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Look for These Other Titles in the Otto Echocardiography Family

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Echocardiography Review Guide: Companion to the Textbook of Clinical
Echocardiography, Second Edition

9
Catherine Otto, Rebecca Schwaegler, and Rosario Freeman

i r
The Practice of Clinical Echocardiography, Fourth Edition
9
h
Catherine Otto

ta
Practical Echocardiography Series

r/
Series Editor: Catherine Otto

e
Volumes Included in This Series:

s
Advanced Approaches in Echocardiography

/r u
Linda Gillam and Catherine Otto

Intraoperative Echocardiography

.t c
Donald Oxorn

a
Echocardiography in Heart Failure

k
Martin St. John Sutton and Susan Wiegers

/: /
Echocardiography in Congenital Heart Disease

s
Mark Lewin and Karen Stout

tt p
h
xiv
Glossary

LCC = left coronary cusp RAE = right atrial enlargement

LMCA = left main coronary artery RAO = right anterior oblique
LPA = left pulmonary artery RAP = right atrial pressure
LSPV = left superior pulmonary vein RCA = right coronary artery
L-TGA = corrected transposition of the great RCC = right coronary cusp
arteries R e = Reynolds number
LV = left ventricle RF = regurgitant fraction
LV-EDP = left ventricular end-diastolic pressure RJ = regurgitant jet

/
LVH = left ventricular hypertrophy R o = radius of microbubble
LVID = left ventricular internal dimension ROA = regurgitant orifice area

9
LVOT = left ventricular outflow tract RPA = right pulmonary artery
RSPV = right superior pulmonary vein

9
M-mode = motion display (depth versus time) RSV = regurgitant stroke volume

r
MAC = mitral annular calcification

i
RV = right ventricle
MI = myocardial infarction RVE = right ventricular enlargement
MR = mitral regurgitation

h
RVH = right ventricular hypertrophy
MS = mitral stenosis RVol =regurgitant volume

a
MV = mitral valve RVOT = right ventricular outflow tract

t
MVA = mitral valve area

r/
MVL = mitral valve leaflet s = second
MVR = mitral valve replacement SAM = systolic anterior motion
SC = subcostal

e
n = number of subjects SEE = standard error of the estimate
NBTE = nonbacterial thrombotic endocarditis SPPA = spatial peak pulse average

s
NCC = noncoronary cusp SPTA = spatial peak temporal average

/r u
ΔP = pressure gradient SSN = suprasternal notch
P = pressure ST = septal thickness
PA = pulmonary artery STJ = sinotubular junction
PAP = pulmonary artery pressure STVL = septal tricuspid valve leaflet

.t c
PCI = percutaneous coronary intervention SV = stroke volume or sample volume
PDA = patent ductus arteriosus or posterior (depends on context)
descending artery (depends on context) SVC = superior vena cava

a
PE = pericardial effusion T½ = pressure half-time
PEP = preejection period TD = thermodilution

k
PET = positron-emission tomography

/: /
TEE = transesophageal echocardiography
PISA = proximal isovelocity surface area TGA = transposition of the great arteries
PLAX = parasternal long-axis TGC = time-gain compensation
PM = papillary muscle Th = wall thickness

s
PMVL = posterior mitral valve leaflet TL = true lumen
post = posterior (or inferior-lateral) ventricular wall TN = true negatives

tt p
PR = pulmonic regurgitation TOF = tetralogy of Fallot
PRF = pulse repetition frequency TP = true positives
PRFR = peak rapid filling rate TPV = time to peak velocity
PS = pulmonic stenosis

h
TR = tricuspid regurgitation
PSAX = parasternal short-axis TS = tricuspid stenosis
PV = pulmonary vein TSV = total stroke volume
PVC = premature ventricular contraction TTE = transthoracic echocardiography
PVD = pulmonary vein diastolic velocity TV = tricuspid valve
PVR = pulmonary vascular resistance
PVD = pulmonary vein diastolic velocity v = velocity
PWT = posterior wall thickness V = volume or velocity (depends on context)
VAS = ventriculo-atrial septum
Q = volume flow rate Veg = vegetation
Q p = pulmonic volume flow rate Vmax = maximum velocity
Q s = systemic volume flow rate VSD = ventricular septal defect
r = correlation coefficient VTI = velocity-time integral
R = ventricular radius WPW = Wolff-Parkinson-White syndrome
RFR = regurgitant instantaneous flow rate
RA = right atrium Z = acoustic impedance
 xv
Glossary

Symbols Greek Name Used for Variable Unit Definition

α alpha Frequency Mass g Grams. Example: LV

mass
γ gamma Viscosity
Pressure mm Hg Millimeters of mercury,
Δ delta Difference 1 mm Hg = 1333.2
θ theta Angle dyne/cm2, where dyne
measures force in
λ lambda Wavelength

/
cm-mg-s2
μ mu Micro-
Resistance dyne · s · cm-5 Measure of vascular

9
π pi Mathematical constant resistance
(approx. 3.14)

9
Time s Second
ρ rho Tissue density ms Millisecond (1/1000 s)

i r
σ sigma Wall stress μs Microsecond
τ tau Time constant of Ultrasound W/cm2 Where watt (W) =

h
ventricular relaxation intensity mW/cm2 joule per second and
joule = m2 · kg · s-2

a
(unit of energy)

r/ t
Velocity (v) m/s Meters per second
cm/s Centimeters per second
UNITS OF MEASURE Velocity- cm Integral of the Doppler

e
time velocity curve (cm/s)
Variable Unit Definition integral over time (s), in units

s
(VTI) of cm
Amplitude dB Decibels = a logarithmic

/r u
scale describing Volume cm3 Cubic centimeters
the amplitude mL Milliliter, 1 mL = 1 cm3
(“loudness”) of the L Liter = 1000 mL
sound wave Volume Rate of volume flow

.t c
Angle degrees Degree = (π/180)rad. flow rate across a valve or in
Example: intercept (Q) cardiac output
angle L/min L/min = liters per minute

a
mL/s mL/s = milliliters per
Area cm2 Square centimeters.
second
A 2D measurement

k
(e.g., end-systolic Wall stress dyne/cm2 Units of meridional or

/: /
area) or a calculated circumferential wall
value (e.g., continuity stress
equation valve area) kdyn/cm2 Kilodynes per cm2

s
Frequency Hz Hertz (cycles per kPa Kilopascals where
(f) second) 1 kPa = 10 kdyn/cm2

tt p
kHz Kilohertz = 1000 Hz
MHz Megahertz =
1,000,000 Hz

h
Length cm Centimeter (1/100 m)
mm Millimeter (1/1000 m or
1/10 cm)
KEY EQUATIONS

/
Ultrasound Physics
f = cycles/s = Hz

9
Frequency
Wavelength λ = c / f = 1.54/f (MHz)
υ = c × Δf/ [2FT (cosθ)]

9
Doppler equation
Bernoulli equation ΔP = 4V 2

i r
LV Imaging
Stroke volume SV = EDV − ESV
EF( % ) = (SV / EDV) × 100 %

h
Ejection fraction
Wall stress σ = PR/2Th

a
Doppler Ventricular Function

t
Stroke volume SV = CSA × VTI
dP/dt = 32 mm Hg / time from 1 to 3 m/s of MR CW jet(sec)

r/
Rate of pressure rise
Myocardial performance index MPI = (IVRT + IVCT) / SEP
Pulmonary Pressures and Resistance
PAPsystolic = 4(VTR )2 + RAP

e
Pulmonary systolic pressure
PAP (when PS is present) PAPsystolic = [4(VTR )2 + RAP] − Δ PRV − PA
PAPmean = Mean Δ PRV − RA + RAP

s
Mean PA pressure
Diastolic PA pressure PAPdiastolic = 4(VPR )2 + RAP

/r u
Pulmonary vascular resistance PVR ≅ 10(VTR )/VTIRVOT
Aortic Stenosis
Maximum pressure gradient (integrate over ejection Δ Pmax = 4(Vmax )2
period for mean gradient)
AVA(cm2 ) = [π(LVOTD / 2)2 × VTILVOT ] / VTIAS-Jet

.t c
Continuity equation valve area
Simplified continuity equation AVA(cm2 ) = [π(LVOTD / 2)2 × VLVOT ] / VAS-Jet
Velocity ratio Velocity ratio = VLVOT /VAS-Jet
Mitral Stenosis

a
Pressure half-time valve area MVADoppler = 220 / T½
Aortic Regurgitation

k
Total stroke volume TSV = SVLVOT = (CSALVOT × VTILVOT )

/: /
Forward stroke volume FSV = SVMA = (CSAMA × VTIMA )
Regurgitant volume RVol = TSV − FSV
Regurgitant orifice area ROA = RSV / VTIAR

s
Mitral Regurgitation
Total stroke volume TSV = SVMA = (CSAMA × VTIMA )

tt p
(or 2D or 3D LV stroke volume)
Forward stroke volume FSV = SVLVOT = (CSALVOT × VTILVOT )
Regurgitant volume RVol = TSV − FSV
Regurgitant orifice area ROA = RSV/VTIAR

h
PISA method
Regurgitant flow rate RFR = 2πr2 × Valiasing
Orifice area (maximum) ROAmax = RFR / VMR
Regurgitant volume RV = ROA × VTIMR
Aortic Dilation
Predicted sinus diameter
Children (<18 years): Predicted sinus dimension = 1.02 + (0.98 BSA)
Adults (18-40 years): Predicted sinus dimension = 0.97 + (1.12 BSA)
Adults (>40 years): Predicted sinus dimension = 1.92 + (0.74 BSA)
Ratio = Measured maximum diameter / Predicted maximum diameter
Pulmonary (Q p) to Systemic (Q s) Shunt Ratio
Q p : Q s = [CSAPA × VTIPA ] / [CSALVOT × VTILVOT ]

xvii
 1 Principles of Echocardiographic Image
Acquisition and Doppler Analysis
ULTRASOUND WAVES
ULTRASOUND TISSUE INTERACTION
Reflection
Scattering
Refraction
Attenuation
TRANSDUCERS
Piezoelectric Crystal
Types of Transducers
Beam Shape and Focusing
Resolution
ULTRASOUND IMAGING MODALITIES
M-Mode
Two-Dimensional Echocardiography
Image Production
Instrument Settings
Imaging Artifacts
Three-Dimensional Echocardiography
Echocardiographic Imaging Measurements
n understanding of the basic principles of
A ultrasound imaging and Doppler echocardiog-
raphy is essential both during data acquisition
and for correct interpretation of the ultrasound infor-
mation. Although, at times, current instruments pro-
vide instantaneous images so clear and detailed that
it seems as if we can “see” the heart and blood flow
directly, in actuality, we always are looking at images
and flow data generated by complex analyses of ultra-
sound waves reflected and backscattered from the
patient’s body. Knowledge of the strengths, and more
importantly, the limitations, of this technique is critical
for correct clinical diagnosis and patient management.
On the one hand, echocardiography can be used for
decision making with a high degree of accuracy in a
variety of clinical settings. On the other hand, if an
ultrasound artifact is mistaken for an anatomic abnor-
mality, a patient might undergo needless, expensive,
and potentially risky other diagnostic tests or thera-
peutic interventions.
In this chapter, a brief (and necessarily simplified)
overview of the basic principles of cardiac ultrasound
imaging and flow analysis is presented. The reader
DOPPLER ECHOCARDIOGRAPHY
Doppler Velocity Data
Doppler Equation
Spectral Analysis
Continuous-Wave Doppler Ultrasound
Pulsed Doppler Ultrasound
Doppler Velocity Instrument Controls
Doppler Velocity Data Artifacts
Color Doppler Flow Imaging
Principles
Color Doppler Instrument Controls
Color Doppler Imaging Artifacts
Tissue Doppler
BIOEFFECTS AND SAFETY
Bioeffects
Safety
SUGGESTED READING
is referred to the Suggested Reading at the end of
the chapter for more information on these subjects.
Because the details of image processing, artifact for-
mation, and Doppler physics become more mean-
ingful with experience, some readers may choose to
return to this chapter after reading other sections of
this book and after participating in some echocardio-
graphic examinations.
ULTRASOUND WAVES
Sound waves are mechanical vibrations that induce
alternate refraction and compression of any physical
medium through which they pass (Fig. 1-1). Like other
waves, sound waves are described in terms of (Table 1-1):
n  requency: cycles per second, or hertz (Hz)
F
n Velocity of propagation
n Wavelength: millimeters (mm)
n Amplitude: decibels (dB)
  
