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PROBLEM-BASED OBSTETRIC
ULTRASOUND
Second Edition
Series in Maternal-Fetal Medicine

About the Series

Published in association with the Journal of Maternal Fetal and Neonatal Medicine,
the series in Maternal Fetal Medicine keeps readers up to date with the latest
clinical therapies to improve the health of pregnant patients and ensure a
successful birth. Each volume in the series is prepared separately and typically
focuses on a topical theme. Volumes are published on an occasional basis,
depending on the emergence of new developments.

Cesarean Delivery: A Comprehensive Illustrated Practical Guide

Gian Carlo Di Renzo, Antonio Malvasi

Obstetric Evidence Based Guidelines, Third Edition

Vincenzo Berghella

Maternal-Fetal Evidence Based Guidelines, Third Edition

Vincenzo Berghella

Maternal-Fetal and Obstetric Evidence Based Guidelines, Two Volume Set, Third Edition
Vincenzo Berghella

The Long-Term Impact of Medical Complications in Pregnancy: A Window into Maternal

and Fetal Future Health
Eyal Sheiner

Operative Obstetrics, Fourth Edition

Joseph J. Apuzzio, Anthony M. Vintzileos, Vincenzo Berghella, Jesus R. Alvarez-Perez

Placenta Accreta Syndrome

Robert M. Silver

Neurology and Pregnancy: Clinical Management

Michael S. Marsh, Lina Nashef, Peter Brex

Fetal Cardiology: Embryology, Genetics, Physiology, Echocardiographic Evaluation,

Diagnosis, and Perinatal Management of Cardiac Diseases, Third Edition
Simcha Yagel, Norman H. Silverman, Ulrich Gembruch

New Technologies and Perinatal Medicine: Prediction and Prevention of Pregnancy

Complications
Moshe Hod, Vincenzo Berghella, Mary D’Alton, Gian Carlo Di Renzo, Eduard
Gratacos, Vassilios Fanos

Problem-Based Obstetric Ultrasound, Second Edition

Amar Bhide, Asma Khalil, Aris T Papageorghiou, Susana Pereira, Shanthi Sairam,
Basky Thilaganathan

For more information about this series please visit: https://www.crcpress.com/

Series-in-Maternal-Fetal-Medicine/book-series/CRCSERMATFET
PROBLEM-BASED OBSTETRIC
ULTRASOUND
Second Edition

Amar Bhide MD MRCOG

Consultant in Maternal-Fetal Medicine
Fetal Medicine Unit, St George’s Hospital Medical School
London, UK
Asma Khalil MBBCh MD MRCOG MSc(Epi) DFSRH Dip(GUM)
Professor and Consultant in Fetal Medicine and Obstetrics
St George’s University Hospitals
London, UK
Aris T Papageorghiou MRCOG
Consultant in Maternal-Fetal Medicine
Fetal Medicine Unit, St George’s Hospital Medical School
London, UK
Susana Pereira MD
Consultant Obstetrician and Sub-specialist in Fetal Medicine
Kingston Hospital
London, UK
Shanthi Sairam MD MRCOG
Consultant OBGyn and Specialist in Fetal Medicine
Mediclinic City Hospital
Dubai, UAE
Basky Thilaganathan MD MRCOG
Professor and Director
Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust
London, UK
CRC Press
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Library of Congress Cataloging-in-Publication Data

Names: Bhide, Amarnath G., author.

Title: Problem-based obstetric ultrasound / Amar Bhide, Asma Khalil, Aris T. Papageorghiou,
Susana Pereira, Shanthi Sairam, Basky Thilaganathan.
Other titles: Series in maternal-fetal medicine. 2158-0855
Description: Second edition. | Boca Raton : CRC Press, [2020] | Series:
Series in maternal-fetal medicine | Preceded by Problem-based obstetric ultrasound /
Basky Thilaganathan ... [et al.]. 2007. | Includes bibliographical references and index.
Identifiers: LCCN 2019034447 (print) | LCCN 2019034448 (ebook) | ISBN 9781498701891
(paperback ; alk. paper) | ISBN 9780367408008 (hardback ; alk. paper) |
ISBN 9780429156694 (ebook)
Subjects: MESH: Ultrasonography, Prenatal--methods |
Pregnancy Complications--diagnostic imaging
Classification: LCC RG527.5.U48 (print) | LCC RG527.5.U48 (ebook) |
NLM WQ 209 | DDC 618.2/07543--dc23
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CONTENTS

1 Ventriculomegaly...................................................................................... 1
2 Intracranial Cysts...................................................................................... 5
3 Agenesis of Corpus Callosum............................................................... 10
4 Abnormal Skull Shape............................................................................ 14
5 Facial Clefts.............................................................................................. 19
6 Micrognathia............................................................................................ 24
7 Nasal Bone................................................................................................ 27
8 Hypertelorism.......................................................................................... 30
9 Chest Tumors........................................................................................... 33
10 Chest Fluid............................................................................................... 37
11 Right-Sided Aortic Arch......................................................................... 41
12 Aberrant Right Subclavian Artery........................................................ 42
13 Dextrocardia............................................................................................. 43
14 Abnormal Four-Chamber View............................................................ 47
15 Abnormal Cardiac Rhythm................................................................... 52
16 Abdominal Wall Defect.......................................................................... 56
17 Abdominal Cyst....................................................................................... 61
18 Abdominal Echogenicity........................................................................ 66
19 Empty Renal Fossa.................................................................................. 70
20 Cystic Kidney........................................................................................... 75
21 Fluid-Filled Kidney................................................................................. 78
22 Echogenic Kidneys.................................................................................. 83
23 Enlarged Bladder..................................................................................... 86
24 Short Limbs.............................................................................................. 90
25 Joint Abnormalities................................................................................. 95
26 Hand Abnormalities............................................................................... 98
27 Spinal Abnormalities............................................................................ 101
28 Spinal Masses......................................................................................... 106
29 Head and Neck Masses........................................................................ 109
30 Increased Nuchal Translucency...........................................................115
31 Placental Abnormalities........................................................................119
32 Single Umbilical Artery........................................................................ 122
33 Oligohydramnios and Anhydramnios............................................... 125
34 Polyhydramnios..................................................................................... 129
35 Amniotic Bands..................................................................................... 133
36 Abnormally Invasive Placenta............................................................. 135
vi Contents

37 Hydrops.................................................................................................. 139
38 Small Fetus............................................................................................. 143
39 Twin-to-Twin Transfusion Syndrome................................................. 149
Index........................................................................................................ 153
1
VENTRICULOMEGALY

The lateral ventricles should be measured at the routine mid-trimester

scan in the axial plane at the level of the cavum septi pellucidi, with the
calipers aligned with the internal borders of the medial and lateral walls
of the ventricle; this should be at the level of the glomus of the choroid
plexus. Fetal ventriculomegaly is characterized by a dilatation of the lateral
ventricles, with or without dilatation of the third or fourth ventricles.
There is no internationally agreed upon terminology, but Table 1.1 shows
two systems used. It can affect one (unilateral) or both ventricles (bilateral).
When mild or moderate, it may be due to normal variation, but it also
represents a common endpoint of various pathologic processes. As the
outcome and prognosis depend on the underlying cause, investigations
are aimed at determining this.
Apart from the underlying etiology and the presence of associated
structural/chromosomal anomalies, post-natal outcome depends on the
progression of ventricular dilatation. In isolated abnormality (absence
of pathology and progression), the outlook for mild ventriculomegaly
(<15 mm) is good with >95% of babies having normal neurodevelopment.
Associated major anomalies (cranial and extracranial) can be present
in 50% of fetuses with VM, of which the most common are agenesis of the
corpus callosum, posterior fossa malformations, and open spina bifida.
The rate of associated anomalies in severe VM is higher than in mild VM.

Investigations needed
The prognosis is highly dependent on:
• Other fetal anomalies
• The cause of the ventriculomegaly
• Progression of the ventriculomegaly

Table 1.1 Different classifications of ventriculomegaly used in the literature

Normal measurement: <10 mm Normal measurement: <10 mm
Mild ventriculomegaly: 10–12 mm Mild ventriculomegaly: 10–15 mm
Moderate ventriculomegaly: 12–15 mm
Severe ventriculomegaly: >15 mm Severe ventriculomegaly: >15 mm
2 Problem-Based Obstetric Ultrasound

Investigations are therefore centered around these issues:

• Optimal imaging is needed: undertake (or refer for) detailed
multiplanar neurosonography; transvaginal scanning is helpful. This
should include assessment of:
• The entire ventricular system
• The periventricular zone/signs of hemorrhage
• The pericerebral spaces and cortical fissures
• Consider fetal MRI.
• Review nuchal translucency and any previous chromosomal anomaly
screening or prenatal diagnosis results.
• Consider karyotype by amniocentesis.
• Maternal serology for toxoplasma/CMV infection.
• Platelet group of parents to look for alloimmune thrombocytopenia
should be considered if there is any possibility there could be
intracranial bleeding.
• Follow up with further scans in the third trimester to assess for
progression: It is important to explain to parents that prenatal imaging
cannot completely rule out associated anomalies and that some may
become evident only later in pregnancy or even at birth. The rate of
associated anomalies detected only at follow-up scan is around 7%;
progression of ventricular dilatation can occur in about 16% of cases.

Bibliography
Carta S, Kaelin Agten A, Belcaro C, Bhide A. Outcome of fetuses with prenatal
diagnosis of isolated severe bilateral ventriculomegaly: Systematic review and
meta-analysis. Ultrasound Obstet Gynecol. 2018 Aug; 52(2): 165–73.
Garel C, Luton D, Oury JF et al. Ventricular dilatations. Childs Nerv Syst. 2003; 19:
517–23.
International Society of Ultrasound in Obstetrics and Gynecology. Sonographic
examination of the fetal central nervous system: Guidelines for performing
the “basic examination” and the “fetal neurosonogram.” Ultrasound Obstet
Gynecol. 2007; 29: 109–16.
Melchiorre K, Bhide A, Gika AD et al. Counseling in isolated mild fetal
ventriculomegaly. Ultrasound Obstet Gynecol. 2009; 34: 212–24.
Pagani G, Thilaganathan B, Prefumo F. Neurodevelopmental outcome in
isolated mild fetal ventriculomegaly: Systematic review and meta-analysis.
Ultrasound Obstet Gynecol. 2014; 44: 254–60.
Rossi AC, Prefumo F. Additional value of fetal magnetic resonance imaging in the
prenatal diagnosis of central nervous system anomalies: A systematic review
of the literature. Ultrasound Obstet Gynecol. 2014; 44: 388–93.
Scala C, Familiari A, Pinas A et al. Perinatal and long-term outcome in fetuses
diagnosed with isolated unilateral ventriculomegaly: Systematic review and
meta-analysis. Ultrasound Obstet Gynecol. 2016 Apr 19.
 Ventriculomegaly 3

Mild/Borderline

Unilateral Bilateral

Isolated Complex

Chromosomal Brain structural Infection Bleed Spine

T21
ACC
T18 Toxo
Encephalocele AITP Spina bifida
T13 CMV
Neuronal
Triploidy

Algorithm 1.1 Classifications of mild/borderline ventriculomegaly.

Severe
ventriculomegaly

Neuronal
Aqueductal Vascular Genetic/
Spina bifida migration
stenosis accident Chromosomal
disorder

X-linked
Schizencephaly hydrocephalus,
Triploidy

Algorithm 1.2 Classifications of severe ventriculomegaly.

4 Problem-Based Obstetric Ultrasound

Figure 1.1 Moderate ventriculomegaly.

Figure 1.2 Severe ventriculomegaly.

2
INTRACRANIAL CYSTS

Many cystic structures in the fetal brain are not true cysts but can be
pseudocysts. Distinguishing between the two can lead you to the diagnosis.
True brain cysts have a capsule, regular margins, and may have a pressure
effect. In contrast, pseudocysts have no capsule, irregular margins, and no
compression effect.
Choroid plexus cysts are collections of the cerebrospinal fluid (CSF)
due to blockage of the glands in the choroid plexus and seen in 1%–3%
of fetuses at the time of the anomaly scan. They are associated with an
increase in the risk of trisomy 18 (Edwards syndrome), however, they are
rarely an isolated finding in this condition. Assess any prior screening for
chromosomal anomalies including non-invasive prenatal screening using
maternal cell-free DNA, nuchal translucency at 11–14 weeks, and check
the maternal age. The association of choroid plexus cysts with trisomy 18
loses significance in women with previous low-risk screening. If the brain
appears otherwise entirely normal, and if the cysts are not very large,
they are harmless and almost always disappear later in the pregnancy.
Reassurance can be offered and no further follow-up is necessary.
Arachnoid cysts are rare cysts arising from the arachnoid and contain
cerebrospinal fluid. They do not communicate with the ventricular system.
They are most often isolated, regular, and non-midline. The size can be
very variable. Midline shift of the brain may be seen due to pressure
effects. If they are isolated, the outlook is usually good, unless the size is
very large.
The interhemispheric “cyst” is a misnomer as it is usually a pseudocyst.
There is ultrasound appearance of a cystic structure in the midline. This is
due to the deficiency in the roof of the third ventricle as a result of agenesis
of the corpus callosum (see Chapter 3).
The aneurysm of vein of Galen is a rare malformation of the posterior
cranial fossa. Vein of Galen is not a cyst, but rather a cranial venous sinus,
which undergoes massive dilatation. Color flow mapping will show
presence of moving blood. It can lead to a cardiac strain as evidenced by
cardiac enlargement and increased pulsatility of the ductus venosus blood
flow. In severe cases, hydrops fetalis can result.
6 Problem-Based Obstetric Ultrasound

Porencephalic cysts are destructive (clastic) lesions—they commonly

communicate with the ventricle due to destruction of white matter. They
are often due to brain hemorrhage and do not show a mass effect.
Cocaine use is associated with transient but intense vasospasm in
blood vessels, including those supplying the brain. The malformations
arising as a result of cocaine use defy any pattern.
Venous malformation is a recently described rare malformation in the
posterior cranial fossa. The venous malformation can contain a blood clot
or very slow flow rates, so there is no flow signal evident on color flow
mapping. The limited available information suggests the outlook to be
guarded due to pressure effects on the developing brain.
Cystic structures in the posterior fossa include:
• Enlarged cisterna magna when it is >10 mm in the transverse
cerebellar view. Detailed ultrasound is needed to demonstrate this
is isolated and that the cerebellum and vermis are normal. It can be
associated with ventriculomegaly, but if it remains isolated and does
not progress, prognosis is generally good.
• Blake’s pouch cysts represent a communication between the 4th
ventricle into the cisterna magna and appear as a unilocular cyst
without any Doppler flow. Careful assessment is mandatory to ensure
the remainder of the brain—in particular cerebellum and vermis—are
normal. This is usually isolated, and most will resolve spontaneously.
• In Dandy-Walker malformation there is dilation of the fourth ventricle
in the posterior fossa and that extends into the cisterna magna. The
cerebellar vermis will be hypoplastic or absent. The condition is often
associated with chromosomal abnormalities (mainly trisomy 18 and
13) or genetic syndromes. Coexisting abnormalities are very common,
as is severe ventriculomegaly. The outlook is guarded.

Bibliography
Epelman M, Daneman A, Blaser SI et al. Differential diagnosis of intracranial cystic
lesions at Head US: Correlation with CT and MR imaging. RadioGraphics. 2006;
26(1): 173–96.
Pilu G, Falco P, Perolo A et al. Differential diagnosis and outcome of fetal
intracranial hypoechoic lesions: Report of 21 cases. Ultrasound Obstet Gynecol.
1997; 9: 229–36.
 Intracranial Cysts 7

Intracranial cysts

Anterior/Middle Posterior cranial

cranial fossa fossa

Midline Paramedian • Dandy-Walker

malformation
• Aneurysm of
• Inter- • Choroid Vein of
hemispheric plexus cyst Galen
cyst – ACC? • Arachnoid • Venous
cyst malformation
• Cocaine abuse

1. Review NT risk
2. Consider karyotyping
3. Flow through ‘cyst’ on color flow imaging?
4. Other abnormalities?
Talipes?
Movements of limbs?
Other makers of trisomy 18?
Hydrops?
Elevated ductus venosus PIV?

Algorithm 2.1 Classification of intracranial cysts and suggested work-up.

Figure 2.1 Choroid plexus cyst.

8 Problem-Based Obstetric Ultrasound

Figure 2.2 Arachnoid cyst.

Figure 2.3 Midline arachnoid (third ventricular) cyst.

Figure 2.4 Vein of Galen malformation.

 Intracranial Cysts 9

Figure 2.5 Posterior fossa cyst.

Figure 2.6 Absent cerebellar vermis.

3
AGENESIS OF CORPUS
CALLOSUM

Corpus callosum is the largest bundle of fibers connecting the left and right
cerebral hemispheres. Its absence is called agenesis of corpus callosum
(ACC) and can be total or partial (usually posterior part missing). ACC
has an estimated prevalence ranging from 2 per 10,000 in the general
population to 200–600 per 10,000 in children with neurodevelopmental
disabilities. Prenatal counseling can be very challenging given the vast
spectrum of outcomes from normal to severe delay in motor and cognitive
functions.

Suspecting ACC
Visualization of the corpus callosum is not part of routine second-trimester
screening. ACC can however be suspected by indirect signs such as
absent cavum septum pellucidum, ventriculomegaly, and midline lesions
including lipomas and cysts. These indirect signs are inconsistent and not
always encountered in fetuses with partial ACC.

Diagnosing ACC
Visualization of the corpus callosum on ultrasound requires additional
views from the ones used for routine screening. Corpus callosum can
usually be seen from 18 weeks in coronal and mid-sagittal views appearing
as a thin anechoic space, bordered superiorly and inferiorly by echogenic
lines. Visualization of the pericallosal artery in mid-sagittal view of the
brain highlights the corpus callosum, running along the superior surface
of the corpus callosum (absent in ACC).

Additional investigations
Karyotype/array comparative genomic hybridization (CGH): The rate of
chromosomal anomalies in fetuses with complete and partial ACC is
increased even in an isolated finding.
 Agenesis of Corpus Callosum 11

Fetal brain MRI: In cases of a prenatal diagnosis of isolated ACC, the risk
of associated anomalies detected only at fetal MRI is about 10% in fetuses
with ACC. The majority of additional anomalies detected at fetal MRI
involve neuronal migration defects.

Prenatal counseling in isolated ACC

In about 70% of children with prenatal diagnosis of isolated ACC, normal
neurodevelopmental outcome is reported. Delay in motor and cognitive
functions, epilepsy, and social and language deficits are the most common
symptoms reported in individuals with ACC. Furthermore, ACC has been
linked with the occurrence of autism, schizophrenia, and attention-deficit
disorders. Parents should be informed that prenatal imaging is not always
able to differentiate between complex and isolated cases with additional
post-natal findings diagnosed in about 5%–10% of cases of ACC.

Bibliography
D’Antonio F, Pagani G, Familiari A et al. Outcomes associated with isolated
agenesis of the corpus callosum: A meta-analysis. Pediatrics. 2016; 138(3):
e20160445.
Santo S, D’Antonio F, Homfray T, Rich P, Pilu G, Bhide A, Thilaganathan B,
Papageorghiou T. Counseling in fetal medicine: Agenesis of the corpus
callosum. Ultrasound Obstet Gynecol. 2012; 40: 513–21.
Youssef A, Ghi T, Pilu G. How to image the fetal corpus callosum. Ultrasound
Obstet Gynecol. 2013; 42: 718–20.
12 Problem-Based Obstetric Ultrasound

Suspect Diagnose Karyotype MRI

• Absent cavum • Corpus callosum • Abnormal in 4%–7% • 8% to 12% of fetuses
septum pellucidum not seen in of apparently have additional
• Ventriculomegaly mid-sagittal view isolated ACC findings on MRI,
• Midline cyst after 20 weeks mostly migration
disorders best seen
in the third trimester

Algorithm 3.1 Work-up of ACC.

Figure 3.1 Agenesis of corpus callosum, note absent cavum septum

pellucidum.
 Agenesis of Corpus Callosum 13

Figure 3.2 Corpus callosum seen in mid-sagittal view.

4
ABNORMAL SKULL SHAPE

During routine examination, the size and shape of the skull are assessed,
as are the integrity of the skull and mineralization. Normally the skull
has an oval shape and is continuously echogenic, with the sutures visible
as narrow gaps.
Brachycephaly and dolichocephaly occur when the head is more
rounded or elongated, respectively. This is most commonly a normal
variant:
• In brachycephaly the head appears shorter and wider. This is most
often due to normal variation but has also been associated with
trisomy 21. Premature fusion of the coronal sutures can also be a cause;
this is seen in Pfeiffer syndrome, where wide-set eyes, brachydactyly
or syndactyly may also coexist.
• Dolichocephaly is frequently associated with pressure effects due to a
fetal breech presentation or reduced amniotic fluid. In late gestation it
can be due to premature fusion of the sagittal suture.
A lemon-shaped skull is a classic sign of an open neural tube defect.
The lemon shape is most often seen in the middle third of pregnancy and
can resolve in the third trimester. In open spina bifida it is associated with
a banana-shaped cerebellum. “Lemon-like” skull without spina bifida has
no clinical significance, but a very careful search of the spine is indicated
before disregarding this finding (refer to Chapter 27).
A strawberry-shaped skull should raise the suspicion of trisomy 18
(Edwards syndrome). Check prior screening: maternal age is more likely
to be advanced and the nuchal translucency may have been raised at 11–14
weeks. Early-onset growth restriction is often present, and the pregnancy
may have been re-dated on an early scan. Other indicators of trisomy 18
may be present, such as choroid plexus cysts, micrognathia, congenital
heart disease, exomphalos, and talipes equinovarus. Trigonocephaly, of
similar appearance, is due to fusion of the metopic suture and can also be
part of Jacobsen or Opitz C syndromes.
Cloverleaf- or trilobate-shaped skull can be associated with
thanatophoric dysplasia, a lethal form of skeletal dysplasia (see Chapter 27).
The finding may also be seen in Apert syndrome or Crouzon syndrome.
 Abnormal Skull Shape 15

Encephalocele is associated with a defect of the skull. Posterior

encephaloceles are much more common than at other sites. The size is
variable, ranging from larger than the skull to very small—so as to
easily be missed. One should also look for features of Meckel–Gruber
syndrome (occipital encephalocele, polycystic kidneys, polydactyly), as it
has autosomal recessive inheritance.
In some conditions the skull is very poorly mineralized and is easily
deformed by the pressure of the ultrasound probe. This can be due to
hypophosphatasia; in achondrogenesis, a lethal skeletal dysplasia, there is
also severe shortening of the long bones.

Bibliography
Accardi MC, Lo Magno E, Ermito S et al. Echotomography of craniosynostosis:
Review of literature. J Prenat Med. 2009 Apr; 3(2): 31–3.
 Abnormal skull shape

Asymmetrical Symmetrical
16 Problem-Based Obstetric Ultrasound

• Reduced ossification • Microcephaly Cloverleaf

Lemon-shaped Strawberry-shaped
• Skull flattening on pressure • Ventriculomegaly Shortening of long bones
Banana cerebellum Soft markers
• Shortening of long bones • Cranial defect Narrow thorax

• Achondrogenesis Spina bifida Trisomy 18 Skeletal dysplasia

Encephalocele
• Hypophosphatasia

Algorithm 4.1 Classification of abnormal skull shape.

 Abnormal Skull Shape 17

Figure 4.1 (a) Normal mid-sagittal section of face. (b) Frontal bossing.

Figure 4.2 Brachycephaly.

Figure 4.3 Lemon-shaped head.

18 Problem-Based Obstetric Ultrasound

Figure 4.4 Banana cerebellum.

Figure 4.5 Strawberry-shaped head.

Figure 4.6 Cloverleaf-shaped head.

5
FACIAL CLEFTS

Facial clefts are usually isolated but may be associated with other medical
conditions such as chromosomal abnormality, genetic syndromes, and a
family history of facial clefts. Cleft lip is associated with a cleft palate in
the majority of cases.
Ultrasound recognition involves obtaining a coronal surface view of the
face showing lips and nostrils. The defect in the alveolar ridge is demonstrable
on a transverse view. A profile view shows “pre-maxillary protrusion” in
cases of bilateral cleft lip/alveolus. The palate is not normally visualized on
ultrasound; however, a defect of the alveolar ridge can be demonstrated, and
in most cases, is associated with a defect of the hard palate.
Pre-natal diagnosis of cleft palate without cleft lip/alveolus is
extremely difficult. The use of “reverse face view” on 3-D ultrasound
has been described to improve pre-natal identification of defects of the
palate. The “equals sign” (a typical echo pattern of the normal uvula) could
help in evaluation of the soft palate in the event of a cleft lip and palate.
Visualization of the equals sign proves an intact palate. Absence of the
equals sign indicates a cleft palate and should prompt further examination
of the soft palate in a median sagittal section. Cleft palate can be confirmed
when the soft palate cannot be visualized.
Careful examination of the fetal heart and brain structure is indicated.
The threshold for referral for fetal echocardiography should be low.
Median and bilateral cleft lip/alveolus are associated with a higher
risk of underlying chromosomal abnormality or midline structural
abnormalities of the brain. Prenatal identification of associated genetic
syndromes is also very difficult in the absence of past or family history.
Facial cleft is a recognized feature of trisomy 13.
Trisomy 13 (Patau syndrome): Mother’s age is likely to be advanced. The
nuchal translucency may have been raised at 11–14 weeks. Cell-free DNA
might have already been performed in the first trimester. Other indicators
of trisomy 13 may be present; there may be CNS abnormalities such as
ventriculomegaly or holoprosencephaly. Heart abnormalities are present in
over 95% of fetuses. Polydactyly and rocker bottom feet may be seen.
20 Problem-Based Obstetric Ultrasound

Bibliography
James JN, Schlieder DW. Prenatal counseling, ultrasound diagnosis, and the role
of maternal-fetal medicine of the cleft lip and palate patient. Oral Maxillofac
Surg Clin North Am. 2016; 28: 145–51.
Wilhelm L, Borgers H. The “equals sign”: A novel marker in the diagnosis of fetal
isolated cleft palate. Ultrasound Obstet Gynecol. 2010; 36: 439–44.
 Facial Clefts 21

Facial cleft

Paramedian Bilateral Midline

Complex – CNS, Likely genetic or

Isolated heart or other chromosomal
structural anomalies syndrome

Cornelia de Lange,
Crouzon, DiGeorge,
Likely genetic or holoprosencephaly,
Likely good outcome chromosomal and trisomy 13/18
syndrome

Algorithm 5.1 Classification of facial clefts.

22 Problem-Based Obstetric Ultrasound

Figure 5.1 (a) Normal alveolar ridge. (b) Bilateral cleft

alveolus and primary palate.

Figure 5.2 Pre-maxillary protrusion.

Other documents randomly have
different content
Turk and Armenian are in the wrong, and that, as very often
happens, it is the innocent who have suffered for the
wrong-doings of the guilty. When it is asserted on behalf of
the Turks that they are engaged in suppressing a revolutionary
movement in Armenia, the statement is fully justified by the
facts of the case. There does exist in Armenia an extremely
vigorous revolutionary movement, and it is equally beyond
question that the methods of some of the leaders of this
movement are no less shocking than the barbarity of the Turk
in suppressing it. At every step," he added, "I became more
and more convinced that the inhuman ferocity displayed in this
terrible struggle for the mastery has not been in the least
exaggerated in the reports of the massacres already published
in England. At Bitlis I heard the story of a Turkish soldier
who boasted, as one who had achieved a glorious feat, that he
had taken part in the disembowelling of thirty pregnant
women. 'Two lives in one,' was the rallying cry of the armed
men who perpetrated this butchery. Another soldier, who had
taken part in a massacre in a church, described, gloating upon
every ghastly detail, how he had slipped and slid along the
blood-washed floor while the inhuman work proceeded.
Unfortunately, something very like a counterpart of these
atrocities is presented by the methods of some of the leaders
of the Armenian revolutionary movement. I believe there is no
doubt of the fact that certain of these Armenian conspirators
arranged to murder the Reverend Dr. Edward Riggs and two other
American missionaries at Marsovan, and fasten the blame upon
the Turks, in order that, as they imagined, the United States
might inflict summary punishment upon the Turkish Government,
thereby rendering Armenian independence possible. The
missionaries only escaped through a timely warning which they
received from an Armenian friend. Dr. Riggs has devoted his
life to the education of the Armenian youth in the missionary
schools, but the conspirators, in their blind fanaticism, gave
this fact little heed."

There could be no denial however, that the treatment of

 Armenia and the Armenians by their Turkish political masters
was horribly bad. In May, the governments of Great Britain,
France and Russia united in proposing certain reforms for
Armenia, over which there were evasive and dilatory
negotiations carried on by the Porte for several months.
Meantime, the Armenians became more aggressive and
threatening, and a secret society called the "Hintchak," which
had been in existence among them since 1887, assumed great
activity. Connected with the Hintchak there was said to be an
organization of spies and "executioners," the latter of whom
carried out decrees of assassination, arson, and
bomb-explosion which the society had pronounced. Finally, on
the 17th of October, an imperial irade (edict, or decree) was
issued, approving and adopting the project of reform which the
British, French and Russian ambassadors had submitted to the
Porte.
{538}
But the appearance of the sultan's ineffectual irade was
speedily followed by fresh reports of frightful massacres of
Armenians, at Trebizond, Erzeroum, Bitlis, Zeitoun, and
elsewhere, with outraging of women and destruction of
property, which increased rather than diminished as time went
on. There was no sign that anything had been done towards
carrying out the promised reforms; though the sultan wrote
personally to Lord Salisbury to remonstrate against an
expression of skepticism concerning them, which the latter had
let fall in a speech, and to say to the British Premier: "I will
execute the reforms. … This is my earnest determination, as to
which I give my word of honour." But nothing came of it all,
and the Powers which had received the Sultan's promises could
agree on no steps further, except to demand and obtain
permission to bring, each, an additional gunboat into the
Bosphorus.

Annual Register, 1895,

pages 284-294 and 190-193.
In response to a resolution of the Senate of the United States
asking for information relative to the treatment of the
Armenian subjects of the Turkish government, the Secretary of
State, Mr. Olney, on the 19th of December, 1895, communicated
the following, among other statements of fact: Of the
massacres at Sassoun, which occurred in August, 1894, "the
Department of State has little trustworthy information. …
Since that time appalling outbreaks against the Armenians have
occurred in many other parts of Asia Minor, where these
unfortunate people form but a small minority of the
population. At first they were scarcely more than local riots,
as at Tokat, in the vilayet of Sivas, in March last, where one
Armenian was killed outright and more than 30 wounded by the
Turkish soldiery. In June last an attempted rising of
Armenians in the province of Aleppo in the mountains of
Kozar-Dagh and Zeitoun was thwarted without bloodshed by the
arrest of the alleged conspirators. … In July a band of armed
Armenians crossing into the vilayet of Erzerum from Russia was
dispersed, several being killed or captured. By August the
Moslem feeling against Armenians had become so far aroused
that rumors of intended massacres came from several
independent quarters, Harpoot, Marsovan, and Bitlis among
them, which led to urgent demands by the United States
minister for adequate measures looking to the due protection
of American citizens in those places.

"On the 30th of September grave disturbances began at

Constantinople itself. Several hundred Armenians, who had
gathered for the purpose of going in a body to the Sultan's
palace and demanding redress for the grievances of their
countrymen, were dispersed by the police after a severe
conflict in which a number of Turks and Armenians were killed
and wounded. Mob violence followed, the Armenians resident in
various quarters of the capital being assailed by an excited
Turkish rabble, and over 50 were slain. The rioting continued
the next day, October 1, in Constantinople and its suburbs.
Some 800 or 1,000 Armenians were captured or arrested, many of
them being armed with new revolvers of a uniform pattern. By
the third day order was restored, and the Armenians who had
sought refuge in their churches returned to their homes. The
effect of this outbreak at the national capital was most
disastrous in the provinces. The danger of a general massacre
of Christians in the vilayets of Adana and Aleppo seemed so
imminent, that renewed orders for the effective protection of
American citizens in those quarters were demanded and
obtained. Fears for their safety at Hadjin, Mersine, and
Marash were especially felt, and the cruiser Marblehead was
promptly ordered to Iskanderoun (Alexandretta), the nearest
seaport.

"On October 8 a Turkish uprising occurred at Trebizond, due,

it is reported, to an attempt to assassinate the late Vali of
Van as he was about to leave for Constantinople, the Turks
claiming that the act was done by an Armenian and that they
were in danger of a general Armenian attack. On the 9th the
disturbance was renewed, many Armenians being killed and their
homes and shops looted by the mob. The authorities attempted
to quell the riot, but having only some 400 soldiers and
policemen at command, were powerless, and murder and pillage
ran their course as long as an Armenian was in sight. The
official Turkish reports give the number of Armenians slain as
182, of Turks 11, but the general estimate places the total
number at some 500. Reinforcements of troops soon arrived, and
quiet was restored. No injury to American citizens or property
occurred.

"From this time the reports of conflicts between Turks and

Armenians, with great loss of life, become frequent and
confused. At Akhissar, some 60 miles from Smyrna, 50 Armenians
were killed October 9. Koordish raids terrorized many parts of
the Armenian provinces. At Bitlis over 500 were reported
killed, the Turkish accounts alleging that the Armenians
attacked the Moslem mosques during the hour of prayer. At
Diarbekir 5,000 are said to have lost their lives, of which
 2,300 were Mussulmans—but the Turkish authorities pronounce
this estimate exaggerated. From Malatia comes the report of a
'great massacre' early in November, when every adult male
Christian is said to have perished. Another sanguinary
outbreak, with great slaughter, is reported from Sivas on
November 12; some 800 Armenians and 10 Koords are said to have
been killed. At Hadjin and Ourfa loss of life is reported, the
American missionaries at those places being protected by
Turkish guards under orders from the Porte.

"The Kaimakam of Hadjin is credibly said to have announced

that he would destroy the town and sow barley on its site.
There being an American school at that place, directed by
American teachers, the United States minister thereupon
notified the Porte that if one of those American ladies
received injury from the riotous conduct of the populace, he
would demand, in the name of the United States, 'the head of
that Kaimakam.' That officer has since been removed. Later
reports allege massacres at Marsovan and Amasia. The consular
agent at Aleppo telegraphs that a severe conflict had occurred
at Aintab, and that great fear prevailed at Aleppo. The
burning of the American buildings at Harpoot took place during
a bloody riot, and many persons are said to have perished in
the province of that name. At Kurun 400 deaths are reported.
Particulars of the recent outbreak at Marash, on November 19,
in which American missionary property was destroyed, have not
yet been received.

{539}

"These scattered notices, for the most part received by

telegraph, are given, not as official averment of the facts
stated, but as showing the alarming degree to which racial
prejudices and fanatical passions have been roused throughout
Asia Minor. As above said, the Department of State has and can
have official knowledge regarding but few of these reported
massacres, and though up to the early part of December the
United States minister estimated the number of the killed as
exceeding 30,000, it is more than likely that the figures are
greatly exaggerated. At latest advices mob violence and
slaughter appear to have been checked, or at least to have
partially subsided. The Turkish Government has been emphatic
in assurances of its purpose and ability to restore order in
the affected localities; new governors have been appointed in
many of the provinces, troops have been sent to the scene of
recent or apprehended disorders, and forces have been massed
to subdue the Armenians who had gained the ascendant in
Zeitoun."

Of the American missionary establishments in Turkey, and of

the extent to which they suffered harm during the outbreaks,
the same report gave the following account:

"The number of citizens of the United States resident in the

Turkish Empire is not accurately known. According to latest
advices there are 172 American missionaries, dependents of
various mission boards in the United States, scattered over
Asia Minor. There are also numbers of our citizens engaged in
business or practicing professions in different parts of the
Empire. Besides these, more or less persons, originally
subjects of Turkey and since naturalized in the United States,
have returned to the country of their birth and are
temporarily residing there. The whole number of persons
comprising these several classes can not be accurately
estimated, but, the families of such citizens being
considered, can hardly be less than five or six hundred, and
may possibly exceed that total.

