting, venography has lost its significance and its selecting illustrative ultrasound scans of high
use is now restricted to exceptional cases where it quality for the atlas, following the motto “an ultra-
serves to obtain supplementary information to sound image must speak for itself ”. The sonomor-
answer specific questions. phologic context is important for didactic
purposes; that is why the pathology of interest is
In patients with arterial disease, duplex ultrasound not shown in a magnified view (zoom) but pre-
is an integral part of the step-by-step diagnostic sented in the constellation in which it appears in
workup. The sonographic findings provide the key the course of a routine examination. In those set-
to adequate therapeutic management (medical tings where the sonication conditions are poor but
therapy, radiologic intervention, or vascular surgi- an ultrasound examination nevertheless appears
cal repair). Together with the patient’s clinical sta- to be indicated from a clinical perspective as in
tus, duplex sonography is thus decisive for postoperative patients, the examples shown were
establishing the indication for medical therapy or not selected specifically but are such as illustrate
X Preface to the Second German Edition

this fact. Angiograms, and in individual cases the beginner with an introduction to vascular
graphic representations, are intended to clarify the ultrasound. It is hoped that the richly illustrated
situation. atlas sections will facilitate the first steps for the
beginner. For experienced sonographers, the
The abundant images contained in the atlas sec- detailed illustrations also of rare vascular pathol-
tions reflect the intention not only to present ogy are expected to broaden their knowledge and
abnormal finding as such but to illustrate more help them diagnose rare disorders with greater
clearly situations that are relevant from a therapeu- confidence. To this end the role of ultrasound
tic perspective and to also show the development examinations is compared with that of other diag-
of vascular pathology. Adhering to the ultrasound nostic modalities and tips and tricks are described
convention of depicting cranial on the left side of that facilitate the examination and provide a basis
the image and caudal on the right, the blood flow for tackling more difficult diagnostic tasks. That is
direction is color coded in accordance with the why all diseases in which ultrasonography is indi-
defaults settings of the ultrasound equipment. This cated and that are of relevance for angiologists and
means, for instance, that the internal carotid artery vascular surgeons are represented by images in the
is coded in blue, indicating arterial blood flow atlas. Rare vascular conditions can often be identi-
away from the transducer. Following this conven- fied sonographically at a glance. Where appropri-
tion, it is thus not necessary to first have to look for ate, additional angiograms illustrate the role of the
the color key, and orientation is facilitated when respective modality in comparison, and occasion-
complex vascular territories such as the abdominal ally the situation is further clarified by an intraop-
and retroperitoneal vessels are examined. erative photograph.

The detailed introduction to the fundamental The constant support I received from Professor
physical principles of diagnostic ultrasound and R. Eisele is gratefully acknowledged. My special
basic hemodynamics under normal and abnormal thanks are due to the co-workers of Springer-
conditions as well as the detailed description of Verlag for their excellent cooperation in preparing
vascular anatomy, examination protocols, and of the second edition and to Ms. R. Mütschele for her
the interpretation of the findings aim at providing assistance in preparing the graphics.

Wilhelm Schäberle
Göppingen, Germany
February 2004
XI

Preface to the First German Edition

Conventional and color duplex ultrasonography and increasingly by vascular surgeons rather than
has evolved into an indispensable tool for the diag- by radiologists. On the basis of a patient’s clinical
nostic evaluation of vascular pathology. As a non- findings, it is thus possible to specifically address
invasive test that can be repeated any time, therapeutically relevant questions in performing
sonography is increasingly replacing conventional the sonographic examination. Besides general
diagnostic modalities that cause more discomfort assessment of the vascular status, ultrasound can
to the patient. The combination of gray-scale thus serve to acquire additional diagnostic infor-
sonographic information for evaluating topo- mation important for therapeutic decision-
graphic relationships and morphologic features of making in general and for planning the surgical
vessels with the qualitative and quantitative data procedure in particular. Duplex sonography in the
obtained with the Doppler technique enables fine hands of the clinician who is also treating the
diagnostic differentiation of vascular disorders. In patient is seen as the continuation of the clinical
particular, the hemodynamic Doppler informa- examination by technical means. That is why the
tion is a useful supplement to the findings obtained emphasis in this book is on the clinical and thera-
with radiologic modalities. Being noninvasive and peutic role of ultrasound findings, and the indi-
easy to perform any time, duplex sonography pre- vidual chapters are organized according to such
cedes more invasive, stressful, and expensive diag- pragmatic aspects.
nostic tests in the step-by-step diagnostic workup
of patients with vascular disease. It provides cru- Each of the six main chapters deals with a specific
cial information for optimal therapy and will vascular territory and consists of a text section as
replace invasive modalities such as angiography well as an atlas section with ample illustrations and
and venography as examiners gain skills and expe- detailed descriptions of normal findings, variants,
rience and ultrasound equipment becomes more and abnormal findings. Whenever considered
sophisticated. appropriate for better illustration of complex
pathology, the sonographic images have been sup-
The significance duplex ultrasonography has plemented with angiograms or CT scans. The
gained in the hands of angiologists and vascular comparison also illustrates the advantages and dis-
surgeons is also reflected in the further education advantages of the respective radiologic modalities.
programs for these specialties. This book there- As many rare vascular disorders are diagnosed at a
fore aims at providing a detailed description of glance by an experienced sonographer, their
the diagnostic information that can be obtained appearance is shown in numerous figures. Series of
by (color) duplex sonography in those vascular ultrasound scans document the course of the
territories that are relevant to angiologists and examination and complex hemodynamic changes
vascular surgeons. Each of the main chapters in vascular disorders as well as their clinical sig-
introduces beginners to the relevant vascular nificance and changes under therapy. The legends
anatomy and scanning technique while at the provide detailed descriptions allowing the reader
same time offering detailed discussions of the to use the atlas sections independently for refer-
parameters involved and a thorough review of ence when looking for information on specific
the pertinent scientific literature to help experi- vascular conditions.
enced sonographers become more confident in
establishing their diagnoses. Different ultrasound modes are described in detail
and their respective merits and shortcomings
The first chapter presents the basic hemodynamic are discussed for the benefit of readers using dif-
concepts that are relevant to vascular sonography ferent equipment. Gray-scale sonography alone
and the fundamental physical and technical prin- (compression ultrasound) is quite sufficient for
ciples of vascular ultrasonography. This introduc- the diagnostic assessment of thrombosis while
tory chapter is intended to help readers grasp the conventional duplex ultrasonography is a valid
potential and limitations of the method. modality for diagnosing therapeutically relevant
abnormal changes of the femoropopliteal ter-
The situation in Germany is different from that in ritory. In most instances, color flow images are
many other countries in that duplex sonography is shown together with the Doppler waveform but
performed primarily by angiologists, internists, occasionally “only” the conventional duplex scan
XII Preface to the First German Edition

is presented to illustrate the fact that many abnor- My special thanks are due to Professor R. Eisele for
malities can be identified by conventional duplex promoting the use of diagnostic ultrasound in the
ultrasound alone. Despite the additional diagnos- department of vascular surgery at our hospital and
tic information obtained with the color-coded for his valuable advice. I thank Ms. G. Rieker and
technique, quantitative evaluation relies on the Ms. E. Stieger and Mrs. B. Sihler for typing the
Doppler frequency spectrum. The color duplex manuscript and Ms. R. Uhlig for the photographic
mode can facilitate the examination procedure work in preparing the figures.
(identification of small vessels, recanalization,

differential diagnosis) but the sonographer needs Finally I would like to express my thanks to the
some basic knowledge of the conventional Dop- publishers, Springer-Verlag, and in particular to
pler technique for the proper interpretation of Ms. Zeck and Dr. Heilmann, for their excellent
color flow images. cooperation and constructive support.

Wilhelm Schäberle
Göppingen, Germany
December 1997
XIII

Contents

1 Fundamental Principles�� 1

1.1 Technical Principles of Diagnostic Ultrasound�� 3
1.1.1 Gray-Scale Ultrasonography (B-Mode)�� 3
1.1.1.1 Historical Milestones�� 3
1.1.1.2 Sound Waves�� 3
1.1.1.3 Generating Ultrasound Waves�� 4
1.1.1.4 Physical Factors Affecting the Ultrasound Scan�� 4
1.1.1.4.1 Reflection and Refraction�� 4
1.1.1.4.2 Scattering and Attenuation�� 5
1.1.1.4.3 Interference�� 6
1.1.1.4.4 Diffraction�� 6
1.1.1.4.5 Attenuation and Absorption�� 6
1.1.1.5 Generating an Ultrasound Image�� 6
1.1.1.5.1 Pulse-Echo Technique�� 6
1.1.1.5.2 Time Gain Compensation�� 7
1.1.1.5.3 A-Mode�� 7
1.1.1.5.4 B-Mode�� 7
1.1.1.5.5 M-Mode�� 7
1.1.1.6 Resolution�� 8
1.1.1.7 Beam Focusing�� 9
1.1.1.8 Types of Transducers�� 9
1.1.1.8.1 Principle of Operation�� 9
1.1.1.8.2 Linear Arrays�� 10
1.1.1.8.3 Curved or Convex Arrays�� 10
1.1.1.8.4 Sector Scanners�� 10
1.1.1.8.5 Phased Arrays�� 10
1.1.1.8.6 Mechanical Sector Scanners�� 10
1.1.1.8.7 Annular Phased Arrays�� 11
1.1.1.8.8 Disadvantages of Mechanical Transducers�� 11
1.1.1.9 Ultrasound Artifacts�� 11
1.1.1.9.1 Posterior Shadowing�� 11
1.1.1.9.2 Acoustic Enhancement�� 11
1.1.1.9.3 Edge Effect�� 12
1.1.1.9.4 Side Lobes�� 12
1.1.1.9.5 Reverberation Artifact�� 12
1.1.1.9.6 Geometric Distortion�� 13
1.1.2 Basic Physics of Doppler Ultrasound�� 13
1.1.2.1 Continuous Wave Doppler Ultrasound�� 15
1.1.2.2 Pulsed Wave Doppler Ultrasound/Duplex Ultrasound�� 15
1.1.2.3 Frequency Processing�� 16
1.1.2.4 Blood Flow Measurement�� 17
1.1.3 Physical Principles of Color-Coded Duplex Ultrasound�� 20
1.1.3.1 Velocity Mode�� 20
1.1.3.2 Power Doppler Mode�� 23
1.1.3.3 B-Flow Mode (Brightness Flow)�� 24
1.1.3.4 Intravascular Ultrasound�� 25
1.1.3.5 Three-Dimensional/Four-Dimensional Ultrasound�� 26
1.1.4 Factors Affecting (Color) Duplex Imaging – Pitfalls�� 26
1.1.4.1 Scattering and Acoustic Shadowing�� 26
1.1.4.2 Mirror Artifact�� 26
1.1.4.3 Maximum Flow Velocity Detectable – Pulse Repetition Frequency�� 26
1.1.4.4 Minimum Flow Velocity Detectable – Wall Filter, Frame Rate�� 30
1.1.4.5 Transmit and Receive Gain�� 30
1.1.4.6 Doppler Angle�� 32
XIV Contents

1.1.4.7 Physical Limitations of Color Duplex Ultrasound�� 32

1.1.5 Ultrasound Contrast Agents�� 33
1.1.5.1 Approved Ultrasound Contrast Agents and Uses�� 33
1.1.5.2 Mechanisms of Action�� 34
1.1.5.3 Ultrasound Techniques Using Contrast Agents�� 35
1.1.5.3.1 Contrast-Enhanced Duplex Ultrasound�� 35
1.1.5.3.2 Contrast Harmonic Imaging�� 35
1.1.5.3.3 Stimulated Acoustic Emission Imaging�� 35
1.1.5.4 Summary of Technical Aspects and Clinical Indications�� 35
1.1.6 Safety of Diagnostic Ultrasound�� 36
1.1.6.1 Thermal Effects�� 36
1.1.6.2 Mechanical Effects�� 36
1.1.6.3 Specific Risks of Individual Ultrasound Techniques�� 36
1.1.6.3.1 B-Mode�� 36
1.1.6.3.2 M-Mode�� 36
1.1.6.3.3 CW Doppler�� 36
1.1.6.3.4 PW Doppler�� 37
1.1.6.3.5 Color Doppler�� 37
1.1.6.4 Conclusion�� 37
1.2 Hemodynamic Principles�� 37
1.2.1 Laminar Flow�� 37
1.2.2 Flow Profiles and Perfusion Regulation�� 40
1.2.2.1 Low-Resistance Flow�� 40
1.2.2.2 High-Resistance Flow�� 40
1.2.2.3 Perfusion Regulation�� 42
1.2.3 Stenosis Grading and Blood Flow Measurement�� 42
1.2.3.1 Poststenotic Parameters�� 47
1.2.3.1.1 Acceleration Time – Resistive Index�� 47
1.3 Machine Settings�� 47

2 Extremity Arteries�� 51
2.1 Pelvic and Leg Arteries�� 53
2.1.1 Vascular Anatomy�� 53
2.1.1.1 Pelvic Arteries�� 53
2.1.1.2 Leg Arteries�� 53
2.1.2 Examination Protocol and Technique�� 55
2.1.2.1 Pelvic Arteries�� 55
2.1.2.2 Leg Arteries�� 56
2.1.3 Specific Aspects of the Examination from the Perspective of the Angiologist and Vascular Surgeon�� 61
2.1.4 Interpretation and Documentation�� 64
2.1.5 Normal Duplex Ultrasound of Pelvic and Leg Arteries�� 64
2.1.6 Abnormal Findings�� 65
2.1.6.1 Atherosclerotic Occlusive Disease�� 65
2.1.6.1.1 Pelvic Arteries�� 67
2.1.6.1.2 Time-Efficient Examination Based on Waveform Analysis�� 68
2.1.6.1.3 Stenosis Grading�� 70
2.1.6.1.4 Leg Arteries�� 71
2.1.6.1.5 Stenosis Grading: Ultrasound Versus Angiography�� 75
2.1.6.1.6 Role of Collateralization in Stenosis Grading�� 77
2.1.6.1.7 Effects of Collateralization on Pre- and Postocclusive Spectral Doppler Waveforms�� 78
2.1.6.1.8 Plaque Configuration and Stenosis Degree�� 79
2.1.6.1.9 Profunda Femoris Artery�� 81
2.1.6.1.10 Spectral Doppler Imaging below the Knee�� 83
2.1.6.1.11 Role of Contrast-Enhanced Ultrasound�� 84
2.1.6.1.12 Identification of Pedal Target Artery for Bypass Grafting�� 85
2.1.6.1.13 Multilevel Obstruction�� 85
2.1.6.1.14 Arterial Occlusion�� 85
2.1.6.2 Arterial Embolism�� 88
XV
Contents