Frequency ( f ) is the number of ultrasound waves in a
1-second interval. The units of measurement are hertz,
1
2
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis

abbreviated Hz, which simply means cycles per second.
A frequency of 1000 cycles/s is 1 kilohertz (KHz), and
1 million cycles/s is 1 megahertz (MHz). Humans can
hear sound waves with frequencies between 20 Hz and
20 kHz; frequencies higher than this range are termed
ultrasound. Diagnostic medical ultrasound typically uses
transducers with a frequency between 1 and 20 MHz.
The speed that a sound wave moves through the
body, called the velocity of propagation (c), is different for
Wavelength Propagation velocity (m/s)
λ
Amplitude (dB)
each type of tissue. For example, the velocity of propa-
gation in bone is much faster (about 3000 m/s) than
in lung tissue (about 700 m/s). However, the velocity
of propagation in soft tissues, including myocardium,
valves, blood vessels, and blood is relatively uniform,
averaging about 1540 m/s.
Wavelength is the distance from peak to peak of an
ultrasound wave. Wavelength can be calculated by
dividing the frequency ( f in Hz) by the propagation
velocity (c in m/s).
/
λ=c f (1-1)
Since the propagation velocity in the heart is con-
stant at 1540 m/s, the wavelength for any transducer
frequency can be calculated (Fig. 1-2) as:

// /
λ (mm) = [1540m s f (Hz)] 1000 mm/m
or as:
/
λ (mm) = 1.54 f
For example, the wavelength emitted by a 5 MHz
transducer can be calculated as:
1s / /
cycles/s = Hz λ = 1540 m s ÷ 5,000,000 cycle s = 0.000308 m
Figure 1–1 Schematic diagram of an ultrasound wave. = 0.308 mm

TABLE 1-1 Ultrasound Waves

Definition Examples Clinical Implications

Frequency (f) The number of cycles per Transducer frequencies
second in an ultrasound are measured in MHz
wave: (1,000,000 cycles/s).
f = cycles/s = Hz Doppler signal frequencies
are measured in KHz (1000
cycles/s).
Velocity of The speed that ultrasound The average velocity of
propagation (c) travels through tissue ultrasound in soft tissue is
about 1540 m/s.
Wavelength (λ) The distance between Wavelength is shorter
ultrasound waves: with a higher-frequency
λ = c/f = 1.54/f (MHz) transducer and longer
with a lower-frequency
transducer.
Amplitude (dB) Height of the ultrasound A log scale is used for dB.
wave or “loudness” On the dB scale, 80 dB
measured in decibels represents a 10,000-
(dB) fold and 40 dB indicates
a 100-fold increase in
amplitude.
Different transducer frequencies
are used for specific clinical
applications because the
transmitted frequency affects
ultrasound tissue penetration,
image resolution, and the
Doppler signal.
The velocity of propagation is
similar in different soft tissues
(blood, myocardium, liver, fat,
etc.) but is much lower in lung
and much higher in bone.
Image resolution is greatest
(about 1 mm) with a
shorter wavelength (higher
frequency).
Depth of tissue penetration
is greatest with a longer
wavelength (lower frequency).
A very wide range of amplitudes
can be displayed using a gray-
scale display for both imaging
and spectral Doppler.
 3
Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1

Wavelength is important in diagnostic applications scale. Decibels (dB) are familiar to all of us as the stan-
for at least two reasons: dard description of the loudness of a sound. Decibels
  
are logarithmic units based on a ratio of the measured
n I mage resolution is no greater than 1 to 2 wave-
amplitude (A2) to a reference amplitude (A1) such that:
lengths (typically about 1 mm). /
n The depth of penetration of the ultrasound dB = 20 log (A2 A1 ) (1-3)
wave into the body is directly related to wave-
Thus, a ratio of 1000 to 1 is:
length; shorter wavelengths penetrate a shorter
distance than longer wavelengths. 20 × log (1000) = 20 × 3 = 60 dB
  

Thus, there is an obvious tradeoff between image a ratio of 100 to 1 is:

resolution (shorter wavelength or higher frequency
preferable) and depth penetration (longer wavelength
or lower frequency preferable).
The acoustic pressure, or amplitude, of an ultra-
sound wave indicates the energy of the ultrasound
signal. Power is the amount of energy per unit time.
Intensity (I) is the amount of power per unit area:
Intensity (I) = power2
(1-2)
This relationship shows that if ultrasound power is
doubled, intensity is quadruped. Instead of using direct
measures of pressure energy, ultrasound amplitude is
described relative to a reference value using the decibel
20 × log (100) = 20 × 2 = 40 dB
and a ratio of 2 to 1 is:
20 × log (2) = 20 × 0.3 = 6 dB
A simple rule to remember is that a 6-dB change
represents a doubling or halving of the signal ampli-
tude or that a 40-dB change represents a 100 times dif-
ference in amplitude (Fig. 1-3). If acoustic intensity is
used instead of amplitude, the constant 10 replaces 20
in the equation so that a 3 dB changes represents dou-
bling, and a 20 dB change indicates a 100-fold differ-
ence in amplitude. Either of these decibel scales may

0 30 Figure 1–2 Transducer frequency versus

.2 wavelength and penetration of the ultra-
.3 sound signal in soft tissue. Wavelength
Wavelength (resolution) has been plotted inversely to show that reso-
.44 Penetration lution increases with increasing transducer
Wavelength (mm)

0.5
Penetration (cm)

20 frequency while penetration decreases. The

.62 specific wavelengths for transducer frequen-
cies of 1, 2.5, 3.5, 5, and 7.5 MHz are shown.

1.0
10

.5
1.5
0 0
0 1 2.5 3.5 5 7.5 10 15 20
Transducer frequency (MHz)

100,000 Figure 1–3 Graph of the decibel scale.

The logarithmic relationship between the
10,000 decibel scale (horizontal axis) and the ampli-
tude ratio (vertical axis) is seen. A doubling
or halving of the amplitude ratio corresponds
Amplitude ratio

1000 to a 6-dB change, and a 100-fold difference

in amplitude corresponds to a 20-dB change.
100

10
2
1

0
0 6 20 40 60 80 100
Decibels
4
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis

be used to refer to transmitted or received ultrasound Z = ρc (1-4)

waves or to describe attenuation effects. The advan-
tages of the decibel scale are that a very large range
can be compressed into a smaller number of values,
and that low-amplitude (weak) signals can be displayed
alongside very high-amplitude (strong) signals. In an
echocardiographic image, amplitudes typically range
from 1 to 120 dB. The decibel scale is the standard for-
mat both for echocardiographic image display and for
the Doppler spectral display, although other amplitude
scales may be an option.
ULTRASOUND TISSUE INTERACTION
Propagation of ultrasound waves in the body to gener-
Although the velocity of propagation differs between
tissues, tissue density is the primary determinant of
acoustic impedance for diagnostic ultrasound. Lung tis-
sue has a very low density compared to bone, which
has a very high density. Soft tissues, such as blood and
myocardium, have much smaller differences in tis-
sue density and acoustic impedance. Acoustic imped-
ance determines the transmission of ultrasound waves
through a tissue; differences in acoustic impedance result
in reflection of ultrasound waves at tissue boundaries.
The interaction of ultrasound waves with the organs
and tissues of the body can be described in terms of
(Fig. 1-4):
  

ate ultrasound images and Doppler data depends on n  eflection

R
a tissue property called acoustic impedance (Table 1-2). n Scattering
Acoustic impedance (Z ) depends on tissue density (ρ) n Refraction
and on the propagation velocity in that tissue (c): n Attenuation

TABLE 1-2 Ultrasound Tissue Interaction

Definition Examples Clinical Implications

Acoustic A characteristic of each Lung has a low density and Ultrasound is reflected from
impedance (Z) tissue defined by slow propagation velocity, boundaries between
tissue density (r) and whereas bone has a high tissues with differences in
propagation of velocity density and fast propagation acoustic impedance (e.g.,
(c) as: velocity. Soft tissues have blood versus myocardium).
Z=r×c smaller differences in
tissue density and acoustic
impedance.
Reflection Return of ultrasound signal Reflection is used to generate Reflection is greatest when
to the transducer from a 2D cardiac images. the ultrasound beam is
smooth tissue boundary perpendicular to the tissue
interface.
Scattering Radiation of ultrasound in The change in frequency The amplitude of scattered
multiple directions from of signals scattered from signals is 100 to 1000
a small structure, such moving blood cells is the times less than reflected
as blood cells basis of Doppler ultrasound. signals.
Refraction Deflection of ultrasound Refraction is used in transducer Refraction in tissues results in
waves from a straight design to focus the double image artifacts.
path because of ultrasound beam.
differences in acoustic
impedance
Attenuation Loss in signal strength Attenuation is frequency A lower-frequency transducer
due to absorption of dependent with greater may be needed for apical
ultrasound energy by attenuation (less penetration) views or in larger patients
tissues at higher frequencies. on transthoracic imaging.
Resolution The smallest resolvable Resolution has three Axial resolution is most precise
distance between two dimensions: along the length (as small as 1 mm), so
specular reflectors on an of the beam (axial), lateral imaging measurements are
ultrasound image across the image (azimuthal) best made along the length
and in the elevational plane. of the ultrasound beam.

Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1
Reflection
The basis of ultrasound imaging is reflection of the
transmitted ultrasound signal from internal structures.
Ultrasound is reflected at tissue boundaries and inter-
faces, with the amount of ultrasound reflected depen-
dent on the:
n  ifference in acoustic impedance between the
D
two tissues
n Angle of reflection
Smooth tissue boundaries with a lateral dimension
greater than the wavelength of the ultrasound beam
act as specular, or “mirrorlike,” reflectors. The amount
of ultrasound reflected is constant for a given interface,
although the amount received back at the transducer
varies with angle because (like light reflected from a
mirror) the angle of incidence and reflection is equal.
Thus, optimal return of reflected ultrasound occurs
at a perpendicular angle (90°). Remembering this fact
is crucial for obtaining diagnostic ultrasound images.
It also accounts for ultrasound “dropout” in a two-
dimensional (2D) or three-dimensional (3D) image
when too little or no reflected ultrasound reaches the
transducer resulting from a parallel alignment between
the ultrasound beam and tissue interface.
Scattering
Scattering of the ultrasound signal, instead of reflec-
tion, occurs with small structures, such as red blood
cells suspended in fluid, because the radius of the cell
(about 4 µm) is smaller than the wavelength of the
ultrasound signal. Unlike a reflected beam, scattered
Transducers
Scattering from
moving blood cells
Reflection
Specular
reflector
Refraction
Attenuation
Figure 1–4 Diagram of the interaction between ultrasound and body
tissues. Doppler analysis is based on the scattering of ultrasound in all
directions from moving blood cells with a resulting change in frequency of
the ultrasound received at the transducer. 2D imaging is based on reflection
of ultrasound from tissue interfaces (specular reflectors). Attenuation limits
the depth of ultrasound penetration. Refraction, a change in direction of the
ultrasound wave, results in imaging artifacts.
5
ultrasound energy may be radiated in all directions.
Only a small amount of the scattered signal reaches
the receiving transducer, and the amplitude of a scat-
tered signal is 100 to 1000 times (40-60 dB) less than
the amplitude of the returned signal from a specular
reflector. Scattering of ultrasound from moving blood
cells is the basis of Doppler echocardiography.
The extent of scattering depends on:
  
n  article size (red blood cells)
P
n Number of particles (hematocrit)
n Ultrasound transducer frequency
n Compressibility of blood cells and plasma
  
Although experimental studies show differences in
backscattering with changes in hematocrit, variation
over the clinical range has little effect on the Dop-
pler signal. Similarly, the size of red blood cells and
the compressibility of blood cells and plasma do not
change significantly. Thus, the primary determinant
of scattering is transducer frequency.
Scattering also occurs within tissues, such as the
myocardium, from interference of backscattered sig-
nals from tissue interfaces smaller than the ultrasound
wavelength. Tissue scattering results in a pattern of
speckles; tissue motion can be measured by tracking
these speckles from frame to frame, as discussed in
Chapter 4.
Refraction
Ultrasound waves can be refracted—deflected from a
straight path—as they pass through a medium with
a different acoustic impedance. Refraction of an
ultrasound beam is analogous to refraction of light
waves as they pass through a curved glass lens (e.g.,
prescription eyeglasses). Refraction allows enhanced
image quality by using acoustic “lenses” to focus the
ultrasound beam. However, refraction also occurs in
unplanned ways during image formation, resulting in
ultrasound artifacts, most notably the “double-image”
artifact.
Attenuation
Attenuation is the loss of signal strength as ultrasound
interacts with tissue. As ultrasound penetrates into the
body, signal strength is progressively attenuated because
of absorption of the ultrasound energy by conversion
to heat, as well as by reflection and scattering. The
degree of attenuation is related to several factors,
including the:
  
n  ttenuation coefficient of the tissue
A
n Transducer frequency
n Distance from the transducer
n Ultrasound intensity (or power)
The attenuation coefficient (α) for each tissue is
related the decrease in ultrasound intensity (measured
6
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis
in dB) from one point (I1) to a second point (I2) sepa-
rated by a distance (l) as described by the equation:
I2 = I1 e − 2αl (1-5)
The attenuation coefficient for air is very high (about
1000×) compared to soft tissue so that any air between
the transducer and heart results in substantial signal
attenuation. This is avoided on transthoracic exami-
nations by use of a water-soluble gel to form an airless
contact between the transducer and the skin; on trans-
esophageal echocardiography (TEE) examination, atten-
uation is avoided by maintaining close contact between
the transducer and esophageal wall. The air-filled lungs
are avoided by careful patient positioning and the use of
acoustic “windows” that allow access of the ultrasound
beam to the cardiac structures without intervening lung
tissue. Other intrathoracic air (e.g., pneumomediasti-
num, residual air after cardiac surgery) also results in
poor ultrasound tissue penetration because of attenua-
tion, resulting in suboptimal image quality.
The power output of the transducer is directly related
to the overall degree of attenuation. However, an increase
in power output may cause thermal and mechanical
bioeffects as discussed in Bioeffects and Safety, p. 27.
Overall attenuation is frequency-dependent such
that lower ultrasound frequencies penetrate deeper
into the body than higher frequencies. The depth of
penetration for adequate imaging tends to be limited
to approximately 200 wavelengths. This translates
roughly into a penetration depth of 30 cm for a 1-MHz
transducer, 6 cm for a 5-MHz transducer, and 1.5 cm
for a 20-MHz transducer, although diagnostic images
at depths greater than these postulated limits can be
obtained with state-of-the-art equipment. Thus, attenu-
ation, as much as resolution, dictates the need for a par-
ticular transducer frequency in a specific clinical setting.
For example, visualization of distal structures from the
apical approach in a large adult patient often requires
a low-frequency transducer. From a TEE approach, the
same structures can be imaged (at better resolution) with
a higher-frequency transducer. The effects of attenua-
tion are minimized on displayed images by using differ-
ent gain settings at each depth, an instrument control
called time-gain (or depth-gain) compensation.
TRANSDUCERS
Piezoelectric Crystal
Ultrasound transducers use a piezoelectric crystal both
to generate and to receive ultrasound waves (Fig. 1-5).
A piezoelectric crystal is a material (such as quartz or a
titanate ceramic) with the property that an applied elec-
tric current results in alignment of polarized particles
perpendicular to the face of the crystal with consequent
expansion of crystal size. When an alternating electric
current is applied, the crystal alternately compresses
and expands, generating an ultrasound wave. The fre-
quency that a transducer emits depends on the nature
and thickness of the piezoelectric material.
Conversely, when an ultrasound wave strikes the
piezoelectric crystal, an electric current is generated.
Thus, the crystal can serve both as a “receiver” and
as a “transmitter.” Basically, the ultrasound transducer
transmits a brief burst of ultrasound and then switches
to the “receive mode” to await the reflected ultrasound
signals from the intracardiac acoustic interfaces. This
cycle is repeated temporally and spatially to generate
ultrasound images. Image formation is based on the
time delay between ultrasound transmission and return
of the reflected signal. Deeper structures have a longer
time of flight than shallower structures, with the exact
depth calculated based on the speed of sound in blood
and the time interval between the transmitted burst of
ultrasound and return of the reflected signal.
The burst, or pulse, of ultrasound generated by the
piezoelectric crystal is very brief, typically 1 to 6 µs,
because a short pulse length results in improved axial
(along the length of the beam) resolution. Damping
material is used to control the ring-down time of the
crystal and, hence, the pulse length. Pulse length also
is determined by frequency because a shorter time
is needed for the same number of cycles at higher
frequencies. The number of ultrasound pulses per
second is called the pulse repetition frequency, or PRF.
The total time interval from pulse to pulse is called
the cycle length, with the percent of the cycle length
used for ultrasound transmission called the duty factor.
Ultrasound imaging has a duty factor of about 1%
compared to 5% for pulsed Doppler and 100% for
continuous-wave (CW) Doppler. The duty factor is a
Transducer Ultrasound
Pulse
Damping Acoustic Pulse
material lens length
Cable
λ
Piezoelectric Impedance
crystal matching
Figure 1–5 Schematic diagram of an ultrasound transducer. The
piezoelectric crystal both produces and receives ultrasound signals, with
the electric input-output transmitted to the instrument via the cable. Damp-
ing material allows a short pulse length (improved resolution). The shape
of the piezoelectric crystal, an acoustic lens, or electronic focusing (with a
phased-array transducer) are used to modify beam geometry. The material
of the transducer surface provides impedance matching with the skin. The
ultrasound pulse length for 2D imaging is short (1-6ms), typically consist-
ing of two wavelengths (λ). “Ring down”—the decrease in frequency and
amplitude in the pulse—depends on damping and determines bandwidth
(the range of frequencies in the signal).
 7
Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1

key element in the patient’s total ultrasound exposure
as discussed in Bioeffects and Safety, p. 27.
The range of frequencies contained in the pulse is
described as its frequency bandwidth. A wider bandwidth
allows better axial resolution because of the ability
of the system to produce a narrow pulse. Transducer
bandwidth also affects the range of frequencies that
can be detected by the system with a wider bandwidth,
which allows better resolution of structures distant
from the transducer. The stated frequency of a trans-
ducer represents the center frequency of the pulse.
Types of Transducers
The simplest type of ultrasound transducer is based
on a single piezoelectric crystal (Table 1-3). Alternate

TABLE 1-3 Ultrasound Transducers

Definition Examples Clinical Implications

Type Transducer characteristics Transthoracic (adult and pediatric) Each transducer type is
and configuration Nonimaging CW Doppler optimized for a specific
Most cardiac transducers 3D echocardiography clinical application.
use a phased array of TEE More than one transducer may be
piezoelectric crystals. Intracardiac needed for a full examination.
Transmission The central frequency Transducer frequencies A higher-frequency transducer
frequency emitted by the vary from 2.5 MHz for provides improved resolution
transducer transthoracic echo to 20 MHz but less penetration.
for intravascular imaging. Doppler signals are optimal at a
lower transducer frequency
than used for imaging.
Power output The amount of ultrasound An increase in transmitted Excessive power output
energy emitted by the power increases the may result in bioeffects
transducer amplitude of the reflected measured by the mechanical
ultrasound signals. and thermal indexes.
Bandwidth The range of frequencies Bandwidth is determined by A wider bandwidth allows
in the ultrasound pulse transducer design. improved axial resolution for
structures distant from the
transducer.
Pulse (or burst) The length of the A higher-frequency signal can A shorter pulse length improves
length transmitted ultrasound be transmitted in a shorter axial resolution.
signal pulse length compared to a
lower-frequency signal.
Pulse The number of The PRF decreases as imaging PRF affects image resolution and
repetition transmission-receive (or Doppler) depth increases frame rate (particularly with
frequency cycles per second because of the time needed color Doppler).
(PRF) for the signal to travel from
and to the transducer.
Duty factor The percentage of time Ranges from about 1% for A higher duty factor means more
that ultrasound is imaging to 5% for pulsed tissue exposure to ultrasound.
transmitted Doppler to 100% for CW
Doppler
Focal depth Beam shape and Structures close to the The length and site of a
focusing are used to transducer are best visualized transducer’s focal zone
optimize ultrasound with a short focal depth, is primarily determined
resolution at a specific distant structures with a long by transducer design, but
distance from the focal depth. adjustment during the exam
transducer. may be possible.
Aperture The surface of the A small nonimaging CW A larger aperture allows a more
transducer face Doppler transducer allows focused beam.
where ultrasound optimal positioning and A smaller aperture allows
is transmitted and angulation of the ultrasound improved transducer
received beam. angulation on TTE imaging.
8
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis
pulsed transmission and reception periods allow
repeated sampling along a single line, with the sam-
pling rate limited only by the time delay needed for
return of the reflected ultrasound wave from the depth
of interest. An example of using the transducer for
simple transmission-reception along a single line is an
A-mode (amplitude versus depth) or M-mode (depth
versus time) cardiac recording when a high sampling
rate is desirable.
Formation of more complex images uses an array
of ultrasound crystals arranged to provide a 2D tomo-
graphic or 3D volumetric data set of signals. Each
element in the transducer array can be controlled
electronically both to direct the ultrasound beam
across the region of interest and to focus the transmit-
ted and received signals. Echocardiographic imaging
uses a sector scanning format with the ultrasound signal
originating from a single location (the narrow end of
the sector), resulting in a fanlike shape of the image.
Sector scanning is optimal for cardiac applications
because it allows a fast frame rate to show cardiac
motion and a small transducer size (aperture or “foot-
print”) to fit into the narrow acoustic windows used for
echocardiography. Three-dimensional imaging trans-
ducers are discussed in Chapter 4.
Most transducers can provide simultaneous imag-
ing and Doppler analysis, for example, 2D-imaging
and a superimposed color Doppler display. Quantita-
tive Doppler velocity data are recorded with the image
“frozen” or with only intermittent image updates, with
the ultrasound crystals used to optimize the Doppler
signal. Although CW Doppler signals can be obtained
using two elements of combined transducer, use of a
dedicated nonimaging transducer with two separate
crystals (with one crystal continuously transmitting
and the other continuously receiving the ultrasound
waves) is recommended when accurate high-velocity
recordings are needed. The final configuration of a
Figure 1–6 Schematic diagram of beam ge-
ometry for an unfocused (left) and focused
(right) transducer. The length of the near zone
and the divergence angle in the far field depend
on transducer frequency and aperture. The
focal zone of a focused transducer can be ad-
justed, but beam width still depends on depth.
Side lobes (and grating lobes with phased-array
transducers) occur with both focused and unfo-
cused transducers and, like the central beam,
are 3D.
transducer depends on transducer frequency (higher-
frequency transducers are smaller) and beam focusing,
as well as the intended clinical use, for example, trans-
thoracic versus TEE imaging.
Beam Shape and Focusing
An unfocused ultrasound beam is shaped like the light
from a flashlight, with a tubular beam for a short dis-
tance that then diverges into a broad cone of light (Fig.
1-6). Even with current focused transducers, ultrasound
beams have a 3D shape that affects measurement accu-
racy and contributes to imaging artifacts. Beam shape
and size depend on several factors, including:
n  ransducer frequency
T
n Distance from the transducer
n Aperture size and shape
n Beam focusing
  