"Outside of the capital and a few commercial seaport towns,

the bulk of this large American element is found in the
interior of Asia Minor and Syria, remote from the few consular
establishments maintained by this Government in that quarter,
inaccessible except by difficult journeys, and isolated from
each other by the broken character of the mountain country and
the absence of roads. Under these circumstances and in the
midst of the alarming agitation which for more than a year
past has existed in Asia Minor, it has been no slight task for
the representative of the United States to follow the
interests of those whose defense necessarily falls to his
care, to demand and obtain the measures indispensable to their
safety, and to act instantly upon every appeal for help in
view of real or apprehended peril. It is, however, gratifying
to bear testimony to the energy and promptness of the minister
in dealing with every grievance brought to his notice, and his
foresight in anticipating complaints and securing timely
protection in advance of actual need. The efforts of the
minister have had the moral support of the presence of naval
vessels of the United States on the Syrian and Adanan coasts
from time to time as occasion required. …

"While the physical safety of all citizens of the United

States appears up to the present date to have been secured,
their property has, on at least two recent occasions, been
destroyed in the course of local outbursts at Harpoot and
Marash. The details of the Harpoot destruction have so far
been only meagerly reported, although it took place about the
middle of November. It is stated that the buildings at that
place were set on fire separately by Kurds and citizens, in
the presence of the Turkish soldiery, during an Armenian riot.
Besides the chapel, girls' theological school and seminary
building, the ladies' house, boarding house, and residences of
three American missionaries were burned, the aggregate loss on
the buildings, personal property, stock, fixtures, and
apparatus being estimated in the neighborhood of $100,000. The
United States minister has notified the Porte that the Turkish
Government will be held responsible for the immediate and full
satisfaction of all injuries on that score. The American
Missionary School of Science at Marash was burned during a
sanguinary outbreak on November 19. The value of the property
destroyed has not been ascertained, but after prompt
investigation the minister will make like demand for adequate
indemnity."

United States, 54th Congress, 1st Session,

Senate Document, Number 33.

"On November 9 one of tho Foreign Consuls arrived at

Constantinople from Erzeroum on leave, and he reported the
scene on his journey as heartrending. 'The whole country
between Trebizond and Erzeroum was devastated. He counted 100
dead bodies lying by the road near one town. Nearly all the
villages were burnt, and in many cases the male population
entirely wiped out.' At last, on December 13, 1895, Lord
Salisbury received the following telegraphic despatch from Sir
Philip Currie: 'It may be roughly stated that the recent
disturbances have devastated, as far as the Armenians are
concerned, the whole of the provinces to which the scheme of
reforms was intended to apply; that over an extent of
territory considerably larger than Great Britain all the large
towns, with the exception of Van, Sassun, and Moush, have been
the scene of massacres of the Armenian population, while the
Armenian villages have been almost entirely destroyed. A
modest estimate puts the loss of life at 30,000. The survivors
are in a state of absolute destitution, and in many places
they are being forced to turn Mussulmans. The charge against
the Armenians of having been the first to offer provocation
cannot be sustained. Non-Armenian Christians were spared, and
the comparatively few Turks who fell were killed in
self-defence. The participation of the soldiers in the
massacres is in many places established beyond doubt.'

"Of the appalling horror of this account I wish it were

needless to speak. … [It] would be none the less horrible if
the whole of the people massacred and outraged, ruined, and
starved, and driven to the snowy mountains in the middle of
winter, had been all the rudest villagers of the most rustic
village communities. But when we know that many thousands of
the victims have been people educated at Christian schools and
 colleges, and who had acquired there, in addition to the
ineradicable virtues of their native and ancient faith, much
also of the refinements and activities of civilised life, we
may reach some true conception of the agonies which have been
inflicted on such a people in the face of Europe and of the
world by the cruelty and brutality of the Turks.
{540}
It is, indeed, right that our first indignation should be
directed against the infamous Government of Turkey. … Let us
remember that this is not a Government with which we have had
nothing to do, or for which we have had no responsibility, but
a Government which the European Powers, and we especially,
have been protecting and nursing for half a century. … Then we
may indeed begin to think, with remorse and shame, of our
handiwork, and of its results. In this particular case,
indeed, the immediate blame lies almost alone with Russia. By
a complete departure from all her previous great traditions
she deliberately refused to join the other Powers of Europe
for the purpose of compelling the Sultan to act with decent
humanity to those of whom she had been the declared defender.
She had the physical power and the geographical opportunity
which others had not; and there can be no doubt whatever that
a joint occupation of the waters of Constantinople by the
fleets of the European Powers would have secured the very
moderate demands that Europe made upon the Porte."

The Duke of Argyle,

Our Responsibilities for Turkey,
pages 116-122.

TURKEY: A. D. 1896.
Conflict in Crete between Christians and Mussulmans,
and its preceding causes.

In 1868, the Cretans, for the second time, were thrust under
the Turkish yoke. "By way of solace the Powers exerted
themselves feebly in inducing the Porte to concede the
so-called 'Organic Statute'

See (in volume 3)

GREECE: A. D. 1862-1881.
Organic Regulation.

… As the Charter remained a dead letter, the Cretans seized

the next favourable opportunity to rise in 1877. Their case
was brought before the Congress of Berlin; but the only relief
the Powers could extend to them was a fresh promise on the
part of the Porte, recorded in the XXIII Article of the
Treaty, to observe scrupulously that Organic Statute, which
had been proved to be unworkable. Meanwhile, the Cretans had
remained under arms during the whole of 1878, the island being
again almost completely devastated by the half-naked and
famishing troops which had survived the Russo-Turkish War.
Ultimately, through the mediation of England, the Porte was
induced, in November of that year, to concede the Pact of
Halepa, so named after the village near Canea where it was
negotiated, and signed under the supervision of the British
Consul, Mr. T. B. Sandwith—this fact being expressly recorded
in the preamble of the document. The arrangement was accepted
by the Cretans as a compromise, in spite of its many and
manifest drawbacks. Nevertheless, it brought about, at the
outset, certain beneficial results. Political parties were
formed in which the Mohammedan Cretans blended, irrespective
of religious differences, with their Christian countrymen; and
the unprecedented phenomenon of a Christian Vali completing
his four years' tenure of governorship was witnessed in the
person of Photiades Pasha.

"But this tendency to conciliation of the conflicting elements

in the island was by no means to the liking of the Porte. The
presence of a Mussulman military governor was therefore
discovered to be necessary; and as his grade was usually
superior to that of the Vali, and the Mussulman sub-governor
was the official whose recommendations were of weight with the
Porte, nothing was easier than to create insuperable
difficulties for the Christian Vali. Thus successive Valis
were compelled—often by private wire from Constantinople—to
tender their resignation; while, at the same time, the Porte
took care not to fulfil the financial engagements prescribed
by the Pact. By these means an acute crisis was brought about
under the Governorship of Sartinski Pasha, a Pole, in 1889,
when a preconcerted plan of deception and treachery was
carried out by the Porte with consummate skill.

"The Cretans, as it is but natural, are guided in critical

contingencies by the advice they seek at Athens. The Porte
therefore promised to the Greek Government, as soon as things
began to assume a threatening aspect in Crete, to satisfy the
demands of the islanders, provided they were prevailed upon to
abstain from occupying certain important positions. In spite
of the transparent perfidy of the proposal, M. Tricoupis, the
then Greek Premier, fell into the snare. While the Cretans
were held back, troops were poured into the island, and the
strategical points having been seized, the Greek Government
and the Cretans were defied. An Imperial firman, issued in
November of that year, abrogated the Pact of Halepa and the
British Government, under whose auspices it was concluded, was
now powerless to exact respect for what was virtually an
international arrangement. There was no longer any question of
a Christian Vali with a fixed tenure of office, or of an
Assembly of Cretan representatives. Shakir Pasha, the
commander of the Turkish troops, was invested with absolute
civil and military authority; Mussulman Albanians occupied the
Christian villages as gendarmes, and Crete continued to submit
to this kind of martial law up to 1894. When, however, Mahmoud
Djelaleddin Pasha, the then Mussulman Vali, surpassed even his
predecessors in arbitrariness, and actually dictated to the
tribunals decisions in favour of Mohammedan litigants, the
Cretans began to lose patience and another outbreak appeared
imminent. It was only then that the Great Powers moved in the
matter and prevailed upon the Porte to revert partly to the
 pre-existing order of things, by appointing Alexander
Karatheodory Pasha, a Christian and a Greek, as Governor.
Beyond this, however, the Pact of Halepa was not observed.
True to its traditional tactics, the Porte took with one hand
what it had given with the other. The Mussulman Deputy
Governor and the military commander frustrated every effort of
the Vali, the very funds necessary for the maintenance of the
gendarmerie being denied him. Karatheodory was consequently
forced to resign. Complete anarchy now reigned in the island."

Ypsiloritis,
The Situation in Crete
(Contemporary Review, September, 1896).

"Occasional skirmishes between the Christian inhabitants and

the soldiers kept the excitement simmering and ushered in the
sanguinary scenes that finally followed. Turkhan Pasha, taking
time by the forelock, armed the Cretan Moslems for the combat
with the approval of the commander of the troops, and the
city of Canea prepared for a blood bath. The Mohammedan Lent
(Ramazan) was drawing to a close, and the three days of
rejoicing which invariably follow (Bairam) were supposed to be
fixed for the attack on the Christians. These anticipations
were duly realised, and on the 24th May, 1896, at 1 o'clock P.
M., the Turks fired the first shots, blowing out the brains of
several Christians to make that Moslem holiday.
{541}
Forearmed, however, is forewarned, and the Christians defended
themselves to the best of their ability on that day and the
25th and 26th, during which every house in Canea was
barricaded, and neighbours living on opposite sides of the
absurdly narrow streets fired at each other from behind stone
heaps piled up in the windows of their bedrooms. The streets
were deserted, all traffic suspended, and it was not until the
27th that the thirty Christian corpses (including two women
and four children) and the twenty lifeless Turks were removed
for burial.
 "These events provoked a new administrative change of scene:
Turkhan Pasha was recalled, and Abdullah Pasha, at the head of
four battalions from Salonica, came to take his place. These
troops laid waste the villages and fields of the provinces of
Apokorona, Cydonia, and Kissamo, burning houses, huts, and
churches on the way. The best soldiers in the world, however,
run terrible risks in the interior of Crete, and Abdullah was
repulsed with the loss of two hundred men at the town of
Vamos. The foreign consuls at Canea, having verified these
facts, strongly blamed his conduct in a joint verbal note, and
the Porte shortly afterwards recalled him, and appointed
Berovitch Pasha [Prince of Samos] in his place. This was the
beginning of the end. The Christians of the island meanwhile
met, and through their delegates formulated certain demands,
which the foreign consuls referred to their ambassadors at
Constantinople, and the famous 'Modifications of the
Convention of Halepa' were framed in consequence. The sultan,
too, yielding to tardy pressure, graciously conceded the
nomination of a Christian governor-general in the person of
Berovitch, the summoning of the National Assembly, and other
demands. … The questions of the tribunals and the gendarmerie
[for the enforcement of peace and order in the island] were to
be arranged by international commissions; but weeks and months
passed away before they were even appointed. … At last the
commissions arrived and began their work in December [1896]."

E. J. Dillon,
Crete and the Cretans
(Fortnightly Review, May, 1897).

TURKEY: A. D. 1896 (January-March

Turkish opposition to English and American measures
for relief to Armenian sufferers.
Work of Miss Clara Barton and the Red Cross Society.

For some time the distribution of supplies from England and

America to the sufferers in Armenia was forbidden by the
Turkish government, for reasons stated by the Turkish minister
at Washington as follows: "The collections are made on the
strength of speeches delivered in public meetings by
irreconcilable enemies of the Turkish race and religion, and
on the basis of false accusations that Turkey repudiates.
Besides, the Sublime Porte is mindful of the true interests of
its subjects, and, distinguishing between the real state of
things and the calumnies and wild exaggerations of interested
or fanatical parties, will under its own legitimate control
alleviate the wants of all Turkish subjects, irrespective of
creed or race." The Red Cross Society, of which the American
branch had prepared to send its President, Miss Clara Barton,
with a small corps of assistants, to the scene of the
suffering, was especially excluded, by the order of the Porte.
Miss Barton and her staff sailed, however, from New York, in
January, and Mr. Terrell, the American minister at
Constantinople, succeeded in obtaining permission for them to
do their humane work as private individuals, not in the name
of the obnoxious society, and without displaying its insignia:
The single-mindedness, the prudence, the patient energy with
which Miss Barton pursued the one object of giving relief to
the suffering, overcame all opposition and all obstructions,
so that, in April, she was able to report:

"The way is all made clear for sending supplies. The suitable
agents all along the route are now known, and have been
arranged with for service, so that heavy supplies can be sent
at any and all times as they are needed. I feel my breath come
lighter as I think of these poor scourged and fever-stricken
towns without even one doctor, when our sixteen strong,
skilled men, with twenty-five camels' burden of supplies,
shall carry some light of hope and help into their night of
hopeless woe. I am happy to be able to say for the comfort of
contributors, that I hold the written word of the Porte,
officially given through the minister of foreign affairs from
the grand vizier, that not the slightest interference with any
 distribution within the province will be had. This official
document was addressed and delivered to Sir Philip Currie, the
British ambassador, and by him passed to me. The decision is
general and final, without question or reservation, and
settles all doubt."

In September Miss Barton returned home for rest, and to bear

her testimony to America of the immensity of the need still
existing in the Armenian provinces and calling for help. Her
departure from Constantinople was reported by the newspapers
to have been the occasion of a remarkable demonstration, by
cheers, flags and salutes, from ship and shore, of the
estimate put upon the work she had done.

TURKEY: A. D. 1896 (August).

Attack of Armenian revolutionists on the
Ottoman Bank at Constantinople.
Turkish massacre of Armenians in the city.

In the spring of 1896, the Armenian revolutionists, encouraged

by the outbreak in Crete, made fresh appeals for attention to
the sufferings of their country, with threats of some
desperate action if no heed was given. In August, the
desperate act was undertaken, at Constantinople, by 30 or 40
madly devoted men. This reckless little band of misguided
patriots made a sudden attack on the Ottoman Bank, a British
institution which controls finance in the Turkish empire,
gained possession of the building, made prisoners and hostages
of two of its directors and some 80 of its clerks, and were
fully prepared with dynamite to destroy everything within its
walls, including themselves, if certain reforms which they set
forth were not instantly decreed. Their theory was, that "the
Ambassadors would force the Sultan to grant the reasonable
reforms which they demanded for the Armenians, rather than
permit the destruction of the Bank and its staff. It was a
scheme borrowed from the theatre, absurd in itself, and made
ridiculous by the way in which they failed to carry it out.
 They went in bravely, and nothing hindered their destroying
the Bank, but they allowed themselves to be talked out of it
by Mr. Maximoff, the Russian dragoman, and would have been the
laughing stock of the world if its attention had not been
absorbed by the massacre which followed.

{542}

"The real heroism of that day was displayed in another quarter

of the city, by another small party of Russian Armenians, men
and women, who took possession of two stone houses and fought
the Turkish troops to the death, the survivors killing
themselves when they could fight no longer. There was no
serious fighting anywhere else, although dynamite bombs were
thrown from the windows of houses and khans upon the troops in
a number of places, showing that some preparation had been
made for a more extended outbreak. There is nothing to be said
in justification of this attempt of the revolutionists. They had
provocation enough to justify anything in reason, but there
was nothing reasonable in this plan, nothing in it to attract
the sympathy of the Powers or to conciliate public opinion;
and if the statements are true which have been made by
Armenians as to certain unexecuted parts of the plan, it was
diabolical. This only can be said on behalf of these
revolutionary committees. They are the natural outcome of the
treatment of the Armenians by the Turkish Government during
the last twenty years. When oppression passes a certain limit
and men become desperate, such revolutionary organisation
always appears. They are the fruit and not the cause of the
existing state of things in Turkey, and if we can judge by the
experience of other countries, the worse things become here,
the more violent will be the action of these committees,
whether Europe enjoys it or not.

"Revolutionists are the same all the world over, but the
Turkish Government is unique, and it is not the attack on the
Bank which interests us but the action of the Government which
followed it. As we have said, the authorities had full
information of what was to be attempted and did nothing to
prevent it, but they made every preparation for carrying out
their own plan. Bands of ruffians were gathered in Stamboul,
Galata, and Pera, made up of Kurds, Lazes, and the lower class
of Turks, armed with clubs, knives or firearms; and care was
taken that no one should kill or plunder in the quarter to
which he belonged, lest he should be recognised and complaint
made afterwards by the Embassies, with a demand for
punishment. A large number of carts were in readiness to carry
off the dead. The troops and police were in great force to
prevent any resistance, and to assist the mob if necessary. It
was a beautiful day, the streets were crowded, and few had any
idea of what had happened at the Bank, when suddenly, without
any warning, the work of slaughter and plunder began,
everywhere at once. European ladies on the way to the
Bosphorus steamers suddenly found themselves surrounded by
assassins, and saw men beaten to death at their feet. Foreign
merchants saw their own employés cut to pieces at their doors.
The streets in some places literally ran with blood. Every man
who was recognised as an Armenian was killed without mercy. In
general, the soldiers took no part in the slaughter and
behaved well, and this somewhat reassured those in the streets
who were not Armenians; but in a few moments the shops were
closed and a wild panic spread through the city. The one idea
of everyone was to get home; and as the foreigners and better
classes live out of the city in summer they had to go to the
Galata bridge to take the steamers, which ran as usual all
through the three days of massacre. This took them through the
streets where the slaughter was going on, and consequently we
have the testimony of hundreds of eye-witnesses as to what
took place. The work of death and plunder continued unchecked
for two days. On Friday there were isolated outbreaks, and
occasional assassinations occurred up to Tuesday.

"The number killed will never be known. The Ambassadors put it

at 5,000 or 6,000; the official report to the palace at 8,750,
besides those thrown into the sea. Thousands of houses, shops
and offices were plundered, including a number belonging to
Greeks and foreigners. Everything was done in the most
systematic way, and there was not a moment of anarchy, not a
moment when the army and police had not perfect control of the
city during all these days. … The majority of those massacred
belonged to the working class—especially the hamals
(porters)—but a large number of gentlemen, merchants and other
wealthy men, were killed, together with about fifty women and
children. The savage brutality of the Moslem mob was something
beyond all imagination, and in many cases the police joined in
beating men to death and hacking others to death with knives,
in the very face of Europeans. … In may cases European
officials appealed to the officers in command of the troops,
who were looking on at the slaughter of helpless, unarmed men,
to interfere and put a stop to it. The reply was 'We have
orders.' It was an officer who killed the clerk of the British
Post-office on the steps. And some of the most cold-blooded
and horrible murders took place in front of the guard house,
at the Galata end of the bridge, in the presence of officers
of the Sultan's household of the highest rank. They also had
their orders.

"Happily for the honour of the Turkish people, there is

another side to the story. It was the Government and not the
people that conducted this massacre. And although the vile
instruments employed were told that they were acting in the
name of the Prophet, and freely used his name, and are
boasting to-day of what they did for Islam, the Sheik-ul-Islam
forbad the Softas taking any part in the slaughter, and many a
pious Turk did what he could to protect his neighbours. … It
is not the people, not even the mob, who are responsible for
this great crime. It was deliberately committed by the
Government. The Ambassadors of the six Powers have declared
this to be an unquestionable fact in the Joint Note addressed
to the Porte.
 "Since the massacre this same Government has been carrying on
a warfare against the Armenians which is hardly less inhuman
than beating out their brains with clubs. There were from
150,000 to 200,000 Armenians in Constantinople. They were
merchants, shopkeepers, confidential clerks, employés in banks
and offices of every kind—the chief business men of the city.
They were the bakers of the city, they had charge of the khans
and bazaars and the wealth of the city; they were the porters,
house-servants, and navvies. … Now the Government has
undertaken to ruin this whole population. They are hunted
about the city and over the hills, like wild beasts. …
Thousands have been sent off at once to the Black Sea ports,
to find their way as best they can without money or food to
their desolated villages in the interior. … Thousands have
fled to foreign countries."

The Constantinople Massacre

(Contemporary Review, October, 1896).

{543}

TURKEY:A. D. 1897 (January-February).

Fresh conflicts in Crete.
Attitude of Christians and Mussulmans towards each other.
Reports of the British Consul-General and others.

Early in January, 1897, while proceedings for the organization

of the new gendarmerie were under way, and while the
discussion of candidates for the National Assembly, to be
elected in March, was rife, fresh hostilities between
Christians and Mussulmans broke out, and there seems to be
good evidence in the following report, by Sir Alfred Biliotti,
the British Consul-General at Canea, that responsibility for
the state of things in Crete should be charged upon one party
hardly more than upon the other. The despatch of the
Consul-General to Lord Salisbury, written January 9, 1897, is
partly as follows:
"In the afternoon of the 3rd instant a great panic occurred in
the town owing to a wounded Christian having been conveyed to
the hospital, where he died of his wounds in the night, and to
a rumour that two Mussulmans had been killed or wounded at the
same time on the road between Canea and Suda Bay. All the
shops were shut up as usual, but there was no general 'sauve
qui peut,' Christians especially having congregated in the
square near the hospital in the hope of finding out further
information. Happening to be in the town, I took a carriage
and drove towards Suda. When at about a mile distant from
Canea I came upon a number of Mussulmans, who told me that
four Christians going to Apokorona had, without any
provocation whatever, discharged their revolvers on three
Mussulmans, two of whom had been severely wounded. I saw one
of them in his cottage hard by the road with a bullet wound in
the abdomen; the other had been conveyed on horseback to the
village of Tsikalaria (southeast of Suda Bay), 2 miles from
where he had been wounded, of which he was a native. The four
Christians fled across the fields, leaving on the road a horse
and an overcoat, and took to the mountains.

"Between half and a quarter of an-hour after this incident

another Christian, a native, like the Turk, of Tsikalaria, was
passing on the road when he was fired upon by Mussulmans in
retaliation for the wounding of their two co-religionists. Not
having been hit, the Christian jumped from his mule and ran
for his life along the Suda road, being pursued by armed
Turks. He was overtaken by three of them about half-a-mile
farther down, and was shot at and mortally wounded at 20 paces
in front of Commander Shortland, of Her Majesty's ship 'Nile,'
who was coming on foot from Suda Bay to Canea. The wounded
Christian was taken charge of by the Albanian corporal
stationed in a Christian monastery close by, and was
subsequently put in a carriage by the Russian Consul, who was
returning from Suda Bay at that moment, and sent to the town
hospital, where he died. While I was making inquiries on the
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