2.1.6.3 Aneurysm�� 89
2.1.6.3.1 True Aneurysm�� 89
2.1.6.3.2 Pseudoaneurysm�� 89
2.1.6.4 Rare Stenosing Arterial Diseases of Nonatherosclerotic Origin�� 92
2.1.6.4.1 Adventitial Cystic Disease�� 93
2.1.6.4.2 Popliteal Artery Entrapment Syndrome�� 95
2.1.6.4.3 Raynaud’s Disease�� 98
2.1.6.4.4 Paraneoplastic Disturbance of Acral Perfusion�� 98
2.1.6.4.5 Buerger’s Disease�� 98
2.1.6.4.6 Vascular Inflammatory Disease�� 99
2.1.6.4.7 Dissection�� 100
2.1.6.4.8 Arteriovenous Fistulas�� 100
2.1.6.4.9 Chronic Recurrent Compartment Syndrome of the Calf�� 100
2.1.7 Follow-Up After Surgical and Interventional Treatment�� 102
2.1.7.1 Thromboendarterectomy�� 102
2.1.7.2 Percutaneous Transluminal Angioplasty and Stenting�� 102
2.1.7.3 Bypass Graft Surveillance�� 104
2.1.7.3.1 Methodological Considerations and Stenosis Criteria�� 105
2.1.7.3.2 Controversy About the Benefit of Duplex Bypass Graft Surveillance Programs�� 107
2.1.7.4 Ultrasound Vein Mapping Prior to Peripheral Bypass Surgery�� 110
2.1.8 Role of (Color) Duplex Ultrasound Compared with Other Modalities: Problems and Pitfalls�� 112
2.1.8.1 Comparison of Hemodynamic and Morphologic Imaging Modalities�� 114
2.2 Arm Arteries�� 116
2.2.1 Vascular Anatomy�� 116
2.2.2 Examination Protocol and Technique�� 117
2.2.3 Clinical Role of Duplex Ultrasound�� 118
2.2.3.1 Atherosclerosis�� 118
2.2.3.2 Vascular Compression Syndromes�� 118
2.2.4 Documentation�� 119
2.2.5 Normal Findings�� 119
2.2.6 Abnormal Findings, Duplex Ultrasound Measurements, and Clinical Role�� 119
2.2.6.1 Atherosclerosis�� 119
2.2.6.2 Vascular Compression Syndromes�� 120
2.2.6.3 Vascular Inflammatory Disease�� 122
2.2.6.4 Buerger’s Disease�� 122
2.2.6.5 Raynaud’s Disease�� 122
2.3 Atlas: Extremity Arteries�� 124

3 Extremity Veins�� 167

3.1 Pelvic and Leg Veins�� 169
3.1.1 Vascular Anatomy�� 169
3.1.2 Examination Protocol�� 171
3.1.2.1 Thrombosis�� 171
3.1.2.1.1 Equipment�� 171
3.1.2.1.2 Patient Positioning�� 171
3.1.2.1.3 Examination Technique�� 172
3.1.2.2 Chronic Venous Insufficiency and Varicosis�� 174
3.1.3 Normal Findings�� 176
3.1.4 Documentation�� 177
3.1.4.1 Deep Vein Thrombosis of the Leg�� 177
3.1.4.2 Chronic Venous Insufficiency and Varicosis�� 178
3.1.5 Clinical Role of Duplex Ultrasound�� 178
3.1.5.1 Thrombosis and Postthrombotic Syndrome�� 178
3.1.5.1.1 Leg Vein Thrombosis�� 178
3.1.5.1.2 Chronic Venous Insufficiency/Postthrombotic Syndrome�� 181
3.1.5.2 Varicosis�� 182
3.1.6 Duplex Ultrasound: Diagnostic Criteria, Indications, and Role�� 184
XVI Contents

3.1.6.1 Thrombosis�� 184

3.1.6.1.1 Controversy About the Ultrasound Strategy in Suspected Deep Vein Thrombosis�� 192
3.1.6.1.2 Additional Examination of the Asymptomatic Leg�� 194
3.1.6.1.3 Pulmonary Embolism�� 194
3.1.6.1.4 Diagnostic Tests Supplementing Compression Ultrasound�� 195
3.1.6.1.5 Thrombus Age�� 198
3.1.6.1.6 Recurrent Thrombosis�� 198
3.1.6.2 Chronic Venous Insufficiency�� 200
3.1.6.3 Varicosis�� 204
3.1.6.3.1 Treatment Options�� 207
3.1.6.4 Varicophlebitis�� 208
3.1.7 Rare Venous Disorders�� 210
3.1.7.1 Venous Aneurysm�� 210
3.1.7.1.1 Sonographic Workup�� 210
3.1.7.1.2 Prevalence of Venous Aneurysms in Ultrasound Studies�� 212
3.1.7.1.3 Therapeutic Relevance of Sonographically Detected Venous Aneurysms�� 212
3.1.7.2 Tumors of the Vein Wall�� 213
3.1.7.3 Venous Compression�� 213
3.1.7.4 Venous Adventitial Cystic Disease�� 213
3.1.7.5 Differential Diagnosis: Lymphedema, Lipedema�� 214
3.1.8 Vein Mapping�� 215
3.1.9 Diagnostic Role of Ultrasound�� 216
3.1.9.1 Deep Vein Thrombosis�� 216
3.1.9.1.1 Ultrasound Versus Venography�� 217
3.1.9.1.2 Ultrasound for Follow-Up and Therapeutic Decision Making�� 218
3.1.9.2 Chronic Venous Insufficiency�� 219
3.1.9.3 Varicosis�� 221
3.2 Arm Veins and Jugular Vein�� 221
3.2.1 Vascular Anatomy�� 221
3.2.2 Examination Protocol and Technique�� 221
3.2.3 Normal Findings�� 222
3.2.4 Documentation�� 222
3.2.5 Clinical Role�� 222
3.2.6 Duplex Ultrasound Findings and Their Diagnostic Significance�� 223
3.2.7 Diagnostic Role of Duplex Ultrasound Compared with Other Modalities�� 223
3.3 Atlas: Extremity Veins�� 224

4 Arteriovenous Fistulas�� 263

4.1 Clinical Role of Arteriovenous Fistula Evaluation�� 264
4.1.1 Background�� 264
4.1.2 Diagnostic Evaluation of Patients with Abnormal and Surgically Created Fistulas�� 264
4.1.2.1 Types of AV Fistulas�� 264
4.1.2.2 Creation of a Hemodialysis Access�� 264
4.1.2.3 Indications for Color Duplex Ultrasound�� 265
4.2 Examination Protocol, Technique, and Diagnostic Role�� 266
4.2.1 Congenital and Acquired Fistulas�� 266
4.2.2 Hemodialysis AV Fistula�� 267
4.2.2.1 Time-Efficient Ultrasound Workup of Hemodialysis Access Problems�� 268
4.3 Doppler Waveform Changes Characteristic of AV Fistulas�� 269
4.4 Fistula Maturation and Flow Volume Measurement�� 269
4.5 Documentation�� 270
4.6 Vascular Mapping Prior to AV Fistula Creation�� 270
4.7 Hemodialysis Access Complications�� 271
4.7.1 Hemodialysis Access Stenosis�� 271
4.7.1.1 Causes of Hemodialysis Access Stenosis�� 271
4.7.1.2 Stenosis Detection and Grading�� 271
4.7.1.3 Proximal Feeding Artery Stenosis�� 273
4.7.2 Diagnostic Evaluation for Specific Hemodialysis Access Problems�� 273
XVII
Contents

4.7.2.1 Peripheral Ischemia�� 273

4.7.2.2 Hemodialysis Access Aneurysm�� 275
4.7.2.3 Inadequate or Excessive Fistula Flow�� 275
4.7.2.4 Arm Swelling�� 277
4.8 Diagnostic Role of Duplex Ultrasound Compared with Other Modalities�� 277
4.8.1 Therapeutic Decision-Making�� 277
4.8.2 Surveillance Programs?�� 278
4.9 Atlas: Arteriovenous Fistulas�� 279

5 Extracranial Cerebral Arteries�� 291

5.1 Normal Vascular Anatomy and Important Variants�� 293
5.1.1 Carotid Arteries�� 293
5.1.2 Vertebral Arteries�� 295
5.2 Examination Technique and Protocol�� 296
5.2.1 Carotid Arteries�� 296
5.2.2 Vertebral Arteries�� 299
5.3 Documentation�� 301
5.4 Normal Findings�� 301
5.4.1 Carotid Arteries�� 301
5.4.2 Vertebral Arteries�� 302
5.5 Clinical Role of Duplex Ultrasound�� 302
5.5.1 Carotid Arteries�� 302
5.5.1.1 Stenosis Grading�� 305
5.5.1.2 Plaque Morphology�� 307
5.5.2 Vertebral Arteries�� 309
5.6 Ultrasound Criteria, Measurement Parameters, and Diagnostic Role�� 309
5.6.1 Carotid Arteries�� 309
5.6.1.1 Plaque Evaluation and Morphology�� 309
5.6.1.1.1 Intima-Media Thickness�� 309
5.6.1.1.2 Plaque Features�� 311
5.6.1.1.3 Plaque Differentiation�� 312
5.6.1.1.4 Plaque Thickness�� 314
5.6.1.1.5 Plaque Morphology: Plaque Surface�� 314
5.6.1.1.6 Plaque Echogenicity: Influencing Factors�� 316
5.6.1.1.7 Gray-Scale Analysis: Potential and Limitations�� 317
5.6.1.1.8 Carotid Plaque Characterization Using Contrast-Enhanced Ultrasound�� 318
5.6.1.2 Stenosis Quantification/Grading�� 319
5.6.1.2.1 Primary and Secondary Criteria for Carotid Stenosis Grading�� 322
5.6.1.3 Occlusion�� 332
5.6.1.3.1 Persistent Primitive Hypoglossal Artery�� 333
5.6.1.4 Postoperative Follow-Up�� 334
5.6.1.4.1 Carotid Endarterectomy (CEA)�� 334
5.6.1.4.2 Carotid Artery Stenting (CAS)�� 337
5.6.1.4.3 Scientific Discrepancies Regarding Restenosis Grading After CAS�� 337
5.6.1.4.4 Stenosis Grading Based on the Continuity Equation�� 340
5.6.1.4.5 Stent Dislocation�� 342
5.6.2 Vertebral Arteries�� 343
5.6.2.1 Stenosis�� 343
5.6.2.2 Occlusion�� 344
5.6.2.3 Dissection�� 344
5.6.2.4 Subclavian Steal Syndrome�� 345
5.7 Diagnosis of Brain Death�� 346
5.8 Rare (Nonatherosclerotic) Vascular Diseases of the Carotid Territory�� 346
5.8.1 Dissection�� 346
5.8.2 Vasculitis�� 348
5.8.2.1 Ultrasound Findings in Takayasu’s Arteritis�� 348
5.8.2.2 Ultrasound Findings in Horton’s Disease�� 349
5.8.3 Fibromuscular Dysplasia�� 350
XVIII Contents

5.8.4 Aneurysm�� 350

5.8.5 Arteriovenous Fistula�� 351
5.8.6 Idiopathic Carotidynia�� 351
5.8.7 Vasospasm�� 352
5.8.8 Compression by Tumor, Carotid Body Tumor�� 352
5.9 Diagnostic Role of Duplex Ultrasound in Evaluating the Extracranial Cerebral Arteries�� 352
5.10 Atlas: Extracranial Cerebral Arteries�� 356

6 Visceral and Retroperitoneal Vessels�� 389

6.1 Abdominal Aorta, Visceral and Renal Arteries�� 391
6.1.1 Vascular Anatomy�� 391
6.1.1.1 Aorta�� 391
6.1.1.2 Visceral Arteries�� 391
6.1.1.3 Renal Arteries�� 392
6.1.2 Examination Protocol and Technique�� 392
6.1.2.1 Aorta�� 392
6.1.2.1.1 Protocol for Ultrasound Examination of the Abdominal Aorta and Aortic Aneurysm�� 392
6.1.2.1.2 Protocol for Ultrasound Follow-Up After Endovascular Aneurysm Repair (EVAR)�� 392
6.1.2.2 Visceral Arteries�� 393
6.1.2.3 Renal Arteries�� 395
6.1.2.3.1 Ultrasound Technique�� 397
6.1.3 Normal Findings�� 397
6.1.3.1 Aorta�� 397
6.1.3.2 Visceral Arteries�� 397
6.1.3.3 Renal Arteries�� 398
6.1.4 Interpretation and Documentation�� 399
6.1.5 Clinical Role of Duplex Ultrasound�� 399
6.1.5.1 Aorta�� 399
6.1.5.1.1 Abdominal Aortic Aneurysm�� 399
6.1.5.1.2 Inflammatory and Atherosclerotic Conditions�� 400
6.1.5.2 Visceral Arteries�� 401
6.1.5.3 Renal Arteries�� 402
6.1.6 Measurement Parameters, Diagnostic Criteria, and Role of Ultrasound�� 405
6.1.6.1 Renal Arteries�� 405
6.1.6.1.1 Role of Color Duplex Ultrasound in the Detection of Renal Artery Stenosis�� 406
6.1.6.1.2 Therapy-Oriented Stenosis Grading�� 408
6.1.6.1.3 Contrast-Enhanced Ultrasound (CEUS)�� 409
6.1.6.1.4 Ultrasound Follow-Up After Renal Artery Stenting�� 409
6.1.6.1.5 Diagnostic Algorithm�� 411
6.1.6.1.6 Renal Artery Occlusion�� 412
6.1.6.1.7 Transplant Kidney�� 412
6.1.6.2 Visceral Arteries�� 414
6.1.6.2.1 Celiac Trunk�� 414
6.1.6.2.2 Visceral Artery Aneurysm�� 415
6.1.6.2.3 Dissection�� 416
6.1.6.2.4 Superior Mesenteric Artery�� 416
6.1.6.2.5 Acute Mesenteric Artery Occlusion�� 418
6.1.6.3 Aorta�� 422
6.1.6.3.1 Aortic Stenosis and Thrombosis�� 422
6.1.6.3.2 Abdominal Aortic Aneurysm�� 423
6.1.6.3.3 Specific Aspects of the Ultrasound Examination in Abdominal Aortic Aneurysm�� 423
6.1.6.3.4 Comparison of Ultrasound and Computed Tomography�� 426
6.1.6.3.5 Abdominal Aortic Aneurysm Screening: Rupture Risk�� 426
6.1.6.3.6 Aortic Dissection�� 426
6.1.6.3.7 Follow-Up After Open Surgical and Endovascular Aneurysm Repair�� 427
6.1.6.3.8 Aortitis: Retroperitoneal Fibrosis – Inflammatory Abdominal Aortic Aneurysm�� 433
XIX
Contents