Aperture size and shape and beam focusing can be
manipulated in the design of the transducer, but the
effects of frequency and depth are inherent to ultra-
sound physics. For an unfocused beam, the initial seg-
ment of the beam is columnar in shape (near field Fn)
with a length dependent on the diameter D of the
transducer face and wavelength (λ):
/
Fn = D2 4λ (1-6)
For a 3.5-MHz transducer with a 5-mm diameter
aperture, this corresponds to a columnar length of 1.4
cm. Beyond this region, the ultrasound beam diverges
(far field), with the angle of divergence θ determined as:
/
sin θ = 1.22λ D (1-7)
This equation indicates a divergence angle of 6°
beyond the near field, resulting in an ultrasound beam
width of about 4.4 cm at a depth of 20 cm for this 3.5-
MHz transducer. With a 10-mm diameter aperture, Fn
Unfocused Focused
transducer transducer
Near zone Beam
Side width
lobes
Focal
zone
Divergence
angle
 9
Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1

30 Figure 1–7 Transducer frequency versus

near zone length and divergence angle.
Transducer frequency is shown on the horizon-

Divergence angle (degrees)

20 tal axis with the length of the near zone shown
Length of near zone (cm)

in yellow and divergence angle in blue for un-

20 focused 5- (squares) and 10-mm (triangles)
10 mm aperture diameter aperture transducers. Equations (1-6)
and (1-7) were used to generate these curves.

10
10
5 mm aperture

0 0
0 5 10
Transducer frequency (MHz)

would be 5.7 cm and beam width at 20 cm would be

Main Side
about 2.5 cm (Fig. 1-7).
lobe lobe 1 Side The shape and focal depth (narrowest point) of the
lobe 2 primary beam can be altered by making the surface of
the piezoelectric crystal concave or by the addition of
an acoustic lens. This allows generation of a beam with
optimal characteristics at the depth of most cardiac
structures, but again, divergence of the beam beyond
F the focal zone occurs. Some transducers allow manip-
ulation of the focal zone during the examination. Even
θ2
with focusing, the ultrasound beam generated by each
transducer has a lateral and an elevational dimension
θ1
that depends on the transducer aperture, frequency,
and focusing. Beam geometry for phased-array trans-
ducers also depends on the size, spacing, and arrange-
ment of the piezoelectric crystals in the array.
In addition to the main ultrasound beam, dispersion
of ultrasound energy laterally from a single-crystal
transducer results in formation of side lobes at an angle
θ from the central beam where sin θ = m λ /D, and
m is an integer describing sequential side lobes (i.e., 1,
2, 3, and so on) (Fig. 1-8). Reflected or backscattered
λ signals from these side lobes may be received by the
transducer, resulting in image or flow artifacts. With
P1 P2 phased-array transducers, additional accessory beams
at an even greater angle from the primary beam,
Main lobe
Intensity

Figure 1–8 Transducer beam side lobes. Top: This diagram shows that
side lobes occur at the points where the distances traversed by the ultrasound
Side pulse from each edge of the crystal face differ by exactly one wavelength. The
lobe 1 Side
distance from the left edge of the crystal (P1) to the position of side lobe 1 is
lobe 2
exactly one wavelength (λ) longer than the distance from the extreme right
edge of the crystal (P2) to the position of side lobe 1. Bottom: The beam inten-
sity plot formed by sweeping along an arc at focal length F. (From Geiser EA:
θ2 θ1 0 θ1 θ2 Echocardiography: physics and instrumentation. In Skorton DJ, Schelbert AR,
Wolf GL, Brundage BH [eds]: Marcus Cardiac Imaging, 2nd ed. Philadelphia:
Angular position WB Saunders, 1996, p 280. Used with permission.)
10
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis

Acoustic
lens

Lateral

Slice thickness
(elevational)
Axial

Resolution components Elevational profile of

A in 3D space B ultrasound beam with depth
Figure 1–9 Axial, lateral, and elevational slice thickness in three dimensions for a phased-array transducer ultrasound beam. A, Axial resolution along
the direction of the beam is independent of depth; lateral resolution and elevational resolution are strongly depth dependent. Lateral resolution is determined by
transmit and receive focus electronics; elevational resolution is determined by the height of the transducer elements. At the focal distance, axial is better than
lateral and is better than elevational resolution. B, Elevational resolution profile with an acoustic lens across the transducer array produces a focal zone in the
slice thickness direction. (From Bushberg JT, et al: The Essential Physics of Medical Imaging. Philadelphia: Lippincott Williams & Wilkins, 2002, Fig. 16-21).

termed grating lobes, also occur as a result of construc-

TABLE 1-4 Determinants of Resolution
tive interference of ultrasound wave fronts. Both the
in Ultrasound Imaging
side lobes and the grating lobes affect the lateral and
elevational resolution of the transducer. Axial Resolution

Transducer frequency
Resolution
Transducer bandwidth
Image resolution occurs for each of three dimensions Pulse length
(Fig. 1-9):
  
Lateral Resolution
n  xial resolution along the length of the ultrasound
A
beam Transducer frequency
n Lateral resolution side to side across the 2D image Beam width (focusing) at each depth*
n Elevational resolution or thickness of the tomo- Aperture (width) of transducer
graphic slice
   Bandwidth
Of these three, axial resolution is most precise, so
Side and grating lobe levels
quantitative measurements are made most reliably using
data derived from a perpendicular alignment between Elevational Resolution
the ultrasound beam and structure of interest. Axial Transducer frequency
resolution depends on the transducer frequency, band-
width, and pulse length but is independent of depth Beam width in elevational plane
(Table 1-4). Determination of the smallest resolvable *Most important.
distance between two specular reflectors with ultrasound
is complex but is typically about twice the transmitted
wavelength; higher-frequency (shorter-wavelength) beam width at each depth. In the focal region where
transducers have greater axial resolution. For example, beam width is narrow, lateral resolution may approach
with a 3.5 MHz transducer, axial resolution is about axial resolution, and a point target will appear as a
1 mm, versus 0.5 mm with a 7.5 MHz transducer. A point on the 2D image. At greater depths, beam width
wider bandwidth also improves resolution by allow- diverges so a point target results in a reflected signal
ing a shorter pulse, thus avoiding overlap between the as wide as the width of the beam, which accounts for
reflected ultrasound signals from two adjacent reflectors. “blurring” of images in the far field. If the 2D image
Lateral resolution varies with the depth of the spec- is examined carefully, progressive widening of the
ular reflector from the transducer, primarily related to echo signals from similar targets along the length of

Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1
Figure 1–10 Beam width effect on 2D imaging. 2D echocardio-
graphic view of the LV from an apical approach. The effect of beam width
can be appreciated by comparing the length of reflections from point targets
near and at greater distances from the transducer as shown by the arrows.
the ultrasound beam can be appreciated (Fig. 1-10).
Erron­eous interpretations occur when the effects of
beam width are not recognized. For example, beam
width artifact from a strong specular reflector may
appear to be an abnormal linear structure. Other
factors that affect lateral resolution are transducer
frequency, aperture, bandwidth, and side and grating
lobe levels.
Resolution in the elevational plane is more difficult
to recognize on the 2D image but is equally impor-
tant in clinical diagnosis. The thickness of the tomo-
graphic plane varies across the 2D image, depending
on transducer design and focusing, both of which
affect beam width in the elevational plane at each
depth. In general, cardiac ultrasound images have a
“thickness” of approximately 3 to 10 mm depend-
ing on depth and the specific transducer used. The
tomographic image generated by the instrument, in
effect, includes reflected and backscattered signals
from this entire thickness. Strong reflectors adjacent
to the image plane may appear to be “in” the image
plane because of elevational beam width. Even more
distant strong reflectors may appear superimposed on
the tomographic plane because of side lobes in the
elevational plane. For example, a linear echo in the
aortic lumen from an adjacent calcified atheroma may
look like a dissection flap. These principles of ultra-
sound imaging also apply to 3D echocardiography
(see Chapter 4).
11
ULTRASOUND IMAGING MODALITIES
M-Mode
Historically, cardiac ultrasound began with a single-
crystal transducer display of the amplitude (A) of
reflected ultrasound versus depth on an oscilloscope
screen. This A-mode display may still be shown on
the 2D image screen to aid the examiner in optimal
adjustment of the instrument controls. Repeated pulse
transmission-and-receive cycles allow rapid updating
of the amplitude-versus-depth information so that
rapidly moving structures, such as the aortic or mitral
valve leaflets, can be identified by their characteristic
timing and pattern of motion (Fig. 1-11).
With the time dimension shown explicitly on the
horizontal axis and each amplitude signal along the
length of the ultrasound beam converted to a corre-
sponding gray-scale level, a motion (M) mode display is
produced. M-mode data are shown on the video moni-
tor either “scrolling” or “sweeping” across the screen
at 50 to 100 mm/s. Two-dimensional (2D) imaging
allows guidance of the M-mode beam to ensure an
appropriate angle between the M line and the struc-
tures of interest.
Because only a single “line of sight” is included in
an M-mode tracing, the pulse repetition frequency
(PRF) of the transmission-and-receive cycle is lim-
ited only by the time needed for the ultrasound beam
to travel to the maximum depth of interest and back
to the transducer. Even a depth of 20 cm requires
only 0.26 ms (given a speed of propagation of 1540
m/s), allowing a PRF up to 3850 times per second.
In actual practice, sampling rates of about 1800
times per second are used. This extremely high sam-
pling rate is valuable for accurate evaluation of rapid
normal intracardiac motion such as valve opening
and closing. In addition, continuously moving struc-
tures, such as the ventricular endocardium, may be
identified more accurately when motion versus time,
as well as depth, is displayed clearly on the M-mode
recording. Other examples of rapid intracardiac
motion best demonstrated with M-mode imaging
include the high-frequency fluttering of the anterior
mitral leaflet in patients with aortic regurgitation and
the rapid oscillating motion of valvular vegetations.
Two-Dimensional Echocardiography
Image Production
A 2D echocardiographic image is generated from the
data obtained by electronically “sweeping” the ultra-
sound beam across the tomographic plane. For each
scan line, short pulses (or bursts of ultrasound) are
emitted at a PRF determined by the time needed for
ultrasound to travel to and from the maximum image
depth. The pulse repetition period is the total time
12
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis

3D/2D M-mode A-mode

Distance Time

Ao Ao

Depth
Ao

LA LA

Distance

Time

Figure 1–11 3D, 2D, M-mode, and A-mode recordings of aortic valve motion. This illustration shows the following: the relationship between the 3D and
2D long-axis image of the aortic valve (left), which shows distance in both the vertical and horizontal direction; M-mode recording of aortic root (Ao), left atrium
(LA), and aortic valve motion, which shows depth-versus-time (middle); and A-mode recording (right), which shows depth only (with motion seen on the video
screen). Spatial relationships are best shown with 3D or 2D imaging, but temporal resolution is higher with M-mode and A-mode imaging.

from pulse to pulse, including the length of the ultra-
sound signal plus the time interval between signals.
Because a finite time is needed for each scan line
of data (depending on the depth of interest), the time
needed to acquire all the data for one image frame is
directly related to the number of scan lines and the
imaging depth. Thus, PRF is lower at greater imag-
ing depths and higher at shallow depths. In addition,
there is a tradeoff between scan line density and
image frame rate (the number of images per sec-
ond). For cardiac applications, a high frame rate (≥30
frames per second) is desirable for accurate display
of cardiac motion. This frame rate allows 33 ms per
frame or 128 scan lines per 2D image at a displayed
depth of 20 cm.
The reflected ultrasound signals for each scan line
are received by the piezoelectric crystal and a small
electric signal generated with:
  
n  mplitude proportional to incident angle and
A ultrasound with tissue and with the key properties:
acoustic impedance
time-gain compensation (TGC), filtering (to reduce
noise), compression, and rectification. Envelope
detection generates a bright spot for each signal
along the scan line, which then undergoes analog-
to-digital scan conversion, since the original polar
coordinate data must be fit to a rectangular matrix
with appropriate interpolation for missing matrix
elements. This image is subject to further “postpro-
cessing” to enhance the visual appreciation of tomo-
graphic anatomy and is displayed in “real time”
(nearly simultaneous with data acquisition) on the
monitor screen.
Although standard ultrasound imaging is based
on reflection of the fundamental transmitted fre-
quency from tissue interfaces, tissue harmonic imaging
(THI) instead is based on the harmonic frequency
energy generated as the ultrasound signal propagates
through the tissues. These harmonic frequencies
result from the nonlinear effects of the interaction of
  

n Timing proportional to distance from the n  armonic signal strength increases with depth
H
transducer of propagation.
   n Harmonic frequencies are maximal at typical
This signal undergoes complex manipulation cardiac imaging depths.
to form the final image displayed on the monitor. n Stronger fundamental frequencies produce
Typical processing includes signal amplification, stronger harmonics.
  

Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1
Near the skin, very
few harmonics are Fundamental
produced Harmonics
Signal strength
At usual imaging
distances, harmonics
are much stronger
0 4 8 12 16
Distance [cm]
Figure 1–12 Relation between imaging distance and strength of funda-
mental and harmonic frequencies. As ultrasound pulse propagates, strength
of fundamental frequency declines, while strength of harmonic frequency in-
creases. At usual imaging distances for cardiac structures, strength of har-
monic frequency is maximized. In this schematic, harmonic frequency strength
is exaggerated; harmonic frequency signal strength is much lower than funda-
mental frequency signal strength. (From Thomas JD, et al: Tissue harmonic
imaging: why does it work? J Am Soc Echocardiog 11:803-808, 1998.)
Thus, harmonic imaging reduces near-field and
side-lobe artifacts and improves endocardial definition,
particularly in patients with poor fundamental fre-
quency images (Fig. 1-12). THI improves visualization
of the left ventricular (LV) endocardium, which allows
border tracing for calculation of ejection fraction,
reduces measurement variability, and results in visu-
alization of more myocardial segments during stress
echocardiography. However, although THI improves
lateral resolution by 20-50%, it reduces axial resolu-
tion by 40 to 100%. Thus, valves and other planar
objects may appear thicker with harmonic, compared
to fundamental, frequency imaging, so that caution is
needed when diagnosing valve abnormalities or mak-
ing measurements of chamber or vessel size.
Instrument Settings
Many of the elements in the process of image for-
mation are features of a particular transducer and
instrument that cannot be modified by the operator.
However, for each patient and echocardiographic
view, optimal image quality depends on transducer
selection and instrument settings. Standard imaging
controls available in most ultrasound systems include:
  
n  ower output: This control adjusts the total ultra-
P image quality resulting from poor ultrasound tissue pen-
sound energy delivered by the transducer in the
transmitted bursts; higher power outputs result
in higher-amplitude reflected signals (see Bioef-
fects and Safety, p. 27.).
n Gain: Adjusts the displayed amplitude of the
received signals, similar to the volume control in
an audio system.
13
n  GC: Allows differential adjustment of gain
T
along the length of the ultrasound beam to
compensate for the effects of attenuation. Near-
field gain can be set lower (because reflected
signals are stronger) with a gradually increased
gain over the midfield (“ramp” or “slope”) and
a higher gain in the far field (because reflected
signals are weaker). On some instruments, near-
field and far-field gain beyond the range of the
TGC are adjusted separately.
n Depth: Displayed depth affects the PRF and
frame rate of the image and also allows maxi-
mal display of the area of interest on the screen.
20 Standard depth settings show the entire plane
(from the transducer down), while “resolution,”
“zoom,” or “magnification” modes focus on a
specific depth range of interest.
n Dynamic range/compression: The amplitude range
(in dB) of the reflected signal is greater than the
display capacity of ultrasound systems so the
signal is compressed into a range of values from
white to black, or gray scale. The number of lev-
els of gray in the image, or dynamic range, can be
adjusted to provide an image with marked con-
trast between light and dark areas or a gradation
of gray levels between the lightest and darkest
areas. A variation of standard gray scale is to use
color intensity for each amplitude value.
  
Other typical instrument controls include prepro-
cessing and postprocessing settings that change the
appearance of the displayed image. Image quality and
resolution also depend on scan-line density and other
factors (see Table 1-4). Scan-line density (or frame rate
or both) can be increased by using a lower depth set-
ting or by narrowing the sector to less than the stan-
dard 60° wide image.
Imaging Artifacts
Imaging artifacts include (1) extraneous ultrasound
signals that result in the appearance of “structures”
that are not actually present (at least at that location),
(2) failure to visualize structures that are present, and
(3) an image of a structure that differs in size or shape
or both from its actual appearance. Obviously, rec-
ognition of image artifacts is important for both the
individual performing the study and the individual
interpreting the echocardiographic data (Table 1-5).
The most common image “artifact” is suboptimal
etration related to the patient’s body habitus with inter-
position of high attenuation tissues (e.g., lung or bone)
or an increased distance (e.g., adipose tissue) between
the transducer and cardiac structures. While, strictly
speaking, poor image quality is not an “artifact,” a low
signal-to-noise ratio makes accurate diagnosis difficult
and precludes quantitative measurements. In many
14
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis

TABLE 1-5 Ultrasound Imaging Artifacts

Artifact Mechanism Example(s)

Suboptimal image Poor ultrasound tissue penetration Body habitus (obesity, lung disease)
quality Postcardiac surgery
Acoustic shadowing Reflection of entire ultrasound signal by a strong Prosthetic valve
specular reflector Calcification
Reverberations Reverberation between two strong parallel reflectors Prosthetic valve
Beam width Superimposition of structures within the beam Aortic valve “in” LA
profile (including side lobes) into a single Atheroma “in” aortic lumen
tomographic image
Lateral resolution Displayed width of a point target varies with depth Excessive width of calcified mass or
prosthetic valve
Refraction Deviation of ultrasound signal from a straight path Double aortic valve or LV image in
along the scan line short-axis view
Range ambiguity Echo from previous pulse reaches transducer on Second, deeper heart image
next cycle
Electronic Instrument specific Variable
processing

patients with suboptimal ultrasound penetration,

image quality is improved by use of tissue harmonic
MVR
imaging. In some cases, TEE imaging may be needed
to make an accurate diagnosis. LA
Acoustic shadowing (Fig. 1-13) occurs when a structure
with a marked difference in acoustic impedance (e.g.,
prosthetic valve, calcium) blocks transmission of the
ultrasound wave beyond that point. The image appears
devoid of reflected signals distal to this structure, since
no signal penetrates beyond the shadowing structure. S
The shape of the shadow (like a light shadow) follows R S
the ultrasound path, so a small structure near the trans-
ducer casts a large shadow. When shadowing occurs,
an alternate acoustic window is needed for evaluation
of the area of interest. In some cases, a different trans-
thoracic view will suffice. In other cases (e.g., prosthetic
mitral valve), TEE imaging may be necessary.
Reverberations (Fig. 1-14) are multiple linear high-
amplitude echo signals originating from two strong
specular reflectors resulting in back-and-forth reflec- Figure 1–13 Example of acoustic shadowing and reverberations.
TEE view in a patient with a valve replacement (MVR) shows shadowing (S)
tion of the ultrasound signal before it returns to the by the sewing ring with reverberations (R) from the valve occluders further
transducer. On the image, reverberations appear as obscuring the ventricle.
relatively parallel, irregular, dense lines extending
from the structure into the far field. Like acoustic
shadowing, prominent reverberations limit evaluation the structures within the 3D volume of the ultrasound
of structures in the far field. In less dramatic cases, beam are displayed in a single tomographic plane. In
reverberations may appear to represent abnormal the focal zone of the beam, the 3D volume is quite
structures. For example, in the parasternal long-axis small and the tomographic “slice” is narrow. In the far
view, a linear echo in the aortic root may originate as a zone, however, strong reflectors at the edge of a larger
reverberation from anterior structures (e.g., ribs) rather beam will be superimposed on structures in the central
than representing a dissection flap. zone of the beam even though signal intensity falls off
The term beam width artifact is applied to two sepa- at the edges of the beam. In addition, strong reflec-
rate sources of image artifacts. First, remember that all tors in side lobes of the beam will be displayed in the

Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1
Transducer
A B
Parallel
Reverberations strong reflectors
A Ultrasound
artifacts
B
Figure 1–14 Reverberation artifacts result from the interaction of ul-
trasound with two parallel strong reflectors. The transmitted ultrasound
beam (red with down arrow) is reflected from the first reflector and returns
to the transducer (red with up arrow) resulting in an ultrasound signal that
corresponds to the correct depth of the reflector. However, ultrasound
signals also reflect back and forth between the two strong reflectors, with
some signals returning to the transducer after two (A), three (B), or more
reverberation cycles. The longer time from transmission to reception of
these late-returning signals results in their display on the ultrasound im-
age at points distal to the actual reflector. In clinical imaging, reverberation
artifacts can either appear as a single linear signal distal to the actual object
or as a band of signals obscuring distal structures (see Fig. 1-13) because
of multiple parallel reflectors.
tomographic section corresponding to the main beam
(Fig. 1-15).
The second type of beam width artifact is a con-
sequence of varying lateral resolution at different
imaging depths. A point target appears as a line whose
length depends on the beam characteristics at that
depth and the amplitude of the reflected signal. For
example, the struts on a prosthetic valve can appear
much longer than their actual dimension because of
poor lateral resolution. Sometimes beam width arti-
facts can be mistaken for abnormal structures such as a
valvular vegetation, an intracardiac mass, or an aortic
dissection flap.
The appearance of a side-by-side double image
results from ultrasound refraction as it passes through
a tissue proximal to the structure of interest. This
artifact often is seen in parasternal short-axis views
15
LA
Ao
RVOT
Figure 1–15 Example of beam width artifact. Apparent “mass” at-
tached to the aortic valve on this off-axis TEE view is the noncoronary cusp
of the aortic valve seen “en face.” Imaging in other planes demonstrated a
normal trileaflet aortic valve.
of the aortic valve or LV, where a second valve or LV
is “seen” medial to and partly overlapping the actual
valve or LV. The explanation for this appearance
is that the transmitted ultrasound beam is deviated
from a straight path (the scan line) by refraction as it
passes through a tissue near the transducer. When this
refracted beam is reflected back to the transducer by a
tissue interface, the reflected signal is assumed to have
originated from the scan line of the transmitted pulse
(Fig. 1-16) and thus is displayed on the image in the
wrong location.
Range ambiguity occurs when echo signals from an
earlier pulse cycle reach the transducer on the next
“listen cycle” for that scan line, resulting in deep struc-
tures appearing closer to the transducer than their
actual location. The appearance of an anatomically
unexpected echo within a cardiac chamber often is
due to range ambiguity, as can be demonstrated by the
disappearance or a change in position of this artifact
when the depth setting (and PRF) is changed. Another
type of range ambiguity is the appearance of an
apparent second heart, deeper than the actual heart—
a double image on the vertical axis. This type of range
ambiguity results from echoes being re-reflected by a
structure close to the transducer (such as a rib), being
re-reflected by the cardiac structures and thus received
at the transducer at a time twice normal. This artifact
can be eliminated (or obscured) by decreasing the
depth setting or adjusting the transducer position to a
better acoustic window.
16
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis
Transducer
Refraction of
ultrasound beam
by intervening
tissue
Specular
reflector
1 septal myocardium. Instead, 2D measurements of
3 2
Double image
of Ao Actual Ao
Figure 1–16 Mechanism of a double-image artifact on 2D echocar-
diography. An ultrasound pulse reflected from point 1 of the LV endocar-
dium returns to the transducer and is shown appropriately as a bright spot
in the correct position on the 2D image. Later in the scan, an ultrasound
pulse is refracted by an intervening tissue so that the beam is reflected back
to the transducer from point 2. However, this reflected signal is shown along
the transmission scan line (point 3) because this is the presumed origin of
the reflected signal. Ao, aorta in cross-section.
Electronic processing artifacts can be difficult to identify
and vary from instrument to instrument. In addition,
types of artifacts other than those listed have been
described.
Three-Dimensional Echocardiography
Three-dimensional echocardiographic imaging is
based on the same ultrasound principles used in 2D
imaging with more complex acquisition of a volume
of ultrasound data and more complex display options.
The physics of 3D imaging are very similar to those
of 2D imaging, and issues like beam width, resolution,
and frame rate affect both approaches (see Chapter
4). Three-dimensional echocardiographic displays
currently used in clinical practice provide perspective
type anatomic images from different points of view, for
example, a view of the left atrial (LA) side of the mitral
valve. The same imaging artifacts seen on 2D images
can be seen with 3D imaging.
Echocardiographic Imaging
Measurements
Echocardiographic measurements are most accurate
using axial resolution (i.e., along the length of the
ultrasound beam). Measurements can be made using
the leading edge–to–leading edge convention or at the
white-black interface between tissues. The rationale
for measuring from the leading edge is that the first
reflection detected from the tissue interface is the best
measure of its actual location, with other signals arriv-
ing slightly later because of reflections from within
the tissue, reverberations, and ring-down artifact. The
leading edge convention is used for M-mode studies
and much of the literature validating echocardio-
graphic measurements for clinical decision making is
based on this measurement approach.
On 2D images, identification of the leading edge
is challenging,—for example, in a parasternal long-
axis view, separating the leading edge of the LV sep-
tal endocardium from signals originating within the
cardiac chambers and great vessels are made using
the white-black interface; LV internal dimensions
are measured from the white-black interface of the
septum to the white-black interface of the posterior
wall. With current image quality, the white-black
interface is a reasonable representation of the actual
tissue-blood interface because the leading edge of
the endocardial echo and white-black interface are
nearly identical. For measurements of great vessels,
such as the aorta, the white-black interface conven-
tion is more reproducible than attempts to identify a
leading edge on 2D images. Measurement of small
solid or planar structures is problematic so direct
measurements of valve thickness, for example, are
not routine.
Quantitative measurements are problematic as the
3D data is viewed as a 2D image, so measurements
are made on 2D images within the 3D data set. Using
this approach, 3D echocardiographic LV volumes are
more accurate than those obtained by 2D imaging, as
discussed in Chapter 4.
DOPPLER ECHOCARDIOGRAPHY
Doppler Velocity Data
Doppler Equation
Doppler echocardiography is based on the change
in frequency of the backscattered signal from small
moving structures (e.g., red blood cells) intercepted
by the ultrasound beam (Table 1-6). A visual anal-
ogy is that Doppler scattering from blood is similar
to scattering of light in fog, while imaging is simi-
lar to reflections from a mirror. A stationary target,
if much smaller than the wavelength, will scatter
ultrasound in all directions, with the frequency of
the scattered signal being the same as the transmit-
ted frequency when observed from any direction. A
moving target, however, will backscatter ultrasound
to the transducer so that the frequency observed
when the target is moving toward the transducer is
higher and the frequency observed when the target
is moving away from the transducer is lower than the

Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1
TABLE 1-6 Doppler Physics
Definition Examples
Doppler effect The change in frequency of A higher velocity corresponds
ultrasound scattered from to a higher Doppler
a moving target frequency shift, ranging
v = c × ∆F / [2 FT (cos θ)] from 1 to 20 kHz for
intracardiac flow velocities.
Intercept angle The angle (θ) between the When the ultrasound beam is
direction of blood flow parallel to the direction of
and the ultrasound beam blood flow (0° or 180°), cos
θ is 1 and can be ignored in
the Doppler equation.
CW Doppler Continuous ultrasound CW Doppler allows
transmission with measurements of high-
reception of Doppler velocity signals but does
signals from the entire not localize the depth of
length of the ultrasound origin of the signal.
beam
Pulsed Doppler Pulsed ultrasound Pulsed Doppler samples
transmission with velocities from a specific
timing of reception site but can only measure
determining depth of the velocity over a limited
backscattered signal range.
PRF The number of pulses The PRF is limited by the time
transmitted per second needed for ultrasound to
reach and return from the
depth of interest.
PRF determines the maximum
velocity that can be
unambiguously measured.
Nyquist limit The maximum frequency The Nyquist limit is displayed
shift (or velocity) as the top and bottom of
measurable with pulsed the velocity range with the
Doppler equal to ½ PRF baseline centered.
Signal aliasing The phenomenon that With aliasing of the LV
the direction of flow for outflow signal, the peak
frequency shifts greater of the velocity curve is
than the Nyquist limit “cut off” and appears
cannot be determined as flow in the opposite
direction.
Sample volume The intracardiac location Sample volume depth
where the pulsed Doppler is determined by the
signal originated time interval between
transmission and
reception.
Sample volume length is
determined by the duration
of the receive cycle.
Spectral analysis Method used to display Spectral analysis is used
Doppler velocity data for both pulsed and CW
versus time, with gray Doppler.
scale indicating amplitude
17
Clinical Implications
Ultrasound systems display
velocity, which is calculated
using the Doppler equation,
based on transducer
frequency and the Doppler
shift, assuming cos θ
equals 1.
Velocity is underestimated
when the intercept angle is
not parallel. This can lead
to errors in hemodynamic
measurements.
CW Doppler is used to
measure high velocities
in valve stenosis and
regurgitation.
Pulsed Doppler is used to
record low-velocity signals
at a specific site, such as
LV outflow velocity or LV
inflow velocity.
The maximum velocity
measurable with pulsed
Doppler is about 1 m/s at 6
cm depth.
The greater the depth,
the lower the maximum
velocity measurable with
pulsed Doppler
Aliasing can result in
inaccurate velocity
measurements if not
recognized.
Sample volume depth and
length are adjusted to
record the flow of interest.
The velocity scale, baseline
position, and time scale
of the spectral display are
adjusted for each Doppler
velocity signal.
18
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis
Stationary Scatterer Moving Scatterer
λ V=
F1 F2 F1 F2
F1 = F2 F1 < F2
Figure 1–17 The Doppler effect. A stationary scatterer (left) scatters ultra-
sound symmetrically in all directions with a wavelength identical to the trans-
mitted wavelength and with the same frequency in all directions (no Doppler
shift). A moving scatterer (right) also scatters ultrasound symmetrically in
all directions. However, the frequency will be higher when the scatterer is
moving toward the transducer (F2) than when it is moving away from the
transducer (F1) because of the movement of the scatterer resulting in waves
closer together in advance of and farther apart behind the moving object.
original transmitted frequency (Fig. 1-17). This Dop-
pler effect is known to all of us from audio examples
of the change in sound of a car horn, siren, or train
whistle as it moves toward (higher pitch) and then
away (lower pitch) from the observer.
The difference in frequency between the transmit-
ted frequency (Ft) and the scattered signal received
back at the transducer (Fs) is the Doppler shift:
Doppler shift = (FS − FT ) (1-8)
Doppler shifts are in the audible range (0-20 kHz)
for intracardiac velocities using diagnostic ultrasound
transducer frequencies. The relationship between the
Doppler shift and blood flow velocity (v, in m/s) is
expressed in the Doppler equation:
/
v = c (FS − FT ) [2 FT (cos θ)] (1-9)
where c is the speed of sound in blood (1540 m/s), θ is
the intercept angle between the ultrasound beam and
the direction of blood flow, and 2 is a factor to cor-
rect for the transit time both to and from the scattering
source (Fig. 1-18).
Note that intercept angle is critically important in
calculation of blood flow velocity. The cosine of an
angle of 0° or 180° (parallel toward or away from
the transducer) is 1, allowing this term to be ignored
when the ultrasound beam is aligned parallel to the
direction of blood flow. In contrast, the cosine of
90° is zero, indicating that no Doppler shift will be
recorded if the ultrasound beam is perpendicular to
blood flow.
In cardiac Doppler applications, the ultrasound
beam is aligned as close as possible to parallel with
the direction of blood flow so that the cos θ can be
assumed to be 1. Because the direction of intracardiac
blood flow can be difficult to ascertain and is not pre-
dictable from the 2D image, especially with abnormal
flow patterns, attempts to “correct” for intercept angle
Blood
flow
c (F S − F T)
2 F T (cos θ)
Doppler Equation θ
FT
FS
T
Figure 1–18 The Doppler equation. The velocity V of blood flow can be
calculated from the speed of sound in blood c, transducer frequency FT,
backscattered frequency FS, and the cosine of the angle θ between the
ultrasound beam and direction of blood flow.
may result in significant errors in velocity calcula-
tion. Even when blood flow direction is apparent in
a 2D plane, direction in the elevational plane remains
unknown. Deviation up to 20° from a parallel intercept
angle results a calculated velocity only 6% less than
the actual blood flow velocity. However, a 60° inter-
cept angle results in a calculated velocity that is only ½
the actual velocity. The importance of intercept angle
is particularly underlined in the setting of abnormal
blood flow with high-velocity jets, such as in valvular
stenosis. Although angle correction for the presumed
direction of blood flow is used in some peripheral vas-
cular applications, this approach is not acceptable for
cardiac applications because of the likelihood that the
“correction” will be erroneous.
Spectral Analysis
When the backscattered signal is received at the trans-
ducer, the difference between the transmitted and
backscattered signals is determined by “comparing”
the two waveforms. This is a complex process because
multiple frequencies are present in the backscattered
signal. Typically, the frequency content of the signal
is analyzed by a process known as a fast Fourier trans-
form (FFT) that derives the component frequencies
of a complex signal. Alternate methods of frequency
analysis, such as the analog Chirp-Z method, also may
be employed.
The display generated by this frequency analysis is
termed spectral analysis (Fig. 1-19). By convention, this
display shows time on the horizontal axis, the zero
baseline in the center, and frequency shifts toward the
transducer above and frequency shifts away from the
transducer below the baseline. Because multiple fre-
quencies exist at any time point, each frequency signal
is displayed as a pixel on the vertical axis, with the gray
scale indicating the amplitude (or loudness) and the
position on the vertical axis indicating the blood flow
 19
Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1