6.2 Visceral and Retroperitoneal Veins�� 435

6.2.1 Vascular Anatomy�� 435
6.2.1.1 Vena Cava�� 435
6.2.1.2 Renal Veins�� 436
6.2.1.3 Portal Venous System and Hepatic Veins�� 436
6.2.2 Examination Technique�� 436
6.2.2.1 Vena Cava�� 436
6.2.2.2 Renal Veins�� 437
6.2.2.3 Portal Vein and Superior Mesenteric Vein�� 438
6.2.3 Clinical Role of Duplex Ultrasound�� 439
6.2.3.1 Renal Veins�� 439
6.2.3.2 Portal Venous System�� 439
6.2.4 Normal Findings�� 439
6.2.4.1 Vena Cava and Renal Veins�� 439
6.2.4.2 Portal Venous System�� 439
6.2.5 Documentation�� 440
6.2.6 Abnormal Ultrasound Findings, Measurement Parameters, and Diagnostic Role�� 440
6.2.6.1 Vena Cava�� 440
6.2.6.1.1 Membranous Vena Cava Obstruction�� 441
6.2.6.2 Renal Veins�� 441
6.2.6.3 Superior Mesenteric Vein and Splenic Vein�� 442
6.2.6.3.1 Splenic Vein Thrombosis�� 443
6.2.6.4 Portal and Hepatic Veins�� 443
6.2.6.4.1 Portal Vein Thrombosis�� 443
6.2.6.4.2 Portal Hypertension�� 443
6.2.6.4.3 Hepatic Veins�� 447
6.3 Atlas: Visceral and Retroperitoneal Vessels�� 449

7 Penile and Scrotal Vessels�� 491

7.1 Vascular Anatomy�� 492
7.1.1 Penile Vessels�� 492
7.1.2 Scrotal Vessels�� 493
7.2 Examination Technique�� 493
7.2.1 Erectile Dysfunction�� 493
7.2.1.1 Ultrasound Examination�� 493
7.2.2 Scrotal Vessels�� 494
7.3 Normal Findings�� 494
7.3.1 Penile Vessels�� 494
7.3.2 Scrotal Vessels�� 494
7.4 Documentation�� 495
7.5 Clinical Role of Duplex Ultrasound�� 495
7.5.1 Erectile Dysfunction�� 495
7.5.1.1 Pathophysiology of Erectile Dysfunction�� 495
7.5.2 Acute Scrotum�� 495
7.5.3 Varicocele�� 496
7.6 Abnormal Findings: Role of Duplex Ultrasound Parameters�� 496
7.6.1 Erectile Dysfunction�� 496
7.6.2 Acute Scrotum�� 497
7.6.3 Varicocele�� 498
7.7 Atlas: Penile and Scrotal Vessels�� 499

Supplementary Information
References�� 504
Subject Index�� 537
1 1

Fundamental Principles
1.1 Technical Principles of Diagnostic Ultrasound – 3
1.1.1 Gray-Scale Ultrasonography (B-Mode) – 3
1.1.1.1 Historical Milestones – 3
1.1.1.2 Sound Waves – 3
1.1.1.3 Generating Ultrasound Waves – 4
1.1.1.4 Physical Factors Affecting the Ultrasound Scan – 4
1.1.1.4.1 Reflection and Refraction – 4
1.1.1.4.2 Scattering and Attenuation – 5
1.1.1.4.3 Interference – 6
1.1.1.4.4 Diffraction – 6
1.1.1.4.5 Attenuation and Absorption – 6
1.1.1.5 Generating an Ultrasound Image – 6
1.1.1.5.1 Pulse-Echo Technique – 6
1.1.1.5.2 Time Gain Compensation – 7
1.1.1.5.3 A-Mode – 7
1.1.1.5.4 B-Mode – 7
1.1.1.5.5 M-Mode – 7
1.1.1.6 Resolution – 8
1.1.1.7 Beam Focusing – 9
1.1.1.8 Types of Transducers – 9
1.1.1.8.1 Principle of Operation – 9
1.1.1.8.2 Linear Arrays – 10
1.1.1.8.3 Curved or Convex Arrays – 10
1.1.1.8.4 Sector Scanners – 10
1.1.1.8.5 Phased Arrays – 10
1.1.1.8.6 Mechanical Sector Scanners – 10
1.1.1.8.7 Annular Phased Arrays – 11
1.1.1.8.8 Disadvantages of Mechanical Transducers – 11
1.1.1.9 Ultrasound Artifacts – 11
1.1.1.9.1 Posterior Shadowing – 11
1.1.1.9.2 Acoustic Enhancement – 11
1.1.1.9.3 Edge Effect – 12
1.1.1.9.4 Side Lobes – 12
1.1.1.9.5 Reverberation Artifact – 12
1.1.1.9.6 Geometric Distortion – 13
1.1.2 Basic Physics of Doppler Ultrasound – 13
1.1.2.1 Continuous Wave Doppler Ultrasound – 15
1.1.2.2 Pulsed Wave Doppler Ultrasound/Duplex Ultrasound – 15
1.1.2.3 Frequency Processing – 16

© Springer International Publishing AG, part of Springer Nature 2018

W. Schäberle, Ultrasonography in Vascular Diagnosis, https://doi.org/10.1007/978-3-319-64997-9_1
1.1.2.4 Blood Flow Measurement – 17
1.1.3 Physical Principles of Color-Coded Duplex Ultrasound – 20
1.1.3.1 Velocity Mode – 20
1.1.3.2 Power Doppler Mode – 23
1.1.3.3 B-Flow Mode (Brightness Flow) – 24
1.1.3.4 Intravascular Ultrasound – 25
1.1.3.5 Three-Dimensional/Four-Dimensional Ultrasound – 26
1.1.4 Factors Affecting (Color) Duplex Imaging – Pitfalls – 26
1.1.4.1 Scattering and Acoustic Shadowing – 26
1.1.4.2 Mirror Artifact – 26
1.1.4.3 Maximum Flow Velocity Detectable – Pulse Repetition
Frequency – 26
1.1.4.4 Minimum Flow Velocity Detectable – Wall Filter, Frame Rate – 30
1.1.4.5 Transmit and Receive Gain – 30
1.1.4.6 Doppler Angle – 32
1.1.4.7 Physical Limitations of Color Duplex Ultrasound – 32
1.1.5 Ultrasound Contrast Agents – 33
1.1.5.1 Approved Ultrasound Contrast Agents and Uses – 33
1.1.5.2 Mechanisms of Action – 34
1.1.5.3 Ultrasound Techniques Using Contrast Agents – 35
1.1.5.3.1 Contrast-Enhanced Duplex Ultrasound – 35
1.1.5.3.2 Contrast Harmonic Imaging – 35
1.1.5.3.3 Stimulated Acoustic Emission Imaging – 35
1.1.5.4 Summary of Technical Aspects and Clinical Indications – 35
1.1.6 Safety of Diagnostic Ultrasound – 36
1.1.6.1 Thermal Effects – 36
1.1.6.2 Mechanical Effects – 36
1.1.6.3 Specific Risks of Individual Ultrasound Techniques – 36
1.1.6.3.1 B-Mode – 36
1.1.6.3.2 M-Mode – 36
1.1.6.3.3 CW Doppler – 36
1.1.6.3.4 PW Doppler – 37
1.1.6.3.5 Color Doppler – 37
1.1.6.4 Conclusion – 37

1.2 Hemodynamic Principles – 37

1.2.1 Laminar Flow – 37
1.2.2 Flow Profiles and Perfusion Regulation – 40
1.2.2.1 Low-Resistance Flow – 40
1.2.2.2 High-Resistance Flow – 40
1.2.2.3 Perfusion Regulation – 42
1.2.3 Stenosis Grading and Blood Flow Measurement – 42
1.2.3.1 Poststenotic Parameters – 47
1.2.3.1.1 Acceleration Time – Resistive Index – 47

1.3 Machine Settings – 47

1.1 · Technical Principles of Diagnostic Ultrasound
3 1
1.1 echnical Principles of Diagnostic
T
Ultrasound

1.1.1 Gray-Scale Ultrasonography (B-Mode)

1.1.1.1 Historical Milestones

The potential for using the reflection of ultrasound in the
visualization of the internal organs of the human body was
recognized about 80 years ago. The first attempts at using
ultrasound in medical diagnosis were made in the late 1930s
by the Austrian neurologist K.T. Dussik. He developed Elongation
what he referred to as hyperphonography, a sonographic
transmission technique for the visualization of the cerebral
ventricles. Also in the 1940s, American scientists began
Compression Expansion
experimenting with ultrasound reflection to examine bio-
logical objects. Among the early pioneers were Ludwig and
Struthers, who used this new technique for detecting gall-
stones. Other important milestones in the history of diag-
.. Fig. 1.1 Diagram of the propagation of a longitudinal wave illus-
nostic ultrasound were the development of B-mode imaging
trating cyclic compression and expansion (Courtesy of Hitachi Ltd.,
by Howry and Bliss and the introduction of the echo pulse which also provided the historical material presented in 7 Sect. 1.1.1.1)
method by Leksell in Sweden, which he used to determine
the position of midline brain structures in the intact skull,
thus marking the start of echoencephalography. In 1954,
.. Table 1.1 Typical sound velocities, densities, and attenu-
Edler and Herz presented the first description of M-mode ation values in some important biological tissues and other
echocardiography. media in the body
The Japanese physicist Satomura is credited with imple-
menting the first medical applications of the Doppler prin- Medium Sound Density Attenuation
velocity (m/s) (g/cm2) (dB/MHz cm)
ciple. He and his colleagues investigated the use of Doppler
frequency shifts to evaluate moving cardiac structures and to Fat 1470 0.97 0.5
measure the velocity of red blood cells. The advent of the first
real-time scanner, developed by Krause and Soldner, com- Bone marrow 1700 0.97 –
pletely changed the practice of medical ultrasound scanning Muscle 1568 1.04 2
and marks yet another important step in the success story of
Liver 1540 1.055 0.7
diagnostic ultrasound.
Modern ultrasound offers excellent image quality and Brain 1530 1.02 1
diagnostic capabilities, with its outstanding position among Bone (compact) 3600 1.7 4–10
radiologic imaging techniques being due to its versatility, low
Water (20°C) 1492 0.9982 0.002
cost, flexibility, and safety.
This chapter introduces the physical and technical fun- Air 331 0.0013 –
damentals of medical ultrasound and outlines the range of
techniques available today, which will help readers to make
optimal use of the diagnostic capabilities of ultrasound and
rise to longitudinal waves (along the direction of travel) and
choose the best technique for the intended application.
transverse waves (perpendicular to the direction of travel).
Particles excited in the ultrasound range vibrate around their
1.1.1.2 Sound Waves resting positions at a rate of 20,000 to one billion times per
When a molecule is activated to vibrate around its equilib- second.
rium position, the vibration is transmitted to a neighbor in In gases and liquids, only longitudinal wave propagation
the medium and from there to the next molecule and so on. is possible, as the shear forces necessary for the spread of
In this way, kinetic energy is propagated from one molecule transverse vibration are absent. In physical terms, biological
to the next, spreading through the medium in a sine wave tissues can be viewed as viscous fluids, which is why the effect
pattern. This pattern of the spreading of kinetic energy is of transverse waves is negligible. In such a medium the speed
known as a continuous wave or an acoustic wave (sound of sound increases with density, which in turn is defined by
wave). A sound wave alternately compresses (positive pres- the force of molecular cohesion (. Table 1.1). The average
sure) and expands (negative pressure) the medium it travels speed of sound in biological tissues is approx. 1540 m/s.
through (. Fig. 1.1). Particles can vibrate parallel or per- Waves can be described with reference to several proper-
pendicular to the direction of energy propagation, giving ties. Wavelength λ is the distance between two consecutive
4 Chapter 1 · Fundamental Principles

on one side and positive on the other. As the degree of stress

1 .. Table 1.2 Commonly used transmit frequencies and result-
ing properties of the ultrasound beam
increases, so does the voltage. Conversely, when a positive
or negative voltage is applied to the surface of a piezoelec-
Transmit Wave- Penetra- Lateral Axial tric crystal, the material expands or contracts, depending on
frequency length tion resolu- resolu- the direction of the current. When an alternating current is
(MHz) (mm) depth tion tion applied, the piezoelectric crystal is activated and begins to
(cm) (mm) (mm)
vibrate. Materials possessing strong piezoelectric properties
2 0.78 25 3 0.8 are quartz and tourmaline. State-of-the-art transducers use
semicrystalline polymers such as polyvinylidene fluoride
3.5 0.44 14 1.7 0.5
(PVDF).
5 0.31 10 1.2 0.35
1.1.1.4 hysical Factors Affecting
P
7.5 0.21 6.7 0.8 0.25
the Ultrasound Scan
10 0.16 5 0.6 0.2 An ultrasound image is created by processing the echoes
15 0.1 3.3 0.4 0.15 returning to the transducer from various depths of the
body upon emission of an ultrasound pulse of a specific
The following relationships exist between these parameters: frequency (. Fig. 1.2a). A two-dimensional (2D) image is
the higher the transmit frequency (and therefore the shorter
generated from adjacent ultrasound lines. Two-dimensional
the wavelength), the higher the resolution – but the lower the
penetration depth morphologic images are acquired by applying short pulses
of energy using only a small number of wavelengths to
optimize spatial resolution. The round trip time is the time
delay between the emission of an ultrasound pulse and the
return of the reflected echo and is a function of the distance
.. Table 1.3 Parameters defining a sound wave
between the transducer and reflector. Reflection occurs at
Property Definition the boundaries between media that differ in their sound
propagation properties, or acoustic impedance. Hence,
Period Duration of a complete vibration an ultrasound image does not represent tissue structures
Wavelength Spatial extension of a period directly but rather interfaces between tissues of different
acoustic impedance. Acoustic impedance describes the
Frequency Number of periods per second
frequency-dependent resistance that an ultrasound beam
Amplitude Measure of sound energy encounters as it passes through a tissue. It is equal to the
speed of sound propagation multiplied by the density of the
tissue. The greater the difference in impedance, the greater
points of maximum compression, and frequency f is the the reflection of the ultrasound wave (and therefore the
number of vibrations of a molecule per unit time, given in greater the strength of the echo or signal) and the smaller its
hertz (Hz). One hertz corresponds to one cycle per second, transmission into deeper tissue (. Fig. 1.2a). Other physi-
or 1 Hz = 1/s. The frequency range of diagnostic ultrasound cal processes besides reflection and scattering that affect
is 2–30 MHz. The speed of a sound wave, C, is the product of the ultrasound scan are refraction, interference, diffraction,
wavelength and frequency: attenuation, and absorption.

C =l× f 1.1.1.4.1 Reflection and Refraction

The propagation of sound waves in biological tissues is gov-
The wavelengths occurring in diagnostic ultrasound are erned by the laws of wave optics. Tissues vary in density and
determined by the frequency emitted by the transducer (car- hence differ in acoustic impedance. Impedance Z is the prod-
rier frequency) and range from 0.78 to 0.15 mm over the uct of the density of a medium and the speed of sound in it.
2–10 MHz frequency range typically used in vascular imag- At an acoustic interface in the body, an incident ultrasound
ing (. Table 1.2). The properties defining a sound wave are beam is partially reflected and partially refracted. Refraction
summarized in . Table 1.3. means that the wave passes through the interface, changing
its direction of travel (. Fig. 1.2b). The difference in acous-
1.1.1.3 Generating Ultrasound Waves tic impedance between the two tissues forming the interface
In most ultrasonic transducers for medical imaging, the determines how much of the beam is reflected and how
piezoelectric effect discovered by Pierre and Jacques Curie much is transmitted: the greater the difference, the greater
in 1880 is used to generate ultrasound waves. When mechan- the amount of energy that is reflected back; the smaller the
ical stress is applied to piezoelectric materials such as ionic difference, the greater the amount of energy that is transmit-
crystals, they experience an elastic deformation which results ted. Medical ultrasound thus functions like a sonar, exploit-
in a shift in internal charge distribution. In this way, electric ing differences in acoustic impedance between two adjacent
voltages are generated at the surfaces – which are negative tissues rather than absolute acoustic properties.
1.1 · Technical Principles of Diagnostic Ultrasound
5 1

Beam perpendicular to interface

Interface
Reflection
Refraction
a'
a'

Reflection Transmission Impedance mismatch

Stronger when the impedance Stronger when the impedance
mismatch is large mismatch is small
Z1 Z2
Sonar and medical ultrasound rely on:
difference in acoustic impedance between two
a tissues/media b

.. Fig. 1.2 a Generation of an ultrasound image: reflection – transmission. b Interaction of ultrasound with interfaces in the body according to
the laws of wave optics (for details see text) (Courtesy of Hitachi Ltd.)

The reflection gradient, R, is given by the following equa- scattered when it strikes an object that is much smaller than
tion for incident angles perpendicular to an interface: its wavelength, and it is reflected when it strikes an object
much larger than its wavelength. Scattering gives rise to the
2
æ Z1 - Z 2 ö characteristic echotexture of parenchymal organs in ultra-
R=ç ÷
è Z1 + Z 2 ø sound images.
Since structures perpendicular to the beam are rare in
For an ultrasound beam striking the interface between liver clinical ultrasound examinations, an ultrasound image is
tissue (Z1 = 1.66 × 105) and renal tissue (Z2 = 1.63 × 105), chiefly generated from a mixture of reflected and scattered
the equation yields a reflection gradient of R = 0.000008, echoes. Aggregations of tissue cells scatter the beam diffusely
meaning that this boundary reflects less than one hundred in all directions. Therefore, a structure appears bright and is
thousandth of the incident energy. In contrast, nearly all of clearly defined when it is perpendicular to the ultrasound
the incident energy (over 99%) is reflected from the inter- beam because the image information is mainly derived from
face between fatty tissue and air (Z1 = 1.42 × 105, Z2 = 43, reflected echoes; its visualization is weaker and less bright
R = 0.9987), leaving virtually no ultrasound energy to travel when the ultrasound beam strikes tangentially and only dif-
deeper into the tissue. This is why the lungs or bowel loops fusely reflected echoes are available to generate the image,
containing air cannot be examined by ultrasonography and although impedance is identical in both cases.
also why it is necessary to eliminate air intervening between Scattering contributes to the attenuation (loss of energy) of
the ultrasound probe and the skin surface by applying ultra- the ultrasound beam as it travels through the body and in turn
sound gel. depends on the transmitted frequency. A higher transmit fre-
The echoes reflected back from an interface between quency results in greater attenuation and limits the penetration
media of different acoustic impedance are available for image depth of the ultrasound pulse. The emitted intensity decreases
generation only if the interface is relatively perpendicular to exponentially with distance and is influenced by an attenuation
the ultrasound beam (angles of incident and reflected beam). coefficient that varies with the type of tissue through which the
For this reason, structures such as vessel walls perpendicular beam travels in the human body (fat, muscle, blood). In the
to the beam appear fairly bright compared to vessel walls tan- human body, it ranges from 0.3 to 0.6 dB/MHz cm. The energy
gential to the beam since most echo pulses are reflected back is converted into absorption heat.
to the transducer by the former. Reflection occurs at the sur- Higher carrier frequencies result in a lower penetration
faces of particles that are larger than the wavelength, while depth because attenuation loss is greater. The increasing
scattering predominates when they are smaller. attenuation can be compensated for to some extent by adjust-
ing amplification (depth-dependent gain) (. Fig. 1.3b).
1.1.1.4.2 Scattering and Attenuation Using transducers with a wide frequency range results in the
The interface between tissues of different acoustic impedance predominance of lower frequencies with greater penetration
is typically not smooth but rough. A sound wave interact- depths because attenuation of higher frequencies is more
ing with a rough surface will be scattered in all directions pronounced.
in the form of a spherical wave rather than along one path In addition to scattering and reflection, there is refraction
(. Fig. 1.3a). An incident ultrasound wave is also mostly at the interface between different media. Refraction in the
6 Chapter 1 · Fundamental Principles

1 Time Gain Compensation

Attenuation Amplification
50% 100% 0 60
dB
2 2 13.3
4 4 26.6

8 8 53.3

Noise

Time
a b Depth [cm] Depth [cm] [µs]

.. Fig. 1.3a, b Scattering and attenuation of sound waves. a Scattering: Most ultrasound beams do not strike reflecting structures in the body at
a right angle, which is why the incident beam is scattered in all directions. As a result, only a small proportion of the emitted energy is backscat-
tered to the transducer and available for generating the ultrasound image. An ultrasound beam reflected from an interface between two tissues
with the same difference in acoustic impedance will yield much stronger echoes than a beam scattered at that interface (resulting in poorer visu-
alization) (Modified from Widder and Görtler 2004). b Attenuation reduces the amplitude of the reflected ultrasound beam with echoes returning
from structures deeper in the body being attenuated more strongly. To create a uniform image from all signals despite their different amplitudes,
time gain compensation (TGC) is used, which changes the receive gain over time, applying greater amplification to echoes returing from deeper
in the body (using a set of sliding knobs or paddles)

direction of the normal to the interface occurs when there 1 dB/mHz cm. The attenuation values for a selection of bio-
is an increase in sound velocity in the next medium, and logical tissues are given in . Table 1.1. The rate of absorption
refraction away from the normal occurs when the velocity depends not only on the tissue type but also on the emitted
decreases. Refraction may lead to misinterpretation of the ultrasound frequency, with higher frequencies attenuating
location and size of the structure visualized. more quickly. Lower ultrasound frequencies, with long wave-
lengths, thus allow the examination of deeper structures,
1.1.1.4.3 Interference while high ultrasound frequencies are desirable for the better
When two or more sound waves superimpose, they can be spatial resolution they afford. For an ultrasound frequency of
out of phase (i.e., one wave’s compression phase coincides 10 MHz, for instance, the attenuation is 10 dB/cm as opposed
with the other’s expansion phase), thus cancelling each other to only 3 dB/cm for 3 MHz. Assuming an output of 100 dB,
out (destructive interference), or they can be in phase (i.e., the penetration depth would be 5 cm for 10 MHz and 17 cm
the compression and expansion phases line up), thus rein- for 3 MHz (corresponding to a total path length of 10 and
forcing each other (constructive interference). The spatial 34 cm, respectively).
distribution of areas of constructive and destructive interfer-
ence is known as the interference pattern. Such interference 1.1.1.5 Generating an Ultrasound Image
patterns are largely responsible for the visual appearance of
an ultrasound image. 1.1.1.5.1 Pulse-Echo Technique
Interferences of sound waves can change the amplitude Nearly all diagnostic ultrasound techniques rely on pulsed
and thus the brightness of an image despite an identical excitation signals. An ultrasound beam is generated by
acoustic impedance in the boundary zone. Depending on the applying short electrical pulses of about 1 s to the piezoelec-
momentary phase of the wave, the amplitude is either ampli- tric crystal in the transducer, which converts the electrical
fied or diminished. energy into mechanical vibrations. The transducer is then
switched to receive mode. The ultrasound wave passes into
1.1.1.4.4 Diffraction the body, is reflected from tissue interfaces, and returns to
Diffraction is the ability of a sound wave to bend around the transducer in the form of an echo. The incoming echoes
the corners of an obstacle in its path and to spread into the are then converted back into electrical signals. The time, t,
shadow region behind the obstacle. between transmission and reception of the pulse is mea-
sured in order to calculate the length of the path traveled,
1.1.1.4.5 Attenuation and Absorption which is the product of ultrasound velocity, c, along the
The intensity of an ultrasound wave diminishes as it propa- path and t. Dividing the product by the factor 2 yields z,
gates through the body. This loss of energy is known as atten- the distance of the reflecting structure from the ultrasound
uation and is caused by different processes, one of which is probe.
absorption – the conversion of ultrasound energy into heat.
Body tissues roughly attenuate ultrasound energy at a rate of z = ct / 2
1.1 · Technical Principles of Diagnostic Ultrasound
7 1

Amplitude

.. Fig. 1.5 In B-mode scanning, the echoes reflected from boundaries

Round trip time between tissues of different acoustic impedance are displayed two-
dimensionally as bright/dark spots with brightness levels representing
.. Fig. 1.4 In A-mode scanning, the amplitudes of the reflected the intensity of the reflected echoes (Courtesy of Hitachi Ltd.)
echoes are displayed unidimensionally, representing the distances of
the reflecting boundaries in the tissue from the transducer (Courtesy of
Hitachi Ltd.) 1.1.1.5.4 B-Mode
B-mode or brightness mode scans differ from A-mode dis-
plays in that the amplitudes of the returning echoes are dis-
If the time difference is 0.13 ms, for instance, the reflect- played on a monitor as dots of varying brightness rather than
ing structure in the body is 10 cm from the ultrasound as spikes (. Fig. 1.5). The brightness of the dots represents
probe. Current ultrasound systems generate and transmit the strength of the echoes. Most modern ultrasound systems
3000–5000 ultrasound pulses per second and simultane- can display 256 levels of brightness (gray scales). The human
ously receive and process returning echoes to generate an eye in comparison can distinguish only about 20 gray levels
image. in an image. The dots representing the echoes returning to
the transducer after emission of a pulse are arranged along
1.1.1.5.2 Time Gain Compensation a straight line (beam line or scan line). After all echoes from
Echoes returning from deeper within the body are weaker preceding pulses have returned, pulses to generate succes-
than those arising from structures closer to the transducer. sive scan lines are transmitted. Once all echoes have been
Since the distance they have to travel is longer, they expe- detected and processed, the complete 2D B-mode image is
rience greater attenuation. To compensate for these dif- displayed.
ferences and to display the signals returning from equally Suppose that we wish to generate a complete B-mode
reflective boundaries with a similar brightness – regardless image with a penetration depth of 15 cm, a width of the scan
of the distance traveled – the incoming echoes are ampli- area, x, of 5 cm, and a line spacing, ∆x, of 1 mm. Using the
fied in a depth-dependent manner. This method of vari- pulse-echo technique, generation of one scan line takes about
able amplification of echoes as a function of their round 0.2 ms. With the known ultrasound speed of 1540 ms in liv-
trip time is known as time gain compensation (TGC), ing tissue, the total scan time, T, can be calculated as:
depth-gain compensation, or swept gain (. Fig. 1.3b). The
user can set the gains for signals returning from different T = ( 2 zx ) / ( cDx )
depths.
In our example, the total scan time is 10 ms, correspond-
1.1.1.5.3 A-Mode ing to a frame rate of 100 Hz. This means that 100 complete
A-mode or amplitude mode is the simplest and oldest tech- images can be generated per second, which is fast enough to
nique of diagnostic ultrasound. The amplitudes of the pulses allow real-time imaging.
returning to the transducer are displayed as spikes along
a vertical baseline on a cathode ray oscilloscope with the 1.1.1.5.5 M-Mode
position of a spike representing the distance between the M-mode or motion mode (also known as time-motion or
reflecting boundary and the transducer (. Fig. 1.4). This TM-mode) differs from B-mode imaging in that the ultra-
technique provides one-dimensional information and can sound beam is stationary and emitted repeatedly to obtain
be used to make precise length and depth measurements. Its echoes from moving reflectors in the beam path at differ-
use is now restricted to specialized applications including the ent times. The M-mode information is displayed along a
measurement of corneal thickness in ophthalmology and the time axis with the resulting tracing depicting the movement
noninvasive evaluation of the paranasal sinuses in othorhi- of a structure such as a cardiac valve in a wavelike manner
nolaryngology. (. Fig. 1.6). As with B-mode imaging, using the pulse-echo
8 Chapter 1 · Fundamental Principles

1 Compromise:
resolution – penetration depth

d – smallest distance between two 1/d

Time structures that is resolved
Resolution, 1/d

1 MHz Frequency 10 MHz

Penetration depth, z

Imaging depth a 1 MHz Frequency 10 MHz

.. Fig. 1.6 In M-mode scanning, the temporal changes in returning

echoes are displayed, representing the motion of reflecting interfaces
toward and away from the transducer over time (Courtesy of Hitachi Ltd.)