APEX AV

Figure 1–19 Examples of pulsed (left) and CW (right) spectral Doppler displays. LV outflow recorded from an apical approach is shown in the standard
format. The baseline has been moved from the middle of the vertical axis to display the antegrade flow signal. Velocities toward the transducer are shown
above and velocities away from the transducer below the baseline. The velocity range is determined by the Nyquist limit (½ PRF) with pulsed Doppler echo.
Velocities are shown in shades of gray corresponding to the amplitude (dB) of the signal. Note the “envelope” of flow with pulsed Doppler because flow is
sampled at a specific intracardiac location with relatively uniform blood flow velocities. With CW Doppler, the curve is “filled in” due to multiple blood flow
velocities along the entire length of the ultrasound beam.

velocity (or frequency shift) component. Thus, each
time point on the spectral display shows:
n  lood flow direction
B
n Velocity (or frequency shift)
n Signal amplitude
  
Each of these components is displayed at 4-ms
intervals (or 250 times per second) simultaneous with
data acquisition.
Continuous-Wave Doppler Ultrasound
CW Doppler uses two ultrasound crystals; one con-
tinuously transmits and one continuously receives the
ultrasound signal. The major advantage of CW Dop-
pler is that very high-frequency shifts (velocities) can be
measured accurately because sampling is continuous.
The potential disadvantage of CW Doppler is that sig-
nals from the entire length of the ultrasound beam are
recorded simultaneously. However, even with overlap
of flow data, a given signal often is characteristic in
timing, shape, and direction, allowing correct identifi-
cation of the origin of the signal. In some cases, other
methods (e.g., 2D echo, color, pulsed Doppler) must be
used to determine the depth of origin of the Doppler
signal.
CW Doppler optimally is performed with a dedi-
cated, nonimaging transducer with two crystals. This
type of transducer has a high signal-to-noise ratio and
a small footprint, allowing it to fit into small acoustic
windows (e.g., between ribs) and to be angled to obtain
a parallel intercept angle between the ultrasound beam
and the direction of blood flow. Use of a simultane-
ous imaging transducer may be helpful in some cases
but, signal quality may be poorer, angulation is more
difficult, and the 2D image may distract the operator
from optimizing the flow signal instead of the anatomic
image (which may not coincide).
Careful technique yields a Doppler spectral signal
that has a smooth contour with a well-defined edge
and maximum velocity, as well as with clearly defined
onset and end of flow. The audible signal is tonal
and smooth. A CW Doppler velocity curve is “filled
in” because lower-velocity signals proximal and distal
to the point of maximum velocity also are recorded.
Note that while the maximum frequency shift depends
on the intercept angle between the Doppler beam and
the flow of interest, amplitude (gray-scale intensity),
shape, and audible quality are less dependent on inter-
cept angle. Thus a “good quality” Doppler signal may
be recorded at a nonparallel intercept angle, resulting
in underestimation of flow velocity. The empirical
method to ensure a parallel intercept angle is to exam-
ine the flow of interest from multiple windows with
transducer angulation both in the plane of view and in
the elevational plane to discover the highest-frequency
shift. The highest value found is then assumed to rep-
resent a parallel intercept angle.
Pulsed Doppler Ultrasound
Pulsed Doppler echocardiography allows sampling
of blood flow velocities from a specific intracardiac
depth. A pulse of ultrasound is transmitted, and then,
after a time interval determined by the depth of inter-
est, the transducer briefly “samples” the backscattered
signals. This transducer cycle of transmit-wait-receive
is repeated at an interval termed the pulse repetition
20
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis

Pulsed Doppler Ultrasound

Transmitted Travel time Receive phase

ultrasound (SV depth) (SV length)
pulse
(F T)

...

Cycle length

9/
9
Time

r
PRF = cycles/s

i
Figure 1–20 Pulsed Doppler ultrasound. The pulsed Doppler transducer

h
goes through a repetitive cycle of transmission of an ultrasound pulse at the
transducer frequency (FT), a waiting period determined by the time needed

a
for the signal to travel to and from the depth of interest, and a receive phase
when the backscattered signals are sampled. The travel-time duration de-

t
termines sample volume depth. The duration of the receive phase deter-

r/
mines sample volume.

e
frequency (PRF) (Fig. 1-20). Because the “wait” inter-

s
val is determined by the depth of interest—the time
it takes ultrasound to travel to and from this depth—

/r u
each transducer cycle is longer for increasing depths.
Thus, the PRF also is depth dependent, being high at
shallow depths and low for more distant sites.
The pulsed Doppler depth of interest is called the Figure 1–21 Principle of signal aliasing. This schematic diagram shows

.t c
sample volume because signals from a small volume of
blood are sampled, with the width and height of this
volume dependent on beam geometry. The length of
how sampling at a constant interval (shown by vertical gray lines with a red
dot where the waveform is sampled) results in ambiguity in the measured
sound wave frequency. Sampling at twice the frequency of the wavelength,
as shown at the top, correctly measures the sound wave frequency. As the

a
the sample volume can be varied by adjusting the length sound wave frequency increases from top to bottom, intermittent sampling
of the transducer “receive” interval. Typically, a sample results in apparent frequencies that are lower and in the opposite direction

k
volume length of 3 mm is used to balance range resolu- of the actual sound waveform.

/: /
tion and signal quality, but a longer (5-10 mm) or shorter
(1-2 mm) sample volume may be useful in specific cases.
Because pulsed Doppler echo repeatedly samples the reverse channel, then back to the forward channel,

s
the returning signal, there is a maximum limit to the and so on. Occasionally, the shape of the waveform
frequency shift (or velocity) that can be measured can be discerned, but more often only an undiffer-

tt p
unambiguously. A waveform must be sampled at least
twice in each cycle for accurate determination of wave-
length. This phenomenon of ambiguity in the speed,
direction, or speed and direction of the sampled signal
entiated band of velocity signals can be appreciated.
Both nonlaminar disturbed flow and aliased laminar
high-velocity flow will appear (and sound) similar on

h
spectral analysis. Methods that can be used to resolve
is known as signal aliasing (Fig. 1-21). In order for the aliasing include:
frequency of an ultrasound waveform to be correctly
  
n Using CW Doppler ultrasound
identified, it must be sampled at least twice per wave-

n Increasing the PRF to the maximum for that
length. Thus, the maximum detectable frequency shift

depth (the Nyquist limit)
(the Nyquist limit) is one half the PRF.
n Increasing the number of sample volumes (high-
If the velocity of interest exceeds the Nyquist limit

PRF Doppler)
by a small degree, signal aliasing is seen with the sig-
n Using a lower frequency transducer
nal cut off at the edge of the display and the “top”

n Shifting the baseline to the edge of the display
of the waveform appearing in the reverse channel

  
(Fig. 1-22). In these cases, baseline shift (in effect, an CW Doppler is the most reliable approach to
electronic “cut and paste”) restores the expected veloc- resolving aliasing for very high velocities. The other
ity curve and allows calculation of maximum veloc- approaches are useful when the aliased velocity
ity. When velocities further exceed the Nyquist limit, exceeds the Nyquist limit by a modest degree (e.g., ≤
repeat “wraparound” of the signal occurs first into twice the Nyquist limit).
 21
Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1

9/
i r 9
a h
Figure 1–22 Pulsed Doppler signal aliasing. The velocity of LV outflow recorded from an apical approach exceeds the Nyquist limit so that aliasing occurs

t
(left) with the appearance of the peak of the outflow curve in the reverse channel (arrow). This degree of aliasing can be resolved by shifting the baseline

r/
(right), in effect an electronic “cut and paste” of the spectral display.

backscattered signals from this sample volume (SV1 ) and

e
a second sample volume (SV2 ) twice as far away (i.e., the

s
SV2 depth of interest) will return to the transducer during
the “receive” phase (albeit one cycle later). This record-

/r u
ing of the signal of interest at a higher PRF allows mea-
surement of higher velocities without signal aliasing (Fig.
SV1 1-24). An even higher PRF can be achieved by using
additional (three or four) proximal sample volumes. Of

.t c
course, the limitation of this approach is range ambigu-
ity. The spectral analysis now includes signals from each
of the sample volume depths and, as with CW Doppler,

a
T the origin of the signal of interest must be determined
based on ancillary data. However, high-PRF Doppler is

k
useful for evaluation of velocities just above the aliasing

/: /
Figure 1–23 High-pulse-repetition frequency (PRF) Doppler ultra- limit of conventional pulsed Doppler. Often, the high
sound. High-PRF Doppler is based on the concept that with a given sam- PRF mode is automatically enabled when the Doppler
ple volume depth (SV1), some ultrasound will penetrate beyond that depth. velocity range is increased.

s
Backscattered signals from exactly twice the set depth (SV2 ) will return to
the transducer (T) during the receive phase of the next cycle. Thus, signals
from both sample volume depths are recorded simultaneously.

tt p
Doppler Velocity Instrument Controls
Pulsed and CW Doppler instrument controls typically
High-PRF Doppler is the deliberate use of range
include:

h
ambiguity to increase the maximum velocity that can be
  
measured with pulsed Doppler echo (Fig. 1-23). When n Power output—adjusts the amount of electrical

the transducer sends out a pulse, backscattered signals energy transmitted to the transducer
from the entire length of the ultrasound beam return to n Receiver gain—changes the degree of amplifica-

the transducer. Range resolution is achieved by sampling tion of returning signals
only those signals in the short time interval correspond- n “Wall” or high-pass filters—eliminate low-

­
ing to the depth of interest. However, signals from exactly frequency Doppler shifts that result from motion
twice as far away as the sample volume will reach the of myocardium and valves (allowing only the
transducer during the “receive” phase of the next cycle. higher frequencies to pass the filter)
Thus, signals from “harmonics” at 2×, 3×, 4×, and so n Baseline shift—moves the zero line toward the

on from the sample volume depth have the potential of top or bottom of the display
being analyzed. Usually signal strength is low and there n Velocity range—increases or decreases the scale

are few moving scatterers at these depths, so this range (within the limits for each Doppler modality)
ambiguity can be ignored. If, instead, the sample volume n Dynamic range—compresses the signal ampli-

is placed purposely at one-half the depth of interest, tude into shades of gray
  
22
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis

3.2 m/s

9/
i r 9
a h
Figure 1–24 Example of HPRF Doppler. In this case, LV outflow velocity exceeds twice the Nyquist limit so that aliasing persists even after baseline shift

t
(left). The “wrapped around” peak velocity is clearly seen (arrow). With high-PRF Doppler, the maximum velocity is resolved in this patient with a subaortic

r/
membrane (right).