technique, it takes 0.2 ms to generate a scan line with a pen-

etration depth of 15 cm. This results in a high frame rate (up
to about 5000 frames per second), affording a high tempo-
ral resolution, which is useful in evaluating rapidly moving
structures such as cardiac valves or vessel walls. M-mode is
b
used for echocardiography, allowing very precise measure-
ment of the cardiac chambers and walls and quantitative
evaluation of cardiac motion. .. Fig. 1.7a, b Parameters affecting axial and lateral resolution.
a Relationship between axial resolution and transmit frequency (wave-
1.1.1.6 Resolution length): axial resolution increases with transmit frequency (but at the
cost of penetration depth). b Effect of beam width on lateral resolution
Image resolution, which is given in millimeters, is defined as (Courtesy of Hitachi Ltd.)
the smallest distance between two structures that is necessary
to represent them as separate entities on a monitor. When
applied to ultrasound scans, resolution describes the spatial by the focusing capabilities of the ultrasound system and the
discrimination between two structures differing in acoustic resulting beam properties.
impedance. A distinction is made between axial resolution Lateral resolution is determined by the width of the ultra-
(resolution in the direction of sound propagation) and lateral sound beam and is best when the beam is narrow (. Fig. 1.7b).
resolution. The beam profile changes along the beam path, consisting of
Axial resolution is determined by the length of the a well-focused, narrow near field and a divergent far field.
excitation pulse and is typically one or a few wavelengths. The ultrasound beam can be focused to improve image qual-
A higher-frequency transducer emits shorter wavelengths, ity. In this way, optimal resolution can be accomplished in a
resulting in better axial resolution. Attenuation, however, small target zone, while resolution outside this zone is much
also increases with frequency, limiting the maximum depth poorer. The slow speed of sound in human tissue (1540 m/s)
from which echoes can be received. Hence, relatively low and the aim of achieving a high frame rate (real-time imag-
transmit frequencies are indispensible for imaging struc- ing) limit the number of scan lines per image. In order to
tures deeper in the body. The examiner must therefore relate the echoes to a specific depth, it is necessary to wait for
strike a balance between spatial resolution and imaging the arrival of the returning echo from the respective depth of
depth (. Fig. 1.7a). Axial resolution depends on wave- the preceding pulse before emission of the next ultrasound
length alone and improves as the wavelength decreases pulse. The transmitted or received pulse is focused in a lon-
(or the frequency increases), ranging from 0.2 to 1 mm gitudinal direction relative to the transducer, and focusing of
(. Table 1.2). the returning pulse in the scan plane is optimized in smaller
Lateral resolution is the ability to separate two closely steps (dynamically, almost continuously with the arrival time
spaced echoes that lie in a plane perpendicular to the direc- of the pulse).
tion of the sound wave. It is also influenced by the transmit The achievable resolution is determined by the wave-
frequency, and hence wavelength, but is mainly determined length of the ultrasound beam. It is ½ λ (wavelength) for axial
1.1 · Technical Principles of Diagnostic Ultrasound
9 1
resolution and much poorer for lateral resolution with a value
of 4 λ. Consequently, a high transmit frequency is desirable
to achieve good axial and lateral resolution (. Table 1.2). On
the other hand, due to attenuation, lower transmit frequen-
cies are necessary to achieve greater penetration depth. When
deeper vessels are scanned, a compromise must be found at
the expense of spatial discrimination of the vessel structures
of interest (poorer spatial resolution resulting from a lower
transmit frequency) (. Fig. 1.7a).
The depth of a reflector in the body (encoded in the
B-mode image) is calculated from the round trip time, + Variable focal zone
which increases with depth, as does attenuation. Therefore, + Multiple zone focusing
echo signals arriving from deeper within the body are pro-
gressively more strongly amplified in order to visualize them .. Fig. 1.8 Beam focusing in modern array probes. By delaying the
with the same intensity in the resulting image (see 7 Sect. firing of the central element after the firing of the outer elements a
1.1.1.5.2). Overall gain and depth gain are adjusted accord- curved wavefront is produced, resulting in a focused beam (Courtesy
of Hitachi Ltd.)
ing to the distance of the vessel of interest from the body
surface. The gain is crucial for the amplitude or intensity
of the signal, and along with output energy and signal-to- Lateral resolution is limited by the proximity of the
noise limit, it must be set properly when assessing vascular transducer elements activated to emit an ultrasound pulse.
structures. Resolution along the longitudinal axis can be improved by
exciting only a limited number of elements at a time and not
1.1.1.7 Beam Focusing the whole array. A more focused beam is achieved by later
There are several techniques for focusing an ultrasound excitation of the transducer elements in the center. Dynamic
beam. The simplest option is to use an acoustic lens, which focusing is accomplished by applying small time delays to the
has the same effect as a glass lens for visible light. A concave excitation pulses driving the individual transducer elements.
acoustic lens placed in front of the transducer provides weak Resolution in the third direction, or slice thickness, depends
focusing at a fixed depth. The site of maximum focusing is on the position in the image.
referred to as the focal point or focal zone. Alternatively, the
crystal in the transducer can be made concave, providing 1.1.1.8 Types of Transducers
internal focusing. This technique is used in single-element
mechanical sector scanners. 1.1.1.8.1 Principle of Operation
More flexible beam forming, with a variable depth of the Most electronic ultrasound transducers used today contain a
focal point, is accomplished using electronic beam focusing. number of individual piezoelectric elements for transmitting
Array transducers consist of multiple crystal elements placed and receiving ultrasonic waves. To create a complete image,
side by side. Depending on the scanner type, the number of the ultrasound beam has to pass through adjacent areas of
individual elements ranges from 60 to 256. Variable num- tissue. Parallel ultrasound beams are generated by varying
bers of elements can be activated simultaneously to form the groups of elements within the array that are simultane-
an ultrasound beam. If the elements forming the beam are ously active. A group of elements is excited to generate the
excited at slightly different times, a concave wavefront is first scan line. The next adjacent scan line is formed by shift-
generated, causing the beam to converge at the focal point. ing the group of active elements along the transducer array,
The site of the focal point can be manipulated by varying the one element position from the first group – for example, ele-
number of active elements and the pattern of excitation of ments 1–5 produce the first beam, 2–6 the second, 3–7 the
individual elements. The user can thus adjust the beam to third, and so on (. Fig. 1.9). The second ultrasound beam
achieve maximum lateral resolution at the anatomic site of generated in this way is said to be shifted by the width of one
interest. Modern scanners use multiple zone focusing, which element. The number of scan lines used to generate an image
reduces the frame rate, as several consecutive beams with can be increased by varying the number of elements acti-
different focal points are transmitted to generate a scan line. vated simultaneously to generate each beam. For instance, if
A technique known as dynamic focusing allows the focus of the second beam is generated using the same group of ele-
the beam to be altered during reception by imposing variable ments as for the first beam plus one additional element on
delays on signals from different depths. With this technique, the left side (and no element on the right side is switched
the reception focus can be optimized without compromising off), then the axis of the second beam is shifted by half an
the frame rate. Groups of 8–128 elements are used for focus- element width relative to the first beam. The third beam is
ing the beam (. Fig. 1.8). generated by removing one element on the right side without
10 Chapter 1 · Fundamental Principles

Element group adding an element to the left side. In this way, the number of
1 lines scanned to produce an image is doubled. A higher line
density is desirable for improving image quality; however, it
also reduces frame rate.

1.1.1.8.2 Linear Arrays

In a linear array transducer, the individual crystal elements
are arranged in a straight row (. Fig. 1.10) and can be pulsed
to generate adjacent parallel ultrasonic beams, producing a
rectangular image with nearly constant resolution over the
entire scan depth. A linear array is made up of 60–196 ele-
ments, with an element width of 1–4 λ, and operates at a
frequency of 5–13 MHz. An acoustic lens can be used for
focusing perpendicular to the direction of beam propagation.

1.1.1.8.3 Curved or Convex Arrays

A curved or convex array transducer is a linear array, with the
individual elements arranged along a curved line, to produce
Scan direction a sector image (. Fig. 1.11). As the lines fan out with increas-
ing distance from the transducer, lateral resolution decreases
.. Fig. 1.9 Emission and reception of a series of parallel ultrasound
with depth. A typical curvilinear array consists of at least
beams by successive excitation of groups of transducer elements for 96 elements and has a radius of 25–80 mm and a frequency
generation of an ultrasound image (Courtesy of Hitachi Ltd.) range of 3–7 MHz. Most curvilinear scanners produce sector
images ranging in size from 60° to 90°.

1.1.1.8.4 Sector Scanners

Sector scanners have a smaller radius (<25 mm) than curved
arrays and also have a small footprint, resulting in a narrow
near field. With a beam-steering angle >90°, these probes are
especially useful where access is difficult, such as in the imag-
ing of the heart through the intercostal spaces (echocardiog-
raphy), or for endoluminal applications such as transvaginal
ultrasound.

1.1.1.8.5 Phased Arrays

In a phased-array transducer, the elements are also arranged
in a linear array. The difference is that all elements are excited
to generate a scan line. However, time delays are introduced
between pulsing consecutive elements to produce a wave-
front that is no longer perpendicular to the transducer face
.. Fig. 1.10 Diagram of a linear array with the crystal elements
arranged in a straight row (Courtesy of Hitachi Ltd.)
(. Fig. 1.12). By choosing appropriate delays between the
excitation of individual elements, it is possible to direct the
beam at a desired angle. Using this method, the beam can be
steered through a range of angles to produce a sector image.
Phased-array transducers use a smaller array of elements
(64–128), resulting in a small footprint of 12–20 mm. The
beam covers a sector of 80–90° with frequency ranging from
2 to 7 MHz. Since they require complex electronic circuitry,
phased-array devices are expensive and are used mainly for
cardiac and transcranial imaging.

1.1.1.8.6 Mechanical Sector Scanners

Compared with electronic phased arrays, mechanical sys-
tems are fairly simple regarding the control of transducer ele-
ments and signal processing. There are basically two designs
.. Fig. 1.11 Diagram of a curved array with the crystal elements of mechanical devices: the rotating wheel transducer and the
arranged along a curved line (Courtesy of Hitachi Ltd.) wobbler transducer.
Other documents randomly have
different content
to the literature of his country, they have received a more than
ample measure of reward from the gratitude of posterity.
Italy produced in the Fourteenth Century many other prose writers
of note, though none so eminent as Boccaccio.
First and foremost we must mention the invaluable Chronicle of
Giovanni Villani. This historian rose in the service of the Florentine
Republic until he became Prior. He was one of the many victims of
the Black Death, and his unfinished work was continued by his
brother Matteo, and this continuation was completed by Matteo's
son, Filippo. All these are quoted as classics by the Accademia della
Crusca. According to competent judges, Giovanni was the most
brilliant, Matteo the most noteworthy for the important events he
narrates, and Filippo remarkable rather for industry and research
than for ability as a writer.
The Travels of Marco Polo, a Venetian, were an inestimable
contribution to the knowledge of remote countries. For centuries he
lay very unjustly under the suspicion of falsehood and exaggeration,
and it was only at a comparatively recent date that his veracity, nay,
his scrupulous exactness, received a tardy vindication.
Jacopo Passavanti, a Dominican. Friar, wrote a devotional book,
entitled, Lo Specchio della Penitenza, written in prose so musical and
flowing as to be preferred by some to the prose of Boccaccio,
because Passavanti never indulges in the over-elaboration
sometimes to be detected in the pages of the Decamerone.
Giovanni Da Catignano known in the Calendar as the Blessed John of
the Cells, after a dissolute youth was converted by the ardent
exhortations of the Abbot of Vallombrosa, and in deep contrition
ended his days as a hermit. Some letters from this interesting
penitent are extant, written in a style so exquisitely Tuscan that they
are quoted by the Accademia della Crusca as models of propriety
and elegance.
Another canonized celebrity, Saint Catherine of Siena, is no less
remarkable for the beauty of her style than for the beauty of her
character.
A Life of Saint Francis of Assisi, entitled Fioretti di San Francesco,
has been highly praised for the freshness and simplicity of the
language. The piety or the modesty of the author induced him to
conceal his identity.
These religious writers, though treating of subjects so different,
almost equalled Boccaccio in perfection of style, but the two authors
who produced collections of stories somewhat similar to his, Franco
Sacchetti and Ser Giovanni Fiorentino, were very far indeed from
approaching his mastery.
On reviewing the literary development of Italy in the Fourteenth
Century, we find that the language attained the fullest perfection
both in prose and verse, only the lighter kinds of poetry remaining
uncultivated. The appearance in one century of two such great poets
as Dante and Petrarch was quite phenomenal and threw a lustre
over the age which has attracted the whole world. But another fact,
less universally known, is equally worthy of attention, namely the
extraordinary merit of the prose writers of the period. It may well be
doubted whether any compositions in Italian prose of a later date
exhibit the rare qualities of those of the Fourteenth Century.
Leopardi, indeed, produced marvels of style, but they were the
result of art and study, whereas the writers of the Fourteenth
Century display an ease and a simplicity, a freshness and a graphic
power, combined with the most exquisite lightness and harmony in
their phrases, that must ever render them more admirable models
than the artificial and laborious productions of later ages.
[1] For details on the subject of this most terrible pestilence,
probably the worst that ever afflicted humanity, we may refer the
reader to Father Gasquet's valuable and interesting work on the
subject.

CHAPTER V.
WRITERS OF THE FIFTEENTH CENTURY.

In striking contrast to the Fourteenth Century, the Fifteenth is

conspicuous for a great dearth of eminent authors. The same may
be noticed in the literary development of England. After the brilliant
apparition of Chaucer, more than a hundred years elapsed before an
eminent writer arose. This may be partly accounted for by the Civil
Wars which devastated the island and brought misery and anarchy in
their train. Widely different was the plight of Italy. There were wars
and disturbances, it is true, but the wealth of the country became
more enormous than ever, and great princes extended munificent
patronage to science and learning. But all intellectual energies were
directed, not to the cultivation of the Italian language, but to the
study of the writers of antiquity. Greek and Latin were alone held in
estimation, the vulgar tongue was contemptuously neglected.
The only eminent prose writer was Feo Belcari, a Florentine
magistrate, who wrote the Lives of the Blessed Giovanni Colombini
and other Friars, and who reproduced the beauty and elegance of
the best authors of the Fourteenth Century. He died at an advanced
age in 1484.
Leon Battista Alberti was a universal genius. He distinguished himself
as painter, sculptor and architect, but his Italian writings would
hardly be of sufficient importance to mention, had not the dearth of
names in this barren century made historians of literature thankful
for any means of filling up the blank.
Leonardo Da Vinci wrote a Treatise on Painting, and he impressed
upon all artists the necessity of being original, and of not copying
their predecessors. It would have been well if the writers of the age
had laid this injunction to heart as well as the painters, for as years
advanced, the servile imitation of conventional forms became more
and more the bane of Italian literature.
Pulci is celebrated for his mock-heroic poem, the Morgante
Maggiore. The giant Morgante is the hero, but we also make the
acquaintance of Orlando, Rinaldo, Charlemagne, and many other
characters that appear in the more famous poems of Bojardo and
Ariosto. It was unfortunate for Pulci that he had such great
successors. He had abundance of wit and originality, but he had
neither the poetical imagination of Bojardo nor the magic style of
Ariosto, so that it is no cause for astonishment that he fell into
neglect.
Matteo Bojardo, Count of Scandiano, was born in 1430 and died in
1494. He was favoured by nature and fortune; a soldier and a
statesman, he had every opportunity of enriching his mind with
varied experiences, nor can we say that those opportunities were
neglected. His Orlando Innamorato, which he did not live to finish,
long as it is, displays great wealth of imagination and considerable
creative power; but unfortunately, his style is heavy and rough, and
was completely eclipsed by the extraordinary merits of Ariosto's
Orlando Furioso, which professes to be only a continuation of the
earlier poem. Fifty years later, Berni entirely re-wrote Bojardo's work
and certainly succeeded in giving it greater elegance, but he did not
make it more interesting to modern readers. In truth, the knights of
the epic cycle beginning with the Morgante Maggiore and ending in
the Eighteenth Century with the Ricciardetto, appear terribly
uninteresting in the present day, and it requires the picturesque and
melodious style of a really great poet like Ariosto to entice the
reader through the account of their numerous adventures.
The celebrated scholar, Angelo Poliziano, shows a poetical mind in his
poems, and his Orfeo may claim the credit of being the first dramatic
work of any literary value in the Italian language. It has many lyric
beauties and the choruses are spirited.[1]
His poem in Ottava Rima on a tournament given by Giniano de
Medici, was interrupted by the tragic death of his patron in the
conspiracy organised by the Pazzi family, nor was the loss of the
remainder of the poem the least deplorable consequence of that
great crime. Politian died in the prime of life in 1494. It is reasonable
to suppose that if his years had been prolonged, he might have
enriched the literature of his country with works of even greater
beauty.
A poet of true tenderness and fire, but more remarkable for the
extraordinary perfection of his Latin poems than for any other
productions of his muse, was Jacopo Sannazzaro, a Neapolitan. He
survived until the year 1530, but his Italian poems are the
productions of his youth. His Arcadia, a pastoral romance in prose
with poems interspersed, acquired a great celebrity and undoubtedly
served as model to Sir Philip Sydney's work of the same name. It is
tender and graceful, but the extreme unreality of the Nymphs and
Shepherds makes it rather cloying to a modern taste. His Italian
poems have not nearly so much melody and fire as those he wrote
in Latin, which are, indeed, so perfect that they cannot be
distinguished, as far as rhythm is concerned, from those of Virgil
himself.
These names practically exhaust the band of Italian writers of the
Fifteenth Century, truly a meagre list, and in striking contrast to the
countless painters who were an ornament to their country during the
same period.
[1] The Chorus from the Orfeo—
"Noi seguiamo, Bacco, te;
Bacco, Bacco, evoè, evoè!"
is quoted by George Eliot in Romola.

CHAPTER VI.

ARIOSTO.

The Sixteenth Century had not seen many years before the world
was presented with one of the most celebrated works in the Italian
Language, a poem destined to acquire a reputation hardly inferior to
that of Dante's great work, the Orlando Furioso of Ariosto.
Ludovico Ariosto was born at Reggio in Lombardy on the eighth of
September, 1474. His father was attached to the Court of Ferrara,
and he himself entered the services of Cardinal Ippolito d'Esté,
brother to the Duke, but in what capacity is not accurately known.
To the Cardinal he dedicated his great work, but received no thanks
for the homage. He fell into complete disgrace by refusing to
accompany his patron to Hungary. He then tried his luck with the
reigning Duke, who was more generous than his kinsman, and who
appointed the poet Governor of Garfagnana, a remote province of
the Duchy, infested by brigands. He retained this post for three
years, and brought the province into such excellent order that he
acquired the love and esteem of the whole district.
When he returned to Ferrara, he enjoyed the highest consideration
and favour of the Duke, who took great pleasure in the
representation of his comedies. He was clandestinely married to a
Florentine lady, by whom, however, he had no children. It is
supposed that secrecy was kept in order to preserve some
ecclesiastical revenues assigned to his share by the Cardinal. From
previous connections he had two sons, on whom the Duke conferred
patents of legitimacy. His descendants acquired considerable
opulence, and became one of the first families of Ferrara. His son
Orazio made himself remarkable by declaring, when the question of
Torquato Tasso's superior genius roused the attention of Italy, that
both poets had their particular beauties, for which opinion he was
fiercely attacked by the zealots in his father's cause. In the
Eighteenth Century, a Marquis Ariosto was intimate with Voltaire at
Brussels. The last descendant of the poet, the Countess Ariosto, died
at Ferrara in 1878, at the age of ninety years.
Ariosto gives us in his Satires with rare candour a picture of his mind
and of the vicissitudes of his life. He was of a buoyant and open
disposition, fond of pleasure and susceptible to the attractions of
love, but faithful and sincere to his friends, and very generous to his
numerous brothers and sisters. Titian was among his friends, and
the great painter has preserved for us the features of the great poet.
Curious anecdotes are told of his absence of mind when plunged in
thought. Once he went through the streets of Ferrara in his
dressing-gown, and was not aware of his apparel until an
acquaintance accosted him and told him of the fact. He built himself
a little house, and placed a Latin inscription over the entrance, and
when someone remarked that it was very small for one who had
described such splendid edifices in his verses, he made answer that
fabrics of the imagination are erected with little, and those of stone
and mortar, with great, cost. His death, the result of indigestion,
owing to the rapidity with which he took his meals in order to return
to his studies, took place in 1533.
Fully to appreciate the genius of Ariosto we must understand the
spirit of his age, for in him were developed, more fully than in any
other writer of the period, the qualities, moral and intellectual, that
gave their stamp to the memorable epoch of the Renaissance. The
taste, the love of beauty, the classical simplicity, the vivid
imagination, the ethereal lightness of touch characterising the
productions of the great contemporary painters, are united in as
high perfection in the verse of Ariosto as on their canvas and
frescoes. He had, with the merits of his age, also its shortcomings:
the want of moral elevation, the frivolity, and the absence of
religious enthusiasm.
He was, therefore, unfitted to be an heroic poet in the stiff old
conventional style, and it was not until he had tried and abandoned
many subjects chat he discovered himself to be something infinitely
more striking and original. At last he discovered in the subject that
inspired Pulci and Bojardo, an inexhaustible mine of poetry, and he
took up the thread of narrative where Bojardo's unfinished poem
had left it, and produced one of the greatest masterpieces in the
whole range of literature.
He is matchless in the ease and clearness of his style, which never
flags for one moment in the forty-six cantos of the work. He is said
to have written with the greatest care, and to have corrected much
and erased not a little. The stanza in the first canto:
"La verginella è simile alla rosa,"
he wrote nine times before he was satisfied. Galileo confessed that
he owed the lucidity of his style to the assiduous study of Ariosto,
but accused him of introducing verses for the sake of the rhyme; but
we may pardon an occasional blemish in a work of such immense
length.
He tells us himself that he saturated his mind with the spirit of the
Latin poets, especially with Catullus, and in his works we find the
urbanity of the Augustan age united to a strength and vivacity of
imagination unknown to the Romans. With great judgement he
improved on the hints they gave him, and the graceful manner in
which he occasionally introduces mythological allusions seems to
have been Milton's model when he did the same. Although he rates
Virgil's flattery of Augustus at its proper value when he says:
"Non era cosi saggio e grande Augusto
Come la tromba di Virgilio suona,
E per avere in poesia buon gusto
Le proscrizioni inique gli perdona,"
he cannot himself be acquitted of the charge of gross flattery to the
House of Este, without having even the excuse of Virgil, for it is well
known with how little applause his patrons received his masterpiece.
Some critics have asserted that he chose his subject merely because
he could introduce the character of Ruggiero, ancestor to his
patrons, but, fortunately for the glory of one of the greatest of
human minds, there is no reason to believe this libel. The subject
recommended itself by its own merits to the poet, as any candid
reader, after perusing the work, will confess. It is impossible to enter
the maze of incidents in the Orlando Furioso without being
bewildered, astonished, dazzled, and lost in all the wonders conjured
up by the poet's fancy. His genius was essentially narrative (as is
proved by his comedies being so vastly inferior to his Epic), and his
subject allowed him to heap story on story, and to develop
adventure out of adventure.
No finer compliment was ever paid by one poet to another, than by
Byron to Scott, when he called him the Northern Ariosto, and the
Italian poet the Southern Scott,
"Who, like the Ariosto of the North, worth."
Sang ladye-love and war, romance and knightly
It was not a mere compliment, but a very just parallel, and it would
be difficult to decide which of the two poets was the greater. Scott
had certainly more power of delineating character; but Ariosto had,
if not the richer, the more vivid imagination. If we take only Scott's
poetical works into consideration, Ariosto would have the advantage;
but if the prose romances of Scott are thrown into the balance, they
incline the scales in his favour. Both poets were, as Byron called
them, bards of chivalry, but Scott's chivalry was that of the soul, and
Ariosto's too often only that of the sword. Perhaps we may come to
a satisfactory conclusion by saying that Ariosto was the greater, and
Scott the nobler, poet.
Ariosto's rapidity of style is such that I know of no poem more
concise than this Epic, containing over forty thousand lines. One of
his tricks to arrest the attention, or to tantalize the curiosity of the
reader, is to break off a story in the middle, passing on to other
incidents, and concluding the interrupted episode in a later canto.
The graceful badinage with which he amuses us when the interest
threatens to flag, is most judiciously introduced, for such a subject
treated with solemn glumness and heavy pomp would become
irksome in the extreme.
Every canto has an introduction, as ingenious in thought as it is
beautiful in expression. The most interesting Introduction is probably
that of the last canto, where he represents his contemporaries
congratulating him on the completion of so arduous a work; but
others deserve scarcely less praise; for instance, that on jealousy,
and that in which he enumerates the great painters of the age,
amongst others, Michael Angelo:
"Quel che a par sculpe e colora,
Michel, più che mortal, Angel divino."
The rapidity of his transitions is truly amazing. He whirls the reader
in two lines from one end of the world to the other. When we are
harassed and wearied by the breathless speed of his Pegasus, he
pauses, lavishing all the riches of his mind on a description or an
incident. Here he reveals himself the wonderful poet he is. The
maiden chained to a rock and about to be devoured by the sea-
monster; Zerbino and Isabella, Ginevra and Ariodante; above all,
Alcina and her magic garden; and, not inferior to any passage in the
greatest poets, the frenzy of Orlando: these are only a few of the
wonderful passages that place his Epic among the noblest
productions of the human mind.
His style is, perhaps, if not the most lofty, yet the most perfect of
any Italian poet; it is so sweetly varied, so gracefully and judiciously
adorned with metaphors and tropes, so picturesque in description,
so vivid in narrative, so exquisitely graduated to impart the suitable
colouring to the poet's thoughts. Perhaps the only quality it lacks, is
the expression of deep emotion, which his joyous and animated
verse seldom attains. Nor can it be said that he ever displays great
depth of thought, so that we seek in vain in his works for those
marvellous flashes that irradiate the mystery of things. With this
want is connected the absence of striking individuality in many of his
characters; they are Knights and Saracens such as tradition supplied.
When he chooses, however, he can individualize his figures, like
Angelica, or Orlando and Alcina, with great success, and many
observations interspersed throughout the work, show keen insight
into human nature. Voltaire, an ardent admirer of this poet, said he
had more knowledge of the human heart than is to be found in all
epics and novels from Homer's Iliad down to Richardson's Pamela.
He regretted Madame du Deffand had not learnt Italian in order to
read so admirable a poet. He says in one of his last poems:
"Je relis l'Arioste ou même la Pucelle."
The Pucelle, indeed, was written in emulation of the Orlando Furioso
which it resembles no more than a statue of Silenus resembles the
Jupiter of Otricoli.
No one represented more truthfully the effect produced by Ariosto
on the mind than Leopardi in the following lines:
"Nascevi ai dolci sogni intanto, e il primo
Sole splendeati in vista,
Cantor vago dell' arme e degl' amori,
Che in età della nostra assai men trista
Empièr la vita di felici errori,
Nova speme d'Italia. O torri, O celle,
O donne, O cavalieri,
O giardini, O palagi! a voi pensando,
In mille vane amenità si perde
La mente mia."
Ariosto began his great poem in 1505, at the age of thirty-one, and
finished it in 1516; but the year before his death he published an
edition with countless alterations and improvements, and with six
additional cantos, and it is in the latter form that it has descended to
posterity. At his death he left five cantos of an unfinished epic,
entitled Rinaldo Ardito, in which many characters of the Orlando
reappear; but the fragment is in a very imperfect state and by no
means approaches the beauty of the completed work.

CHAPTER VII.

POETS CONTEMPORARY WITH ARIOSTO.

The age of Ariosto is remarkable for the first appearance of blank

verse in the Italian language. The Italia Liberata of Trissino, on the
subject of the victories of Belisarius over the Goths, is the first work
in that metre. Trissino thought himself a second Homer, and his epic
is full of injudicious imitations of the Iliad. The scene between
Jupiter and Juno on Mount Ida is transferred to Justinian and
Theodora, in the Palace of Constantinople, with very voluptuous
amplifications More than with this ponderous epic, Trissino did his
country service by writing the first Italian tragedy, Sofonisba, a work
containing passages almost worthy of Euripides. With a style less
languid and prosaic, Trissino might have achieved considerable
success in the drama.
The poet who came nearest to Ariosto in elegance of style, though
far indeed from possessing equal fire and genius, was Francesco
Berni, mentioned in a previous chapter, as having recast the Orlando
Innamorato of Bojardo. He cannot have had a very original mind, or
he would not have submitted to the drudgery of re-writing, line for
line, the work of another man, when he might have been employed
on poems of his own; but he had plenty of vivacity and raciness, as
his Satires and Sonnets attest. So popular did they become, that
light and comic poetry came to be called after him, Poesia Bernesca.
His end was more tragic than his works. Unfortunately for himself,
he lived in Florence in the intimacy of the Medici family. A bitter feud
arose between the Duke Alexander and Cardinal Ippolito. The Duke
endeavoured to bribe Berni to poison the Cardinal, and on his
refusing to be a party to so terrible a crime, Alexander had him
poisoned in his turn, lest he should reveal the secret of his guilt.
Luigi Alamanni was an indefatigable writer of poetry. He wrote two
enormous epics, Giron il Cortese and the Avarchide; but it would
require the musical diction of Ariosto to make such productions live;
and, unfortunately, Alamanni, though a scholarly and painstaking
writer, had nothing like Ariosto's powers of versification. The work by
which he is most honourably remembered is a didactic poem, La
Coltivazione, on the same subject as the Georgics.
Giovanni Rucellai, a nephew of Lorenzo the Magnificent, was also
indebted to the Georgics for his poem, Le Api (on Bees), in blank
verse, of which there is an excellent defence in the introductory
lines, quite the most original and pleasing passage in the poem.
Monsignor Giovanni Della Casa acquired an immense reputation in his
own age for his works in prose and verse, in Latin and Italian; but as
his merit consists exclusively in the finished style—his thoughts not
rising above conventionality—he has been neglected for writers
combining equal, if not greater, beauty of language with more
originality of thought.
Annibal Caro rendered signal service to his country by giving it a
spirited translation of the Æneid, and his works in prose and verse
are all characterised by vigour of style. He rose from a humble origin
to considerable wealth and prominence, and he became notorious by
reason of a bitter feud with a contemporary critic of the name of
Castelvetro. He had written a poem in praise of the House of Valois,
"Venite all'ombra de' gran gigli d'oro," and Castelvetro wrote a sharp
and acrimonious criticism upon it, to which he retorted in his
Apologia with almost insane rancour. Castelvetro was not tardy in
replying, and Caro is suspected of having used all his influence to
ruin the career of his adversary. But it is painful to dwell upon these
ebullitions of spite, unfortunately too frequent in the annals of
literature.
Cardinal Bembo was a writer fastidiously elegant. He is reported to
have possessed forty portfolios, in the first of which he put the first
draft of his works; in the second, the second; and so on until the
fortieth revision reached the fortieth receptacle, after which alone
would he suffer the work to see the light. His productions are such
as might be expected from a man so minutely laborious. He is more
intent upon words than upon realities. His poetry is modelled on
Petrarch, his prose on Boccaccio. He wrote a History of Venice in
twelve books, originally in Latin, translating it himself into Italian. A
dialogue, entitled Gli Asolani, is interesting to English readers from
its similarity of title to Browning's Asolando. The name is taken from
Asolo, a spot on the mainland not far from Venice, whither he loved
to retire, as Browning did three hundred years later. His letters are
esteemed his best production, being less over-elaborated in style
than his other works. His Latin works are entirely modelled on those
of Cicero.
Francesco Grazzini, surnamed Il Lasca, was a sort of inferior Berni in
his poems, but he is remarkable as one of the founders of the
Florentine Accademia della Crusca.
Bernardino Rota, a Neapolitan, produced some really pathetic poems
on the death of his wife.
The Sixteenth Century was remarkable for three poetesses of
considerable merit: Vittoria Colonna, Gaspara Stampa, and Veronica
Gambara. Vittoria Colonna was the widow of the Marquis of Pescara,
and dedicates many of her verses to his memory. Gaspara Stampa, a
native of Padua, was deeply in love with Collatino Collalto, and gave
utterance to her passion in numerous Sonnets, some of which rise to
considerable beauty and dignity. Veronica Gambara, of Brescia,
produced some noble verses, especially the fine Sonnet in which she
implores, in the name of Christ, Charles V and Francis I, to put an
end to their hostilities.
Although he lived until nearly the end of the century, we may for
convenience mention Angelo Di Costanzo in this chapter. He was born
in Naples, in 1507, of a wealthy and noble family, but in spite of his
wealth he had many sorrows. Don Pedro de Toledo, Viceroy of
Naples, banished him from the city of his birth. His first wife died in
youth; his second wife caused him much unhappiness by her
misconduct; and to complete his misfortunes, he lived to deplore the
loss of his two sons. He appealed in vain to be allowed to return to
his home. His petitions were rejected, and he died in grief and exile
in 1591. Some of his poems are eminently beautiful; his Sonnet on
Virgil, "Quella cetra gentil," is justly celebrated. In prose he wrote a
history of Naples, frequently reprinted.
On reviewing the poetry of this period, with the brilliant exception of
Ariosto, the result is, perhaps, a feeling of disappointment. Certainly,
the achievements are not commensurate with the undoubted culture
and intellect of the writers. There is nothing (always excepting
Ariosto) that has taken hold of the world's attention. How different in
this respect are the poets from the painters of the same period! How
obscure by the side of Michael Angelo, Raphael, Correggio, Titian,
Giorgione, Sebastian del Piombo, Tintoretto, and the whole galaxy
sparkling for ever in the heaven of Art! Some powerful minds, such
as Vida and Fracastoro, were diverted into the path of Latin poetry;
but I think the chief explanation of the inferiority of the poets is their
lack of really fine subjects; for how can a poet write nobly if he has
no adequate theme for his verse? Their amorous poetry ran too
much in the Petrarchan groove; their heroic poetry was too apt to
assume the form of ponderous epics, utterly unreadable without the
graces of Ariosto. Religious enthusiasm seems to have been remote
from their minds. Another generation had to arise before that fire
was again kindled on the shrine of Poetry.

CHAPTER VIII.

MACHIAVELLI AND THE PROSE WRITERS OF THE

SIXTEENTH CENTURY.

Niccolò Machiavelli, the profoundest thinker and the keenest politician

of his century, was born in Florence on the third of May, 1469. In
1498 he was made Secretary of State of the Florentine Republic. But
this dignity was the cause of his subsequent adversity. When the
Medici family was restored to power in Florence, he was imprisoned,
fined, and even put to the torture. He profited by an amnesty issued
by Leo X on his accession, but he was relegated to poverty and
obscurity. Impatient of both, he curried favour with the reigning
dynasty, but such was the ill-luck that steadily pursued him through
life, that no sooner had he acquired a certain degree of favour than
the Medici were again expelled from Florence, and he, as one of
their adherents, was regarded by the triumphant party with
suspicion and hostility. He did not long survive the wreck of all his
hopes, dying on the twenty-second of June, 1527.
In his generation, Italy had fallen on evil days. The invasion of
Charles VIII of France opened the flood-gates of a deluge of
disasters; and the devastations of the King were succeeded by the
crushing despotism of the Emperor. The immense wealth,
accumulated during centuries of prosperity, was rapidly melting
away. The Republic of Venice lost much of her trade owing to the
rivalry of Holland and Portugal, and the stream of commerce was
directed from the Adriatic by the discovery of the new passage to
India round the Cape of Good Hope. The reckless extravagance of
Leo X exhausted the Papal Treasury; a great religious schism cut off
abundant supplies from distant countries; and the terrible sack of
Rome, with the ruinous ransom demanded from Clement VII,
completed, in the year of Machiavelli's death, a long series of
disasters. Freedom was crushed by native tyrants and foreign
oppressors. The present was ghastly with innumerable wounds, the
future looked blacker than the grave. What wonder was it, therefore,
that men sought refuge from such horrors in every finesse that
diplomacy could suggest? This is the true explanation and the one
excuse of Machiavelli's tortuous policy. He is utterly unscrupulous,
but it is the unscrupulousness of a patriot at bay who has exhausted
all other means of self-defence.
Still, it cannot be denied that Machiavelli is anything but a
sympathetic figure. We admire the keenness of his intellect as we
admire the keenness of a sharp-edged sword; but where is the love
of humanity, the enthusiasm for great ideals, the indignation of a
noble mind at the iniquities of an evil age? Wonderful is the
penetration of his remarks; unrivalled his insight; above praise the
clearness and precision of his thoughts. No historian has ever
surpassed him in unrolling a panorama of past events. No politician
has ever laid down more sagacious rules for attaining an object in
view. No statesman has ever discerned with a keener eye the
symptoms of the times.
But if we ask what profit has been derived from the exertions of this
most acute and logical of minds, what is the answer? His name has
become a byeword as the symbol of a heartless intriguer, and his
works glare like a meteor of evil in the dark and troubled sky of his
century.
Great praise is due to his History of Florence. In the first book, with
a concise lucidity which later historians have emulated without
surpassing, he surveys the events of ten centuries, and that noble
introduction is followed by a work which displays to the fullest
advantage the great powers of its author.
The Discourses on the First Decade of Livy and The Art of War both
treat of the same subject; the necessity of a freedom-loving nation
to attain and preserve a high standard of military efficiency. The
system of hiring venal condottieri had profoundly demoralised the
forces of Italy, indeed, it had paved the way for the invasion of
France and the dominion of Spain, and its effects were felt even to
the middle of the present century, for no other explanation suffices
to account for the submission of a nation with such a history as Italy
to the oppression of foreign garrisons. So clear-sighted a patriot as
Machiavelli could not fail to see the evil and to point out the remedy.
His despatches and correspondence are also invaluable for the
history of his times.
But the work pre-eminently associated with his name is the treatise,
entitled Il Principe, a manual for a ruler who desires to keep an
unsteady throne and to outwit unscrupulous enemies. He advocates,
it is true, a policy regardless of all mercy and morality in the pursuit
of its object; but injustice to Machiavelli, we must bear in mind what
his object was. He had seen his country desolated for years by cruel
and rapacious invaders, and he thought, most justly, that the only
chance of Italy against her enemies was the establishment of the
dominion of one powerful and politic prince over the whole
Peninsula, and it was to establish a standard of conduct for such a
prince that he wrote his book.
His story, Belphegor, and his plays, among which the Mandragora
stands pre-eminent, are witty and lively, but they frequently overstep
the limits of decorum. All his works are interspersed with
innumerable proofs of the keenness of his observation, and the style
is clear and forcible, but somewhat wanting in colour. He wrote a
few poems, but they are of no great value or interest.
Machiavelli is as undoubtedly the first prose writer of the age as
Ariosto is the first poet, Second to him as an historian, though at a
wide interval, we may place his friend and fellow-townsman,
Francesco Guicciardini, born in 1480, died in 1540. He studied law to
such good purpose at Florence, Ferrara and Padua, that at the early
age of twenty-two he was chosen to lecture on the Institutes of
Justinian, and at the age of thirty-one he was sent as Ambassador to
Ferdinand of Aragon, which post he occupied for two years. With the
help of that King, Julius the Second forced the Florentines to submit
again to the rule of the Medici family. Guicciardini was suspected by
the friends of liberty of having a hand in the negotiations between
the Pope and the King, and of being a tool of that ambitious dynasty.
Such, in truth, he proved himself; and harshness, rancour, and
vindictiveness characterised his conduct towards his political
opponents. When Leo X visited Florence in 1515, Guicciardini was
sent by the Republic to receive him at Cortona. No circumstance
could have proved more favourable to the historian's career. Leo X
looked upon him with the utmost favour, and nominated him to high
and important offices, which his successor, Adrian VI, continued, and
to which Clement VII subsequently added others. When the "Holy
League," headed by the Duke of Urbino, was formed against the
Emperor Charles V, Guicciardini was one of its leading spirits. But the
Imperial arms prevailed; Clement VII had to take refuge in the
Castle of St. Angelo, and had the agony of seeing Rome stormed
and plundered under his very eyes. Atrocious were the cruelties
committed. St. Peter's itself was stained with the blood of the
slaughtered. Huge contributions were levied on the citizens, and an
enormous ransom exacted from the Pope. Seeing Clement, himself a
Medici, deprived of liberty and even in danger of his life, the
Florentines took to arms and expelled the obnoxious dynasty. But
the unexpected happened. The injured Pope and the tyrannical
Emperor became reconciled; and probably to atone for the atrocities
committed by his forces, Charles V lent effective aid to Alexander de
Medici in his endeavour to regain his lost dominion over Florence.
Guicciardini became the instrument of Alexander, a cruel and
relentless tyrant, who was subsequently assassinated by his kinsman
Lorenzino. Guicciardini was an active agent in the election of Cosimo
I, and when he was reproached for imposing another tyrant on his
country, he answered that the more princes were assassinated, the
more would arise. But Cosimo was ungrateful when Guicciardini
demanded the reward of his services; bitter disappointment was in
store for him; he withdrew from public affairs, and lived in
retirement at Arcetri, where he died.
It was in the leisure hours of this retirement that he wrote the
history on which his literary reputation is founded. It embraces the
period from the invasion of Charles VIII to the year 1532. It is a
valuable and important work; but, as may be gathered from the
details of his life, the author shows no elevation or purity of mind.
His view of human nature is low; his estimate of his fellow-creatures
harsh and cynical. But if the colours are unpleasing, the picture is
valuable, and it would have been a great loss had it not been
preserved for posterity.
Guicciardini is often heavy and prolix, and many ludicrous stories
have been told of the sufferings of those readers who
conscientiously plodded through the entire work. Thus it is related of
the jocular Governor of a Province, that he promised a free pardon
to a convict if he would read Guicciardini's History from the first
page to the last. The prisoner gladly embraced this opportunity of
regaining his liberty. He little knew the task that was imposed upon
him. As he turned over page after page of the ponderous tomes, a
deadly weariness overpowered him, until at last the endless details
of the Siege of Pisa exhausted his patience. "Take me back to the
galleys," he exclaimed. "Rather that than the misery of toiling
through this awful book."
Agnolo Firenzuola was a good prose writer, out a very inferior poet;
indeed, so great is the contrast between the two classes of his
works, that it is difficult to believe that they can emanate from the
same pen. The most striking of his works is a Dialogue on the
Beauty of Women.
Pier Francesco Giambullari wrote a History of Europe from the
accession of Charlemagne to the year 913. The history is unfinished,
the author dying in 1555. He was one of the founders of the
Florentine Accademia della Crusca. He has been highly praised for
the dignity and finish of his style.
Vasari and Cellini are names renowned in the annals of Art, the
former for his invaluable biographies of painters, and the latter as a
sculptor and a worker in gold and bronze. His biography is a striking
memorial of the man and the age.
Benedetto Varchi had many qualities of an able historian, but as he
was in the pay of the Grand Duke Cosimo I, his independence may
be more than suspected.
In contrast to him, Jacopo Nardi was a bitter opponent of the Medici
family, and in his History of Florence from 1494 to 1531 he paints
them in the blackest colours. So determined an adversary of the
ruling dynasty could not be suffered to remain in Florence. He was
driven into banishment, and took refuge in Venice, where he died
after the middle of the Century. As a biographer he distinguished
himself by his life of Antonio Giacomini.
The Sixteenth Century was fertile in historians, for we have to
chronicle the name of another in Bernardo Segni. He wrote the
History of Italy from 1527 to 1555, or three years before his death.
Dealing with contemporary events, he could not treat his subject
with the requisite independence, and living a quiet and studious life,
it is difficult to see how he could gather reliable information, or have
access to important documents.
Vincenzo Borghini was a laborious antiquarian, who wrote a book on
the Origin of the City of Florence.
Giambattista Adriani professed to continue Guicciardini's work in his
History of his Own Times, but it is complete in itself, and has many
merits, both of style and subject. Adriani was celebrated in his day
as a public speaker, and his Latin Orations were so much admired
that they were translated into Italian as soon as they were held. He
died in 1579.
Camillo Porzio who survived until 1603, wrote several historical
monographs concerning the Kingdom of Naples.
Skilful as they were in all the arts of composition, the writers of the
Sixteenth Century too frequently indulged in redundant prolixity.
Conscious of this defect, Bernardo Davanzati determined to cultivate
the opposite quality of laconic conciseness. He was brilliantly
successful. He translated Tacitus, that great model of brevity, and
boasted that his rendering contained fewer words than the original
without sacrificing a particle of the sense. He wrote a book on the
Reformation in England, a Funeral Oration on Cosimo I, and several
treatises on finance and agriculture.
In reviewing the writers of this Epoch, we are struck with the
number and merit of the historians. The other Prose Writers appeal
but faintly to modern readers. With the exception of Baldassare
Castiglione, who, in his Cortegiano gives us a pleasing picture of the
more refined circles of Italian society, and of Vasari and Benvenuto
Cellini, they do not disclose much of the manners and customs of
their age. No Boccaccio arose to portray for future times the men
and women of his day.
The stories of Bandello and of Luigi Da Porto have but little to
recommend them except the fact that they supplied Shakespeare
with some of his plots. Bandello, however, is by no means destitute
of vivacity. Straparola, the author of Tredici Piacevoli Notti, and
Fiorentini, the author of Il Pecorone, also had the honour of
furnishing hints to the great dramatist. Too often it happens that the
extreme prolixity of the writers of the Sixteenth Century drowns their
thoughts in an ocean of words. It is strange that the great
convulsion of the Reformation did not produce any theological work
written in the Italian language. The controversies were all carried on
in Latin, but even in Latin nothing was produced in the Peninsula
that is now remembered. Indeed, the great Catholic reaction had the
effect of making writers fearful of giving offence. It restricted them
more and more within academic grooves, thus unhappily fostering
that tendency to conventionality and unreality which immersed
Italian literature deeper and deeper into a morass of mediocrity.

CHAPTER IX.

BERNARDO AND TORQUATO TASSO.

It is but seldom that poets are as romantic as their poems, or as

interesting as the offspring of their imagination. When, therefore, a
poet arises gifted with an interesting personality, the attention he
excites becomes universal. Such was the fate of Torquato Tasso. It
would not be altogether unjust to say that had he not suffered so
many misfortunes, his name would not be a household word, for the
merit of his poems hardly sustains the dignity of his renown.
His father, Bernardo, a native of Bergamo, was born in 1493, and
died in 1569. He was a writer in prose and verse, his chief work
being the Amadigi, an epic of immense length, well and carefully
written, but without any spark of genius. He was attached to the
Court of Ferrante Sanseverino, Prince of Salerno, and when his
master was driven out of his dominions by the Emperor Charles V, he
followed his fortunes, leaving his wife, Properzia de' Rossi, and three
children, the youngest of whom was Torquato, born in 1544, to the
care of her relatives. His devotion to the fallen fortunes of the Prince
of Salerno was the cause of many of the sorrows of his illustrious
son. His patrimony was sequestrated, and when he died, he had
nothing to leave to his children. Nor was this the greatest of his
trials. He never saw his wife again, and when he wished to have her
with him in Rome, she was in a dying condition. All she could do,
was to send him the little Torquato, whose training was henceforth
confided to the father's care.
The youth displayed as much love and more aptitude for poetical
composition. When he was eighteen, he published his epic, Rinaldo,
a wonderfully mature work for so young a writer. Torquato Tasso was
one of those poets who produce their finest works in the earlier
portion of their career. The works by which alone he is remembered,
were all produced before his thirty-second year. His mind attained
full mastery over its powers at a very early period, and when, like
the voice of a singer, it lost its freshness, it also lost its charm.
Corneille and Tennyson resemble him in this peculiarity of producing
their masterpieces in comparative youth, but in their case, the
division between the two periods is not quite so marked as in his.
Corneille produced no really great drama after La Mort de Pompée,
but some of his later tragedies have occasional flashes of his early
fire. Tennyson gave no memorable creation to the world after Maud,
but his Idylls of the King offer some poetical details, and a few lyrics
are not devoid of that perfection which characterised his previous
poems. But Tasso produced absolutely nothing that could, by any
stretch of indulgence, be said to add to his renown after the
publication of the Gerusalemme Liberata. On the contrary, he rather
injured his reputation by yielding to the cavils of his detractors, and
re-writing his great work under the title of Gerusalemme
Conquistata, and producing an epic so feeble and lifeless that it
immediately sank into utter neglect.
Precocious as he was in the manifestation of brilliant genius, his
father was anxious that such powers should be cultivated to the
utmost, and Torquato was sent to study law at Padua. But the law
was little to his taste. His Rinaldo procured him immense renown,
and he found it more agreeable to bask in the sunshine of the
brilliant society that courted him in the dawn of his celebrity, than to
spend laborious hours in the pursuit of a dry and distasteful science.
No poet at so early an age ever had so brilliant a prospect of renown
and fortune before him. But the very extent of the admiration he
excited laid the foundations of the terrible disasters that were to
overtake him ere many years had elapsed.
Cardinal Luigi of Este, attracted by his brilliant reputation, offered
him a post in his household and an introduction to the Court of
Ferrara. The dazzling offer was accepted by the poet; but the
kindness of the Cardinal had results more fatal than could have
attended the machinations of his bitterest enemies.
At first all went well. Tasso produced a favourable impression upon
the Duke Alfonso and upon his two sisters, Lucrezia and Eleonora.
He accompanied the Cardinal on a mission to the Court of Charles IX
of France, and after a year's sojourn in Paris, where he was fêted by
the leading authors, including Ronsard, then at the height of his
fame, he returned to Ferrara to receive new proofs of the favour of
the Duke. But the more he rose in the estimation of his master, the
more he excited the jealousy of those who were equally ambitious
but less successful. There is, indeed, no truth in the popular legend
of his love for the Princess Eleanora. The object of his affections
appears to have been a lady of the Court, Leonora Scandiano. The
poet Guarini was also in love with this lady, and bitter hostility
resulted from the rivalry of the two poets. The malignant envy of his
opponents was excited by the brilliant success of his pastoral play,
Aminta, produced in 1573. So much was that poem talked of, that
the Princess Lucrezia, who had meanwhile married the Duke of
Urbino, sent for Tasso to read it to her at Pesaro. So pleased was
she both with the work and the writer, that she invited him to pass
the summer at her palace of Castel Durante. The exquisite beauty of
the gardens and the grounds is said to have been in his mind when
he described the gardens of Armida in the Gerusalemme.
This was the happiest time of Tasso's life. He was honoured with the
favour of the highest in the land, and with the admiration of the
whole of Italy. He was congenially employed on the completion of
the great epic which was to make his name immortal. Never was a
poet placed in a more brilliant position, nor more apparently certain
of a splendid and triumphant career.
But the seeds of evil were already sown, and the mischief soon
became apparent. He completed the Gerusalemme in 1575, and
from that moment his peace of mind was gone. Whether he
overworked himself in that great task, or whether he had secret
causes of annoyance and humiliation, of which his biographers know
nothing, it is difficult to conjecture, but from that period his temper
seems to have become morbidly suspicious and irritable. He was
painfully sensitive to criticism, and he harassed himself and others
by perpetually altering and correcting passages to which objection
had been taken. When at last the poem was published, which was
not until some time after its completion, it was attacked by the
Accademia della Crusca with considerable harshness and unfairness.
The great fault found by the Academy was that the idiom was not
always purely Tuscan. The very first line of the first Canto was
singled out for censure:
"Canto l'arme pietose e il Capitano."
The poet uses the word "pietose" in the sense of 'pious," whereas
the Academy contended that it could never mean anything but
"compassionate."
Tasso was not only worried by these minute quibbles, but he was
also haunted by the dreadful apprehension that his religious
orthodoxy might be impugned, and he himself applied to the Fathers
of the Holy Inquisition for an examination and a vindication. In vain
the Fathers assured him with unanimous cordiality that such a
process was utterly superfluous, and that the purity of his faith had
never for a moment been held in doubt; he still professed himself
dissatisfied, and he long continued to torment himself with religious
scruples.
The Duke of Ferrara, doubtless highly gratified at the success of the
masterpiece of his Court Poet, appointed Tasso his private secretary
when that post became vacant through the death of Giambattista
Pigna in 1577. Probably the arduous duties and the heavy
responsibilities of this appointment weighed him down with a fresh
load of anxiety, and he may have felt that he had become more than
ever the object of malice and envy; whatever the cause, excitability
verging on frenzy, and suspicion verging on madness betrayed
themselves more and more in his speech and actions. He fancied,
perhaps not without reason, that some of his letters had been
intercepted; he firmly believed, though with less foundation, that
there was a plot to poison him. He had also the annoyance,
peculiarly galling to an author, of knowing that spurious copies of his
great epic were being circulated throughout Italy, full of mistakes
and interpolated passages.
All these causes of uneasiness culminated in frightful violence in the
month of June of that fatal year. One evening in the apartments of
the Princess Lucrezia, and even in her presence, he drew a dagger
and stabbed a manservant whom he suspected of being concerned
in the robbery of some missing documents. He was arrested, and
the Duke ordered him to be kept a close prisoner. When released
from captivity, he was so excited with grief and indignation, that all
observers pronounced him mad. He took refuge in a Franciscan
Monastery; but when the Duke refused to receive his letters, he
dreaded the effects of his master's anger, and fled from Ferrara in a
pitiable condition, without his manuscripts, without sufficient clothes,
and without a particle of money. He seems actually to have begged
his way from Ferrara to Sorrento, near Naples, where his sister was
married to Marzio Sersale. It would be difficult to find a more
picturesque episode in the life of any poet than that of Tasso
presenting himself to his sister in the garb of a mendicant. She
received the unhappy wanderer with hospitality and affection,
welcomed him in her house, and when he was sufficiently recovered
from the fatigues of mind and body to discuss his affairs, gave him
the sensible advice never to return to the Court of Ferrara.
Unhappily, this advice was rejected; but to be perfectly just in our
estimate of Tasso's conduct, we must bear in mind the position of
men of letters of the Sixteenth Century in Italy. The complete
absence of copyright law made it impossible for even the most
popular writer to derive emolument from his books, for as soon as
they acquired any popularity, they were shamelessly pirated all over
the Peninsula. Enormously popular as they were, even during their
lifetime, it does not appear that either Ariosto or Tasso ever profited
to the extent of even one scudo by the sale of their poems. Thus a
writer, unless he possessed ample means, or held some lucrative
office, was entirely dependent for his bread on the fickle favour of
the great. Tasso, in consequence of the reverses experienced by his
father and the sequestration of his property, was absolutely devoid
of anything he could call his own, and owed even the barest
necessaries of life to the bounty of the Prince whom his violent
conduct had, it must be admitted, justly offended. Great as his
reputation was, he might well doubt whether any other sovereign in
Italy would extend to him even a quarter of similar favour after the
reckless and violent conduct of which he had been guilty.
Whatever may have been his motives, he wrote again and again to
Alfonso and the Princesses for pardon for his errors and for
permission to return. Eleonora alone answered him, and her reply
was not encouraging. The mortification of being repulsed was
doubtless intolerable to his proud spirit. He deserted Sorrento and
the sister whose affection he should have valued above all the
favours of princes. He went straight to Ferrara, but the doors of the
Palace were barred against him, and to add to his afflictions, the
Duke refused to allow his manuscripts to be given up to him. He was
lonely and destitute, and the bitterness of his fall was intensified by
the jeers of those who, on the very spot of his disgrace, had envied
him the brilliancy of his triumph. Without a morsel of bread to eat,
or a roof under which to take shelter, he sold some valuable trinkets
which had been given to him in happier days by the Princess
Lucrezia, and with the proceeds he made his way through Mantua
and Padua to Venice.
In these towns he seems to have been received with the
consideration due to his poetical renown; but still the painful
question as to where he should find a permanent home occurred to
him in moments of anxiety and gloom. Strange to say, help came to
him from an unexpected quarter. The Duke of Urbino's marriage with
the Princess Lucrezia had turned out most unhappily, and the couple
were now separated. It probably occurred to the Duke that the best
way of annoying the House of Este would be to show favour to the
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Ultrasonography in Vascular Diagnosis A Therapy Oriented Textbook and Atlas 3rd Edition Wilhelm Schäberle

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Translated by Bettina Herwig

ISBN 978-3-319-64996-2 ISBN 978-3-319-64997-9 (eBook)

Library of Congress Control Number: 2018954360

Printed on acid-free paper

To my wife Solange and my children Jan and Philip

Preface to the Second English

Preface to the Second German Edition

Preface to the First German Edition

© Springer International Publishing AG, part of Springer Nature 2018

1.2 Hemodynamic Principles – 37

1.3 Machine Settings – 47

1.1.1 Gray-Scale Ultrasonography (B-Mode)

1.1.1.1 Historical Milestones

on one side and positive on the other. As the degree of stress

C =l× f 1.1.1.4.1 Reflection and Refraction

Beam perpendicular to interface

Reflection Transmission Impedance mismatch

1 Time Gain Compensation

.. Fig. 1.5 In B-mode scanning, the echoes reflected from boundaries

d – smallest distance between two 1/d

1 MHz Frequency 10 MHz

Imaging depth a 1 MHz Frequency 10 MHz

.. Fig. 1.6 In M-mode scanning, the temporal changes in returning

technique, it takes 0.2 ms to generate a scan line with a pen-

1.1.1.8.2 Linear Arrays

1.1.1.8.3 Curved or Convex Arrays

1.1.1.8.4 Sector Scanners

1.1.1.8.5 Phased Arrays

1.1.1.8.6 Mechanical Sector Scanners

In striking contrast to the Fourteenth Century, the Fifteenth is

POETS CONTEMPORARY WITH ARIOSTO.

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MACHIAVELLI AND THE PROSE WRITERS OF THE

Niccolò Machiavelli, the profoundest thinker and the keenest politician

BERNARDO AND TORQUATO TASSO.

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1.2 Hemodynamic Principles – 37

1.3 Machine Settings – 47

1.1.1 Gray-Scale Ultrasonography (B-Mode)

1.1.1.1 Historical Milestones