In addition, pulsed Doppler controls include:

e
TABLE 1-7 Doppler Ultrasound Artifacts
  
n Sample volume depth

s
Artifact Result

n Sample volume length

The number of sample volumes (high pulse

/r u
n Nonparallel Underestimation of velocity

repetition frequency Doppler echo) intercept angle
­
  
Each of the three major Doppler modalities may Aliasing Inability to measure maximum
be integrated with 2D imaging. However, while color velocity

.t c
Doppler flow imaging is nearly always conjoined with Range ambiguity Doppler signals from more
2D imaging, pulsed Doppler signal quality is opti- than one depth along the
mized when the 2D image is “frozen,” and CW Dop- ultrasound beam are recorded

a
pler is optimized using a dedicated, small-footprint Beam width Overlap of Doppler signals from
transducer with no 2D imaging. adjacent flows

/: / k
Mirror image Spectral display shows
Doppler Velocity Data Artifacts unidirectional flow both above
and below the baseline.
Many Doppler artifacts are related to ultrasound phys-
Electronic Bandlike interference signal

s
ics and beam geometry, analogous to those seen with interference obscures Doppler flow.
2D imaging. Others are specific to Doppler echocar-

tt p
diography (Table 1-7). Transit-time effect Change in the velocity of the
Clinically, the most important potential artifact ultrasound wave as it passes
through a moving medium
is velocity underestimation resulting from a nonparallel results in slight overestimation
intercept angle between the ultrasound beam and the

h
direction of blood flow (Fig. 1-25). Velocity underesti-
mation can occur with either pulsed or CW Doppler
techniques and is of most concern when measuring
high-velocity jets due to valve stenosis, regurgitation,
or other intracardiac abnormalities.
With pulsed Doppler echo, signal aliasing limits the
maximum measurable velocity. If the examiner recog-
nizes that aliasing has occurred, appropriate steps can
be taken to resolve the velocity data if needed. Aliasing
can be due to nonlaminar disturbed flow, as well as
high-velocity laminar flow.
Range ambiguity is inherent to CW Doppler but can
occur with pulsed Doppler as well. With a sample
volume positioned close to the transducer, strong
of Doppler shifts.
signals from twice (or three times) the depth of the
sample volume will be received in the next “receive”
phase and may be misinterpreted as originating
from the set sample volume depth. For example, in
an apical four-chamber view, placement of a sample
volume in the LV apex at half the distance to the
mitral annulus results in a spectral display showing
the inflow signal across the mitral valve from the
“second” sample volume depth. This phenomenon
 23
Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1

100 1 Figure 1–25 Effect of intercept angle on ve-

Cosine locity calculations. The importance of a paral-
Percent error lel intercept angle between the ultrasound beam
and direction of blood flow is shown. The cosine
80
0.5 function versus intercept angle (horizontal axis)
varies from 1 at a parallel angle (0° and 180°)
to 0 at a perpendicular angle (90°). The error
Percent error

60 with a non-parallel intercept angle varies from

Cosine
only 6% at a 20° angle to 50% at a 60° angle. At
0 a perpendicular (90°) intercept angle, no blood

/
flow velocities are recorded.
40

9
– 0.5

9
20

i r
20 degrees
6% error
0 –1

h
0 20 40 60 80 100 120 140 160 180

a
Intercept angle (degrees)

r/ t
AR

s e
/r u
LV inflow

.t c
k a
/: /
Figure 1–27 Mirror-image Doppler artifact. A mirror-image Doppler arti-
Figure 1–26 Doppler beam width artifact. This CW Doppler recording fact with apparent weaker flow signals in the reverse channel (arrow).

s
from an apical window shows superimposed signals of aortic regurgitation
(AR) and LV inflow in diastole because the width of the ultrasound beam

tt p
encompasses both flows. Bright lines caused by motion of prosthetic mitral or gain of the instrument. Interrogation of a flow sig-
valve disks also are seen (short arrow).
nal from a near-perpendicular angle also can result in
flow signals on both sides of the baseline.
of range ambiguity is used constructively in the

h
high-PRF Doppler mode.
Beam width (and side or grating lobes) affects the
Doppler signal, as occurs with 2D imaging, resulting
in superimposition of spatially adjacent flow signals
on the spectral display. For example, LV outflow and
inflow may be seen on the same recording, especially
with CW Doppler. Similarly, the LV inflow signal
may be seen superimposed on the aortic regurgitant
jet (Fig. l-26).
A mirror-image artifact is common with spectral anal-
ysis, appearing as a symmetric signal of somewhat
less intensity than the actual flow signal in the oppo-
site flow direction (Fig. 1-27). Mirroring often can be
reduced or eliminated by decreasing the power output
Electronic interference appears as a band of signals
across the spectral display that may obscure the flow
signals. These artifacts are the result of inadequate
shielding of other electric instruments in the examina-
tion environment and are particularly common during
studies in the intensive care unit, interventional proce-
dure areas, or operating room.
The transit time effect is the change in propagation
speed that occurs as an ultrasound wave passes through
a moving medium, such as blood. This phenomenon
is separate from the Doppler effect (which affects the
backscattered signal) and is the basis of volume flow
measurement with a transit-time flow probe. On the
spectral display, the transit-time effect may result in a
slight broadening of the velocity range at a given time
24
Chapter 1 | Principles of Echocardiographic Image Acquisition and Doppler Analysis

Pulsed Doppler Color Flow point (“blurring” on the vertical axis), which poten-
Ultrasound Imaging tially can result in slight overestimation of velocity.

Color Doppler Flow Imaging

Multigate Principles
along each Doppler color flow imaging is based on the principles

/
scan line
of pulsed Doppler echocardiography. However, rather
than one sample volume depth along the ultrasound

9
beam, multiple sample volumes are evaluated along
each sampling line (Fig. 1-28). By combining data

9
from adjacent lines, a 2D image of intracardiac flow

i r
is generated.
Sample Along each scan line, a pulse of ultrasound is trans-

h
volume mitted, and then the backscattered signals are received
from each depth along that scan line (Table 1-8). In

a
order to calculate accurate velocity data, several bursts

t
Figure 1–28 Color Doppler flow imaging. With pulsed Doppler, the along each scan line are used—typically eight—which

sample volume depth is determined by the time needed for ultrasound to
travel to and from the depth of interest (left). With color flow imaging, mul-
tiple sample volume “gates” along each scan line are interrogated, with this
r/
is known as the burst length (Fig. 1-29). The PRF, as for
conventional pulsed Doppler, is determined by the
maximum depth of the Doppler signals. Signals from

e
process repeated for scan lines across the 2D image (right).
the eight sampling bursts at each position are analyzed

s
/r u
TABLE 1-8 Color Doppler Flow Imaging
Definition Examples Clinical Implications

.t c
Sampling line Doppler data is displayed Instead of sampling A greater number of sampling
from multiple sampling backscattered signals from lines results in denser Doppler
lines across the 2D one depth (as in pulsed data but a slower frame rate.
image. Doppler), signals from

a
multiple depths along the
beam are analyzed.

k
Burst length The number of Mean velocity is estimated A greater number of bursts

/: /
ultrasound bursts from the average of the results in more accurate mean
along each sampling backscattered signals from velocity estimates but a slower
line each burst. frame rate.

s
Sector scan The width of the A greater sector width requires A narrower sector scan allows a
width displayed 2D and color more sampling lines or less greater sampling line density

tt p
image dense velocity data. and faster frame rate.
Sector scan The depth of the The maximum depth of the The minimum depth needed to
depth displayed color sector scan determines PRF display the flow of interest

h
Doppler image (as with pulsed Doppler) and provides the optimal color
the Nyquist limit. display.
Color scale Color display of Doppler Most systems use shades The color scale can be adjusted
velocity and flow of red for flow toward the by shifting the baseline and
direction transducer and blue for flow adjusting the maximum
away from the transducer. velocity displayed (within the
Nyquist limit).
Variance The degree of variability Variance typically is A variance display highlights flow
in the mean velocity displayed as a green scale disturbances and high-velocity
estimate at each depth superimposed on the red- flow, but even normal flows
along a sampling line blue velocity scale. Variance will be displayed as showing
can be turned on or off. variance if velocity exceeds
the Nyquist limit.
  

Principles of Echocardiographic Image Acquisition and Doppler Analysis | Chapter 1
8 bursts
Color
Doppler
scan lines
For each
scan line
Figure 1–29 Color Doppler flow imaging burst length. Along each color
Doppler scan line, several (typically eight) bursts of ultrasound are transmit-
ted and received to allow adequate velocity resolution.
to obtain mean velocity estimates for each depth along
the scan line. Velocities are displayed using a color
scale showing flow toward the transducer in red and
flow away from the transducer in blue, with the shade
of color indicating velocity up to the Nyquist limit.
The option of displaying “variance” allows an addi-
/r u
tional color (usually green) to be added to indicate that
there was variability in the estimated mean velocity
for the eight bursts along that sample line, indicating
either a flow disturbance or aliasing of a high-velocity
.t c
signal. This process is repeated for each adjacent scan
line across the image plane. Because each of these pro-
cesses takes a finite amount of time depending on the
a
speed of sound in tissue, the rapidity with which this
image can be updated (the frame rate) depends on a
k
combination of these factors.
/: /
Color Doppler Instrument Controls
s
The color flow display is dependent on each specific
ultrasound instrument to some extent. However, many
tt p
parameters are adjustable by the operator, so an opti-
mal examination requires careful attention to instru-
ment settings.
h
The color flow map usually can be varied in terms of:
n Color scale (assignment of colors to direction

and velocity)
n Velocity range (within the Nyquist limit at that

depth)
n Zero baseline position on the color scale

n Addition of variance to the color scale

The specific color scale used is a matter of personal
preference, with the diagnostic goal being to opti-
mize the display and recognition of abnormal flow
patterns.
The velocity range of the color flow map is determined
by the Nyquist limit, and as for conventional pulsed
Doppler, the range can be altered by shifting the zero
25
baseline, changing the pulse repetition frequency, or
altering the depth of the displayed image. In addition,
the velocity range can be set at a value lower than the
Nyquist limit to enhance visualization of low-velocity
flows, such as pulmonary venous inflow.
Color Doppler power output and gain are adjusted
so that gain is just below the level at which random
background noise appears. “Wall filters” can be varied
/
to exclude low-velocity signals from the color flow dis-
play. In addition, many instruments allow variation in
9
the assignment of a returning signal to 2D or Doppler
display (depending on signal strength). One approach
9
to optimizing the color flow display is to reduce the 2D
i r
gain because the instrument does not display flow data
on top of “structures,” even when the 2D signal is due
h
to excessive gain.
Perhaps the most important technical factor in
a
color flow imaging is optimization of frame rate. Color
t
flow frame rate depends on sector width, depth, pulse
r/
repetition frequency, and the number of samples per
sector line. The examiner optimizes frame rate by
focusing on the flow of interest, narrowing the sec-
e
tor, and decreasing the depth as much as possible
s
(Fig. 1-30). When frame rate remains inadequate for
timing flow abnormalities, a color M-line through
the area of interest may be helpful, for example in
assessment of aortic regurgitation.
Color Doppler Imaging Artifacts
Color flow artifacts again relate to the physics of 2D
and Doppler flow image generation (Table 1-9). Shad-
owing may be prominent distal to strong reflectors with
absence of both 2D and flow data within the acoustic
shadow.
Ghosting is the appearance of brief (usually one or
two frames) large color patterns that overlay anatomic
structures and do not correspond to underlying flow
patterns. This artifact is caused by strong moving
reflectors (such as prosthetic valve disks). Typically, this
artifact is solid red or blue and is inconsistent from beat
to beat.
Color Doppler gain settings have a dramatic effect
on the color flow image. Extensive gain settings result
in a uniform speckled pattern across the 2D image
plane resulting from random background noise. Con-
versely, too low a gain setting results in a smaller dis-
played flow area than is actually present, an effect
colloquially known as “dial-a-jet.” Most experienced
echocardiographers recommend setting the gain level
just below the level of random background noise to
optimize the flow signal.
As for any Doppler technique, the intercept angle
between the ultrasound beam and direction of blood
flow for each scan line affects the color display in terms
of both direction and velocity. Thus a uniform flow
velocity traversing the image plane may appear red
(toward the transducer) at one side of the sector and
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN