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Daniel S. Duick
Robert A. Levine
Mark A. Lupo Editors

Thyroid and Parathyroid

Ultrasound and
Ultrasound-Guided FNA
Fourth Edition

123
Thyroid and Parathyroid
Ultrasound and Ultrasound-
Guided FNA
Daniel S. Duick • Robert A. Levine
Mark A. Lupo
Editors

Thyroid and Parathyroid

Ultrasound and
Ultrasound-Guided
FNA
Fourth Edition
Editors
Daniel S. Duick Robert A. Levine
University of Arizona, College Geisel School of Medicine at
of Medicine Dartmouth, Thyroid Center of
Phoenix, AZ, USA New Hampshire,
St. Joseph Hospital,
Endocrinology Associates, P. A. Nashua, NH, USA
Scottsdale, AZ, USA

Mark A. Lupo
Florida State University,
College of Medicine
Tallahassee, FL, USA

Thyroid & Endocrine

Center of Florida
Sarasota, FL, USA

ISBN 978-3-319-67237-3    ISBN 978-3-319-67238-0 (eBook)

https://doi.org/10.1007/978-3-319-67238-0

Library of Congress Control Number: 2017960819

© Springer International Publishing AG 2018, 2013, 2008, 2000

This work is subject to copyright. All rights are reserved by the Publisher,
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Foreword

 ourth Edition of the “Thyroid and Parathyroid

F
Ultrasound and Ultrasound-Guided FNA”
When I began my career in endocrinology in 1971, and spe-
cifically in thyroidology, evaluation of the thyroid nodule
simply involved a careful history and physical examination, as
well as, in some cases, nuclear scanning. Ultrasound and, for
that matter, other imaging techniques were not available.
Despite what seems crude by today’s standards, we thought
we did pretty well. Then, years later, thyroid ultrasound
became available, and that revolutionized our approach to
patient evaluation and management and especially, with the
additional advent of fine needle aspiration, to cytologic
evaluation of nodules. Indeed, thyroid ultrasound has become
standard practice in the evaluation of patients with thyroid
nodules; it is an indispensable extension of our eyes and
fingers.
In this fourth edition of the “Thyroid and Parathyroid
Ultrasound and Ultrasound-Guided FNA” by Duick, Levine,
and Lupo, the authors manage to synthesize the essentials of
their prior three editions and provide a comprehensive and
expanded review on the latest in the diagnosis and manage-
ment of thyroid nodules, as well as focusing on parathyroid
disease and non-endocrine lesions of the neck. They rely not
only on their extensive collective clinical experience but on
reviews of prior and current peer-reviewed publications. The
authors, all experts in thyroid and p
­ arathyroid disease, cover
not only thyroid and parathyroid disease but also have a
vi Foreword

chapter on imaging of the salivary glands and other non-

endocrine lesions of the neck, mindful of the fact that those
of us who perform (and evaluate) neck ultrasound also detect
non-thyroid and parathyroid lesions. In this edition, the
authors expand the chapters on both surgical and nonsurgical
management.
Since the publication of the third edition of this book, the
use of molecular markers in thyroid evaluation has become
both more sensitive and specific, and an excellent chapter
addresses this issue.
Finally, as more endocrinologists and surgeons perform
ultrasounds in their office practices, it is essential that
detailed reports are available to referring physicians and that
they also include adequate information for billing purposes.
The authors recognize this and include a chapter on author-
ing ultrasound reports.
In summary, this fourth edition brings together the collec-
tive wisdom of specialists who treat patients with thyroid
nodules, thyroid cancer, and parathyroid disease and should
serve as the “go-to” source for surgeons, endocrinologists,
fellows, and residents.

Peter A. Singer, MD
Clinical Endocrinology,
Thyroid Diagnostic Center,
Keck School of Medicine of USC
Los Angeles, CA, USA
Preface

 ourth Edition of the Thyroid Ultrasound

F
and Ultrasound-Guided FNA Textbook
Ultrasound has become ingrained as the classical utilization
of applied technology for both diagnostic and interventional
therapeutic approaches to the management of thyroid and
parathyroid conditions. It is an invaluable tool for the prac-
tice of thyroidology and is most beneficial when performed in
real time by a physician or a practitioner who is skilled and
knowledgeable in the anatomy of the neck.
The recognition of imagery patterns suggestive of a gener-
alized disease state, the presence and evaluation of thyroid
nodules, the search for a parathyroid tumor when there is
biochemical evidence of hyperparathyroidism, and the assess-
ment for residual tissue and lymphadenopathy of the postop-
erative thyroid cancer neck are all related issues that
ultrasound is capable of optimally imaging.
There continues to be technologic advances in demon-
strating ultrasound images on the visual screen which enhance
gray scale and employ both color flow Doppler and power
Doppler which add additional information to the analysis of
the thyroid gland, parathyroid tumors, and lymph nodes as
well as other structures in the neck.
Ultrasound remains the number one invaluable tool for
assessing the endocrine neck, and the performance of real-­
time ultrasound is unquestionably the optimum methodology
for utilization.

Scottsdale, AZ, USA Daniel S. Duick, MD, MACE

Contents

1 History of Thyroid Ultrasound. . . . . . . . . . . . . . . . . . .    1

Robert A. Levine and J. Woody Sistrunk
2 Thyroid Ultrasound Physics�����������������������������������������   15
Robert A. Levine
3 Doppler Ultrasound�������������������������������������������������������   43
Robert A. Levine
4 Normal Neck Anatomy and Method of Performing
Ultrasound Examination�����������������������������������������������   71
Vijaya Chockalingam, Sarah Smith, and Mira Milas
5 Pediatric Ultrasound of the Neck��������������������������������� 107
Hank Baskin
6 Diffuse Thyroid Disease (DTD) and Thyroiditis������� 141
Stephanie L. Lee
7 Ultrasound of Thyroid Nodules����������������������������������� 189
Susan J. Mandel and Jill E. Langer
8 Ultrasound and Mapping of Neck Lymph Nodes ����� 225
Catherine F. Sinclair, Dipti Kamani, Gregory W.
Randolph, Barry Sacks, and H. Jack Baskin Sr.
9 Ultrasonography of the Parathyroid Glands ������������� 263
Dev Abraham
10 Surgical Trends in Ultrasound Applications for the
Treatment of Thyroid Nodules, Thyroid Cancer,
and Parathyroid Disease. . . . . . . . . . . . . . . . . . . . . . . . 293
Stacey Klyn and Mira Milas
x Contents

11 Ultrasound of Salivary Glands and the

Non-­endocrine Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Vinay T. Fernandes and Lisa A. Orloff
12 Ultrasound-Guided Fine-­Needle Biopsy
of Thyroid Nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Mark A. Lupo and Daniel S. Duick
13 Laser and Radiofrequency Ablation Procedures. . . . 389
Petros Tsamatropoulos and Roberto Valcavi
14 Percutaneous Ethanol Injection (PEI)
for Thyroid Cysts and Other Neck Lesions ��������������� 429
Andrea Frasoldati, Petros Tsamatropoulos,
and Daniel S. Duick
15 Utilization of Molecular Markers
in the Diagnosis and Management
of Thyroid Nodules ������������������������������������������������������� 465
Susan J. Hsiao and Yuri E. Nikiforov
16 Ultrasound Elastography of Thyroid Nodules����������� 489
Ghobad Azizi and Carl D. Malchoff
17 Authoring Quality Ultrasound Reports ��������������������� 517
J. Woody Sistrunk
Index����������������������������������������������������������������������������������������� 535
Contributors

Dev Abraham, MBBS, MRCP(UK) Department of

Medicine, University of Utah, Salt Lake City, UT, USA

Ghobad Azizi, MD Endocrinology, Wilmington

Endocrinology, Wilmington, NC, USA

H. Jack Baskin Sr., MD, MACE University of Central

Florida College of Medicine, Orlando, FL, USA

Hank Baskin, MD, DABR Pediatric Section, Intermountain

Healthcare Imaging, Department of Radiology, University of
Utah School of Medicine, Medical Imaging, Primary
Children’s Hospital, Salt Lake City, UT, USA

Vijaya Chockalingam, MD Endocrinology, Banner

University Medical Center, Phoenix, AZ, USA

Daniel S. Duick, MD, MACE University of Arizona College

of Medicine, Phoenix, AZ, USA

Endocrinology Associates, PA, Scottsdale, AZ, USA

Vinay T. Fernandes, MD, FRCSC Otolaryngology – Head &

Neck Surgery, University of Toronto, Toronto, ON, Canada

Andrea Frasoldati, MD, PhD Endocrinology Unit, Medical

Specialities Department, Arcispedale S. Maria Nuova –
IRCCS, Reggio Emilia, Italy
xii Contributors

Susan J. Hsiao, MD, PhD Department of Pathology & Cell

Biology, Columbia University Medical Center, New York,
NY, USA

Dipti Kamani, MD Department of Otolaryngology, Division

of Thyroid and Parathyroid Surgery, Massachusetts Eye and
Ear Infirmary, Boston, MA, USA

Stacey Klyn, DO Department of Surgery, Banner University

Medical Center, Phoenix, AZ, USA

Jill E. Langer, MD Department of Radiology, Perelman

School of Medicine, University of Pennsylvania, Philadelphia,
PA, USA

Stephanie L. Lee, MD, PhD, FACE, ECNU Section of

Endocrinology, Diabetes and Nutrition, Thyroid Health
Center, Boston Medical Center, Boston, MA, USA

Robert A. Levine, MD, FACE, ECNU Geisel School of

Medicine at Dartmouth College, Thyroid Center of New
Hampshire, St. Joseph Hospital, Nashua, NH, USA

Mark A. Lupo, MD, FACE, ECNU Thyroid & Endocrine

Center of Florida, Sarasota, FL, USA
Florida State University, College of Medicine, Sarasota
Florida Campus, Sarasota, FL, USA

Carl D. Malchoff, MD, PhD Internal Medicine and Neag

Comprehensive Cancer Center, UConn Health, Farmington,
CT, USA

Susan J. Mandel, MD, MPH Division of Endocrinology,

Diabetes and Metabolism, Department of Medicine, Perelman
School of Medicine, University of Pennsylvania, Philadelphia,
PA, USA
 Contributors xiii

Mira Milas, MD, FACS Thyroid, Parathyroid & Adrenal

Disorders Center, Diabetes and Endocrinology Institute,
Phoenix, AZ, USA

Department of Surgery, Endocrine Surgery Center, University

of Arizona College of Medicine – Phoenix, Phoenix, AZ,
USA

Banner – University Medical Center Phoenix, Phoenix, AZ,

USA

Yuri E. Nikiforov, MD, PhD Department of Pathology,

Division of Molecular & Genomic Pathology, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA

Lisa A. Orloff, MD, FACE, FACS Otolaryngology, Stanford

University Medical Center, Stanford, CA, USA

Gregory W. Randolph, MD, FACS, FACE Thyroid Surgery

Oncology, Harvard Medical School, Boston, MA, USA

Division of Thyroid and Parathyroid Endocrine Surgery,

Department of Otolaryngology – Head and Neck Surgery,
Massachusetts Eye and Ear Infirmary, Boston, MA, USA

Department of Surgery, Endocrine Surgery Service,

Massachusetts General Hospital, Boston, MA, USA

Barry Sacks, MD Beth Israel Deaconess Medical Center,

Natick, MA, USA

Catherine F. Sinclair, BMBS(Hons), FRACS, BSc(Biomed)

Department of Otolaryngology, Icahn School of Medicine at
Mount Sinai, New York, NY, USA

J. Woody Sistrunk, MD, FACE, ECNU Jackson Thyroid &

Endocrine Clinic, PLLC, Jackson, MS, USA
xiv Contributors

Sarah Smith, RDMS Sonographer, Medsmart Inc. and

Alumnus, West Coast Ultrasound Institute, Phoenix, AZ,
USA

Petros Tsamatropoulos, MD Endocrinology Unit, Centro

Palmer, Reggio Emilia, Italy

Roberto Valcavi, MD, FACE Endocrinology Unit, Centro

Palmer, Reggio Emilia, Italy
Chapter 1
History of Thyroid
Ultrasound
Robert A. Levine and J. Woody Sistrunk

Abbreviations
AACE American Association of Clinical Endocrinologists
AIUM American Institute of Ultrasound Medicine
ATA American Thyroid Association
ECNU Endocrine Certification in Neck Ultrasound
MHz Megahertz

R.A. Levine, MD, FACE, ECNU (*)

Geisel School of Medicine at Dartmouth College, Thyroid Center
of New Hampshire, St. Joseph Hospital, Nashua, NH, USA
e-mail: [email protected]
J.W. Sistrunk, MD, FACE, ECNU
Jackson Thyroid & Endocrine Clinic, PLLC, Jackson, MS, USA

© Springer International Publishing AG 2018 1

D.S. Duick et al. (eds.), Thyroid and Parathyroid Ultrasound
and Ultrasound-Guided FNA,
https://doi.org/10.1007/978-3-319-67238-0_1
2 R.A. Levine and J.W. Sistrunk

Introduction
The visual application of sound in medicine has revolution-
ized the diagnosis and management of thyroid disease. The
safety of ultrasound, along with improvements in image qual-
ity and equipment availability, underlies the importance of
thyroid ultrasound to today’s endocrinologist and endocrine
surgeon.
The thyroid is amenable to ultrasound study because of its
superficial location, vascularity, size, and echogenicity [1]. In
addition, the thyroid has a very high incidence of nodular
disease, the vast majority benign. Most structural abnormali-
ties of the thyroid need evaluation and monitoring but may
not require intervention [2]. Between 1965 and 1970, there
were seven articles published specific to thyroid ultrasound.
In the last 5 years, there have been over 10,000 articles pub-
lished. Thyroid ultrasound has undergone a dramatic trans-
formation from the cryptic deflections on an oscilloscope
produced in A-mode scanning, to barely recognizable B-mode
images, followed by initial low-resolution gray scale, to cur-
rent high-resolution images. Recent advances in technology,
including harmonic imaging, spatial compound imaging, elas-
tography, and three-dimensional reconstruction, have all fur-
thered the field.
The development of high-resolution thyroid ultrasound
required decades of study in both the acoustics of sound
and data processing. Some animals, for example, dolphins
and bats, have the ability use ultrasound in their daily
activities in everything from catching prey to finding a
mate. As early as the 1700s, the Italian biologist Lazzaro
Spallanzani demonstrated that bats use high frequency
sound waves to navigate in complete darkness [3]. The aim
of this chapter is provide an overview of the basic advance-
ments in the field of ultrasound that have provided the
ability to easily and safely see and interpret structures
inside the neck.
 Chapter 1. History of Thyroid Ultrasound 3

Beginnings of Ultrasound History

One of the earliest experiments regarding transmission of
sound was performed in 1826 in Lake Geneva by Jean-Daniel
Colladon. Using an underwater bell he determined the speed
of sound transmission in water. In the 1800s, properties of
sound including wave transmission, propagation, reflection,
and refraction were defined. In 1877 Lord Rayleigh’s English
treatise, “Theory of Sound,” added mathematics and became
the basis for the applied study of sound. The principles
described lead to the science of using reflected sound in iden-
tifying and locating objects. In 1880, Pierre and Jacques Curie
discovered the piezoelectric effect, determining that an elec-
tric current applied across a crystal would result in a vibration
that would generate sound waves and that sound waves strik-
ing a crystal would, in turn, produce an electric voltage.
Piezoelectric transducers were capable of producing sonic
waves in the audible range and ultrasonic waves above the
range of human hearing [3].

Sonar
The first patent for a sonar device was issued to Lewis
Richardson, an English meteorologist, only 1 month after
the Titanic sank following collision with an iceberg. The
first functional sonar system was made in the United States,
by Canadian Reginald Fessenden, in 1915. The Fessenden
“fathometer” could detect an iceberg 2 miles away. As elec-
tronics improved, Paul Langevin designed a device called a
hydrophone. It became of the one of the first measures
available to detect German U-Boats during World War
I. The hydrophone was the basis of the pulse-echo sonar
that is still employed in ultrasound equipment today [3, 4].
Rudimentary high frequency ultrasound analysis was used
on a commercial basis in the 1930s and 1940s to detect defects
4 R.A. Levine and J.W. Sistrunk

in steel such as the hull of a ship. Although crude by today’s

standards, inhomogeneity suggested abnormalities, whereas a
flawless appearance suggested uniform material [4]. With the
end of World War II, the development of the computer and
the invention of the transistor advanced the development of
medical ultrasound [3].

Early Medical Applications of Ultrasound

The initial use of ultrasound in medicine in the 1940s was
therapeutic rather than diagnostic. Following the observation
that very high-intensity sound waves had the ability to dam-
age tissues, lower intensities were tried for therapeutic uses.
Focused sound waves were used to mildly heat tissue for
therapy of rheumatoid arthritis, and early attempts were
made to destroy the basal ganglia to treat Parkinson’s disease
[4]. The American Institute of Ultrasound in Medicine
(AIUM) was formed in 1952 with therapeutic ultrasound in
physical medicine being the primary focus. Although mem-
bers performing diagnostic ultrasound were not accepted
until 1964, diagnostic ultrasound is currently the primary
focus of this organization [3].
Early in the twentieth century, Paul Langevin described
the ability of high-intensity ultrasound to induce pain in a
hand placed in a water tank. The 1940s saw therapeutic ultra-
sound tried in numerous applications ranging from gastric
ulcers to arthritis. Attempts to destroy the basal ganglia in
patients with Parkinson’s disease now seem archaic. At the
time therapeutic ultrasound was headed toward the museum
of medical quackery, consideration of ultrasound as a diag-
nostic tool in medicine had begun. Although Drs. Gohr and
Wedekindt at the Medical University of Koln, Germany, sug-
gested that ultrasound could detect tumors, exudates, and
abscesses, the results were not convincing. Karl Theodore
Dussik is credited as the first physician to use diagnostic
ultrasound. In his 1952 report, “Hyperphonography of the
Brain,” ultrasound was utilized in localizing brain tumors and
 Chapter 1. History of Thyroid Ultrasound 5

the cerebral ventricles by transmitting ultrasonic sound

through the skull. While the results of these studies were later
discredited as predominantly artifact, this work played a sig-
nificant role in stimulating research into the diagnostic capa-
bilities of ultrasound [3].

A-Mode Ultrasound
One of the first studies of diagnostic ultrasound was per-
formed by George Ludwig. Using A-mode ultrasound, his
main focus was using ultrasound to detect gallstones, shown
as reflected sound waves on an oscilloscope screen. Through
his study of various tissues, including the use of live subjects,
clinical utility of diagnostic ultrasound was described.
Despite the limited efficacy of his rudimentary ultrasound
system, Ludwig’s most important achievement may be his
determination of the velocity of sound transmission in ani-
mal soft tissues. Ludwig also determined that the optimum
frequency of an ultrasound transducer for deep tissue was
between 1 and 2.5 MHz. The ultrasound characteristics of
mammalian tissue were further defined by physicist Richard
Bolt at Massachusetts Institute of Technology and neurosur-
geon H. Thomas Ballantine, Jr. at Massachusetts General
Hospital [3].
Most of early ultrasound used a transmission technique,
but by the mid-1950s that was supplanted by a reflection
technique. Providing information limited to a single dimen-
sion, A-mode scanning showed deflections on an oscilloscope
indicating distance to reflective surfaces [4] (see Fig. 2.7).
A-mode ultrasonography was used for detection of brain
tumors, shifts in the midline structures of the brain, localiza-
tion of foreign bodies in the eye, and detection of detached
retinas [4]. In the first presage that ultrasound may assist in
the detection of cancer, John Julian Wild reported the obser-
vation that gastric malignancies were more echogenic than
normal gastric tissue. Along with Dr. John Reid, he later stud-
ied 117 breast nodules using a 15 MHz sound source and
6 R.A. Levine and J.W. Sistrunk

reported the ability to determine their size with an accuracy

of 90% [3].

B-Mode Ultrasound
During the late 1950s, the first two-dimensional B-mode
scanners were developed. B-mode scanners display a compi-
lation of sequential A-mode images to create a two-­
dimensional image (see Fig. 2.8). Douglass Howry developed
an immersion tank B-mode ultrasound system which was
featured in the Medicine section of Life Magazine in
September 1954 [3]. Several additional models of immersion
tank scanners followed. All utilized a mechanically driven
transducer that would sweep through an arc, with an image
reconstructed to demonstrate the full sweep. Continued
development led to the “Pan-scanner,” a more advanced
B-mode device, but it still employed a cumbersome bathtub
of water. Later advances included a handheld transducer that
still required a mechanical connection to the unit to provide
data regarding location and water-bag coupling devices to
eliminate the need for immersion [3].
By 1964, the work of Joseph H. Holmes along with William
Wright and Ralph (Edward) Meyerdirk lead to the prototype
of the “compound contact” scanner, with direct contact of the
transducer with the patient’s body. As stated in a 1958 Lancet
article describing ultrasound evaluation of abdominal masses,
“Any new technique becomes more attractive if its clinical
usefulness can be demonstrated without harm, indignity or
discomfort to the patient” [5].

Applying Ultrasound Technology

to the Thyroid
The 1960s brought continued development of microelectron-
ics including semiconductors that revolutionized the ability
to process signals and produce visual displays. The phased
 Chapter 1. History of Thyroid Ultrasound 7

array transducer utilized in modern day ultrasound derived

from highly classified submarine technology. During the
1970s additional advances in transducer design, including the
linear array and mechanical oscillating transducers, lead to
the two-dimensional imaging which remains the standard
today. With these improvements and the addition of gray-­
scale displays, ultrasound representation of the thyroid began
to resemble that seen in the operative field or gross anatomy
lab [4].
In 1967 Fujimoto reported data on 184 patients studied
with a B-mode ultrasound “tomogram” utilizing a water bath
[6]. The authors reported that no internal echoes were gener-
ated by the thyroid in patients with normal thyroid function
and non-palpable thyroid glands. They described several
basic patterns generated by palpably abnormal thyroid tissue.
Thyroid tissue with strong internal echo attenuation charac-
teristics was considered “malignant.” Unfortunately, 25% of
benign adenomas showed the malignant pattern, and 25% of
papillary carcinomas were found to have the benign pattern.
Although the first major publication of thyroid ultrasound
attempted to establish the ability to determine malignant
potential, the results were nonspecific in a large percentage
of the cases. However, this was a seminal paper in ultrasound
and is considered the first on thyroid ultrasound to attempt
to establish the malignant appearance of nodules [4, 6].
In 1971 Manfred Blum published a series of A-mode ultra-
sounds of thyroid nodules (see Fig. 2.7). He demonstrated the
ability of ultrasound to distinguish solid from cystic nodules,
as well as accuracy in measurement of the dimensions of thy-
roid nodules [7]. Additional publications in the early 1970s
further confirmed the capacity for both A-mode and B-mode
ultrasound to differentiate solid from cystic lesions but con-
sistently demonstrated that ultrasound was unable to distin-
guish malignant from benign solid lesions with acceptable
accuracy [8].
The advent of gray-scale display resulted in images that
were far easier to view and interpret [6]. In 1974 Ernest
Crocker published The Gray Scale Echographic Appearance
8 R.A. Levine and J.W. Sistrunk

of Thyroid Malignancy. Using an 8 MHz transducer with a

0.5 mm resolution, he described “low amplitude, sparse and
disordered echoes” characteristic of thyroid cancer when
viewed with a gray-scale display [9]. The pattern felt to be
characteristic of malignancy was what would now be consid-
ered “hypoechoic and heterogeneous”.
With each advance in technology, interest was rekindled in
ultrasound’s ability to distinguish benign from malignant
lesions. Initial reports of ultrasonic features typically described
findings as being diagnostically specific. Later, reports fol-
lowed showing overlap between various disease processes. For
example, following an initial report that the “halo sign,” a rim
of hypoechoic signal surrounding a solid thyroid nodule, was
seen only in benign lesions [10], Propper reported that two of
ten patients with this finding had carcinoma [11]. As discussed
in Chap. 7, the halo sign is still ­considered to be one of the
numerous features that can be used in determining the likeli-
hood of malignancy in a nodule.
In 1977 Walfish recommended combining fine-needle aspi-
ration biopsy with ultrasound in order to improve the accu-
racy of specimen acquisition [12]. Subsequent studies
demonstrated that biopsy accuracy is greatly improved when
ultrasound is used to guide needle placement. Most patients
with prior “nondiagnostic” biopsies will have an adequate
specimen obtained when ultrasound-guided biopsy is per-
formed [13]. Ultrasound-guided fine-needle aspiration results
in improved sensitivity and specificity, as well as a greater
than 50% reduction in nondiagnostic and false-negative
biopsies [14].
Over the past several years, the value of ultrasound in
screening for suspicious lymph nodes prior to surgery in
patients with biopsy proven cancer has been established.
Current guidelines for the management of thyroid cancer
indicate a pivotal role for ultrasound in monitoring for
locoregional recurrence [15].
During the 1980s Doppler ultrasound was introduced,
allowing detection of blood flow in tissues. As discussed
in detail in Chap. 3, the role of Doppler in assessing the
 Chapter 1. History of Thyroid Ultrasound 9

l­ikelihood of malignancy has undergone a recent reevalua-

tion. Doppler imaging may demonstrate the increased blood
flow characteristic of Graves’ disease [16] and may be useful
in distinguishing between Graves’ disease and thyroiditis,
­especially in pregnant patients or when radioisotope scan-
ning is unavailable (see Chap. 3). Doppler imaging is useful
in determining the subtype of amiodarone-induced thyro-
toxicosis [17].

Recent Advances in Technology

Recent technological advancements include intravenous
sonographic contrast agents, three-dimensional ultrasound
imaging, and elastography. Intravenous sonographic contrast
agents are available in Europe but remain experimental in
the United States. All ultrasound contrast agents consist of
microspheres, which function both by reflecting ultrasonic
waves and, at higher signal power, by reverberating and gen-
erating harmonics of the incident wave. Ultrasound contrast
agents have been predominantly used to visualize large blood
vessels and have shown promise in imaging peripheral vascu-
lature as well as liver tumors and metastases [18]. While no
studies have been published demonstrating any advantage of
contrast agents in routine thyroid imaging, the use of contrast
agents or B-flow imaging may be helpful in the immediate
assessment of successful laser or radiofrequency ablation of
thyroid nodules [19].
Three-dimensional display of reconstructed images has
been available for CT scan and MRI for many years and has
demonstrated practical application. While three-dimensional
ultrasound has gained popularity for fetal imaging, its role in
diagnostic neck ultrasound remains unclear. Obstetrical
ultrasound has the great advantage of the target being sur-
rounded by a natural fluid interface, greatly improving sur-
face rendering, whereas 3D thyroid ultrasound is limited by
the lack of a similar interface distinguishing the thyroid from
adjacent neck tissues. It has been predicted that breast
10 R.A. Levine and J.W. Sistrunk

­ iopsies may eventually be guided in a more precise fashion

b
by real time 3D imaging [20], and it is possible that, in time,
thyroid biopsy will similarly benefit. At present, however, 3D
ultrasound technology does not provide a demonstrable
advantage in thyroid imaging.
Elastography is a promising technique in which the com-
pressibility of a nodule is assessed by ultrasound, while exter-
nal pressure is applied. With studies showing good predictive
value for detection of malignancy in breast nodules, recent
investigations of its role in thyroid imaging have been prom-
ising. Additional prospective trials are ongoing to assess the
role of elastography in predicting the likelihood of thyroid
malignancy. The role of elastography in the selection of nod-
ules for biopsy or surgery is discussed in Chap. 16.

 pplication of Neck Ultrasound by

A
Endocrinologists and Endocrine Surgeons
With the growing recognition that real time ultrasound per-
formed by a clinician provides far more useful information
than that obtained from a radiology report, point of care
ultrasound has gained acceptance. The first educational
course specific to thyroid ultrasound was offered in 1998 by
the American Association of Clinical Endocrinologists
(AACE). Under the direction of Dr. H. Jack Baskin, 53 endo-
crinologists were taught to perform diagnostic ultrasound
and ultrasound-guided fine-needle aspiration biopsy. By the
turn of the century, 300 endocrinologists had been trained.
Endocrine University, established in 2002 by AACE, began
providing instruction in thyroid ultrasound and biopsy to all
graduating endocrine fellows. By 2016 over 6000 endocrinol-
ogists had completed an AACE ultrasound course. In 2007 a
collaborative effort between the American Institute of
Ultrasound in Medicine (AIUM) and AACE established a
certification program for endocrinologists trained in neck
ultrasound. By 2016 the ECNU (Endocrine Certification
in Neck Ultrasound) program had certified over 470
 Chapter 1. History of Thyroid Ultrasound 11

e­ndocrinologists as having the training, experience, and

expertise needed to perform thyroid and parathyroid ultra-
sound and fine-needle aspiration biopsy. In 2011 the American
Institute of Ultrasound in Medicine began accrediting quali-
fied endocrine practices as centers of excellence in thyroid
and parathyroid imaging. To date, 89 practices have received
AIUM site accreditation in thyroid and parathyroid
ultrasound.

Conclusion
When the American Association of Clinical Endocrinologists
began its efforts to teach thyroid ultrasound to Endocrinologists
in 1998, an ultrasound machine seemed a foreign concept in
the office. At present, it is becoming the exception to find
endocrinologists who do not have thyroid ultrasound and
ultrasound-guided FNA biopsy as part of their practice.
In parallel with the growth of thyroid ultrasound in endo-
crinology, the American Thyroid Association (ATA) guide-
lines for the management of thyroid nodules and thyroid
cancer have placed an increasing emphasis on the sono-
graphic characteristics of thyroid nodules. The 2006 guide-
lines mention ultrasound characteristics of thyroid nodules
five times [21]. The 2009 ATA guidelines make 14 references
to ultrasound characteristics [22], and the latest 2015 ATA
guidelines mention ultrasound characteristics of thyroid nod-
ules and thyroid cancer 100 times [15].
In the 50 years since ultrasound was first used for thyroid
imaging, there has been a profound improvement in the tech-
nology and quality of images. The transition from A-mode to
B-mode to gray-scale images was accompanied by dramatic
improvements in clarity and interpretability of images. Current
high-resolution images are able to identify virtually all lesions
of clinical significance. Ultrasound characteristics can predict
which nodules are likely to be benign and detect features
including irregular margins, microcalcifications, and central
vascularity that may deem a nodule suspicious [4]. Ultrasound
12 R.A. Levine and J.W. Sistrunk

plays a clear fundamental role in thyroid nodule and lymph

node evaluation as well as the selection of which should
undergo biopsy [15]. Ultrasound has proven utility in the
detection of recurrent thyroid cancer in patients with negative
whole body iodine scan or undetectable thyroglobulin [15, 23].
Recent advances including the use of contrast agents, tissue
harmonic imaging, elastography, and multiplanar reconstruc-
tion of images have further enhanced the diagnostic value of
ultrasound images. Ultrasound guidance of fine-needle aspira-
tion biopsy has been demonstrated to improve both diagnos-
tic yield and accuracy and has become the standard of care.
Routine point of care use of ultrasound is often considered an
extension of the physical examination by endocrinologists and
endocrine surgeons. High-quality ultrasound systems are now
available at prices that make this technology accessible to
virtually all providers of endocrine care [4].

Acknowledgment The authors wish to acknowledge the work of Dr.

Joseph Woo and his excellent web-based overview of the history of
ultrasound. Relevant parts of his work with application to thyroid ultra-
sound have been presented here. For his full text, please access http://
www.ob-ultrasound.net/ history1.html.

References
1. Solbiati L, Osti V, Cova L, Tonolini M. Ultrasound of the thy-
roid, parathyroid glands and neck lymph nodes. Eur Radiol.
2001;11(12):2411–24.
2. Tessler FN, Tublin ME. Thyroid sonography: current applications
and future directions. AJR. 1999;173:437–43.
3. Woo JSK. A short history of the development of ultrasound in
obstetrics and gynecology. http://www.ob-ultrasound.net/his-
tory1.html. Accessed 29 June 2016.
4. Levine RA. Something old and something new: a brief history of
thyroid ultrasound technology. Endocr Pract. 2004;10(3):227–33.
5. Donald I, Macvicar J, Brown TG. Investigation of abdominal
masses by pulsed ultrasound. Lancet. 1958;271:1188–95.
6. Fujimoto F, Oka A, Omoto R, Hirsoe M. Ultrasound scanning
of the thyroid gland as a new diagnostic approach. Ultrasonics.
1967;5:177–80.
 Chapter 1. History of Thyroid Ultrasound 13

7. Blum M, Weiss B, Hernberg J. Evaluation of thyroid nodules by

A-mode echography. Radiology. 1971;101:651–6.
8. Scheible W, Leopold GR, Woo VL, Gosink BB. High resolu-
tion real-time ultrasonography of thyroid nodules. Radiology.
1979;133:413–7.
9. Crocker EF, McLaughlin AF, Kossoff G, Jellins J. The gray
scale echographic appearance of thyroid malignancy. J Clin
Ultrasound. 1974;2(4):305–6.
10. Hassani SN, Bard RL. Evaluation of solid thyroid neoplasms
by gray scale and real time ultrasonography: the “halo” sign.
Ultrasound Med. 1977;4:323.
11. Propper RA, Skolnick ML, Weinstein BJ, Dekker A. The
nonspecificity of the thyroid halo sign. J Clin Ultrasound.
1980;8:129–32.
12. Walfish PG, Hazani E, Strawbridge HTG, et al. Combined ultra-
sound and needle aspiration cytology in the assessment and
management of hypofunctioning thyroid nodule. Ann Intern
Med. 1977;87(3):270–4.
13. Gharib H. Fine-needle aspiration biopsy of thyroid nod-
ules: advantages, limitations, and effect. Mayo Clin Proc.
1994;69:44–9.
14. Danese D, Sciacchitano S, Farsetti A, Andreoli M, Pontecorvi
A. Diagnostic accuracy of conventional versus sonogra-
phy guided fine-needle aspiration biopsy in the manage-
ment of nonpalpable and palpable thyroid nodules. Thyroid.
1998;8:511–5.
15. Haugen BR, Alexander EK, Bible KC, Doherty G, et al. 2015
American Thyroid Association management guidelines for adult
patients with thyroid nodules and differentiated thyroid cancer.
Thyroid. 2016;26(1):1–133.
16. Ralls PW, Mayekowa DS, Lee KP, et al. Color-flow Doppler
sonography in Graves’ disease: “thyroid inferno.”. AJR.
1988;150:781–4.
17. Bogazzi F, Bartelena L, Brogioni S, et al. Color flow Doppler
sonography rapidly differentiates type I and type II amiodarone
induced thyrotoxicosis. Thyroid. 1997;7(4):541–5.
18. Grant EG. Sonographic contrast agents in vascular imaging.
Semin Ultrasound CT MR. 2001;22(1):25–41.
19. Andrioli M, Valcavi R. Ultrasound B-flow imaging in the
evaluation of thermal ablation of thyroid nodules. Endocrine.
2015;48(3):1013–5.
20. Lees W. Ultrasound imaging in three and four dimensions. Semin
Ultrasound CT MR. 2001;22(1):85–105.
Exploring the Variety of Random
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The text on this page is estimated to be only 26.12%
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144 THE GOLDEN STAIRCASE His eye was on the Inchcape

float ; Quoth he, ' My men, put out the boat, And row me to the
Inchcape Rock, And 1 11 plague the Abbot of Aberbrothok.' The
boat is lower'd, the boatmen row, And to the Inchcape Rock they go
; Sir Ralph bent over from the boat, And he cut the Bell from the
Inchcape float. Down sunk the Bell with a gurgling sound, The
bubbles rose and burst around ; Quoth Sir Ralph, ' The next who
comes to the Rock Won't bless the Abbot of Aberbrothok.' Sir Ralph
the Rover sail'd away, He scour'd the seas for many a day ; And now
grown rich with plunder'd store, He steers his course for Scotland's
shore. So thick a haze o'erspreads the sky, They cannot see the Sun
on high ; The wind hath blown a gale all day, At evening it hath died
away. On the deck the Rover takes his stand, So dark it is they see
no land. Quoth Sir Ralph, ' It will be lighter soon, For there is the
dawn of the rising Moon.' ' Canst hear,' said one, ' the breakers roar
? For methinks we should be near the shore.' 1 Now where we are I
cannot tell, But I wish I could hear the Inchcape Bell.' They hear no
sound, the swell is strong ; Though the wind hath fallen they drift
along, Till the vessel strikes with a shivering shock, — ' O Christ ! it
is the Inchcape Rock ! '
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THE GOLDEN STAIRCASE 145 Sir Ralph the Rover tore his
hair ; He cursed himself in his despair ; The waves rushed in on
every side, The ship is sinking beneath the tide. But even in his
dying fear One dreadful sound could the Rover hear, A sound as if
with the Inchcape Bell, The Devil below was ringing his knell.
ROBERT SOUTHEY. THE ARAB'S FAREWELL TO HIS STEED MY
beautiful ! my beautiful ! thou standest meekly by, With thy proudly
arched and glossy neck, and dark and fiery eye ; Fret not to roam
the desert now with all thy winged speed, — I may not mount on
thee again, — thou'rt sold, my Arab steed ! Fret not with that
impatient hoof, — snuff not the breezy wind ; The furthest that thou
fliest now, so far am I behind : The stranger hath thy bridle rein —
thy master hath his gold — Fleet limbed and beautiful, farewell !
thou 'rt sold, my steed — thou 'rt sold ! Farewell! those free untired
limbs full many a mile must roam, To reach the chill and wintry sky
which clouds the stranger's home ; Some other hand, less fond,
must now thy corn and bread prepare ; The silky mane I braided
once must be another's care ! K
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U6 THE GOLDEN STAIRCASE The morning sun shall dawn

again, but never more with thee Shall I gallop through the desert
paths, where we were wont to be : Evening shall darken on the
earth ; and o'er the sandy plain Some other steed, with slower step,
shall bear me home again. Yes, thou must go I the wild, free breeze,
the brilliant sun and sky, Thy master's home — from all of these my
exiled one must fly : Thy proud, dark eye will grow less proud, thy
step become less fleet, And vainly shalt thou arch thy neck thy
master's hand to meet. Only in sleep shall I behold that dark eye
glancing bright, Only in sleep shall hear again that step so firm and
light; And when I raise my dreaming arm to check or cheer thy
speed, Then must I starting wake, to feel — thou'rt sold, my Arab
steed. Ah ! rudely then, unseen by me, some cruel hand may chide,
Till foam-wreaths lie, like crested waves, along thy panting side :
And the rich blood that is in thee swells in thy indignant pain, Till
careless eyes which rest on thee may count each started vein. Will
they ill-use thee ? If I thought — but no, it cannot be ; Thou art so
swift, yet easy curbed; so gentle, yet so free:
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THE GOLDEN STAIRCASE 147 And yet, if haply, when thou

'rt gone, my lonely heart shall yearn, Can the hand which casts thee
from it now command thee to return ? Return ! alas, my Arab steed !
what shall thy master do, When thou who wert his all of joy hast
vanished from his view ? When the dim distance cheats mine eye,
and through the gathering tears Thy bright form for a moment like
the false mirage appears ? Slow and unmounted will I roam, with
weary feet alone, Where with fleet step and joyous bound thou oft
hast borne me on ; And sitting down by the green well, I '11 pause
and sadly think, 1 'Twas here he bo\7ed his glossy neck when last I
saw him drink ! ' When last I saw thee drink ! — away ! the fevered
dream is o'er ; I could not live a day and know that we should meet
no more. They tempted me, my beautiful ! for hunger's power is
strong ; They tempted me, my beautiful ! but I have loved too long.
Who said that I had given thee up? Who said that thou wert sold ?
'Tis false ! — 'tis false, my Arab steed ! I fling them back their gold !
Thus, thus, I leap upon thy back, and scour the distant plains ; Away
! who overtakes us now shall claim thee for his pains ! THE HON.
CAROLINE NORTON.
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148 THE GOLDEN STAIRCASE BERNARDO DEL CARPIO THE

warrior bow'd his crested head, and tamed his heart of fire, And
sued the haughty king to free his long imprison'd sire ; ' I bring thee
here my fortress keys, I bring my captive train, I pledge thee faith,
my liege, my lord 1 — oh, break my father's chain ! ' ' Rise, rise !
even now thy father comes, a ransom'd man this day ; Mount thy
good horse, and thou and I will meet him on his way.' Then lightly
rose that loyal son, and bounded on his steed, And urged, as if with
lance in rest, the charger's foamy speed. And lo ! from far, as on
they press'd, there came a glittering band, With one that 'midst
them stately rode, as a leader in the land ; ' Now haste, Bernardo,
haste ! for there, in very truth, is he, The father whom thy faithful
heart hath yearn'd so long to see.' His dark eyes flash'd, his proud
breast heaved, his cheek's blood came and went ; He reach'd that
grey-hair'd chieftain's side, and there, dismounting, bent ; A lowly
knee to earth he bent, his father's hand he took,— What was there
in its touch that all his fiery spirit shook ?
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THE GOLDEN STAIRCASE 149 That hand was cold — a

frozen thing — it dropp'd from his like lead, — He look'd up to the
face above — the face was of the dead! A plume waved o'er the
noble brow — the brow was fix'd and white ; — He met at last his
father's eyes — but in them was no sight ! Up from the ground he
sprang, and gazed, but who could paint that gaze ? They hush'd
their very hearts, that saw its horror and amaze ; They might have
chain'd him, as before that stony form he stood, For the power was
stricken from his arm, and from his lip the blood. ' Father ! ' at
length he murmur'd low — and wept like childhood then,— Talk not
of grief till thou hast seen the tears of warlike men ! — He thought
on all his glorious hopes, and all his young renown, — He flung the
falchion from his side, and in the dust sat down. Then covering with
his steel-gloved hands his darkly mournful brow, 1 No more, there is
no more,' he said, ' to lift the sword for now. — My king is false, my
hope betray'd, my father, oh ! the worth, The glory, and the
loveliness, are pass'd away from earth ! 'I thought to stand where
banners waved, my sire! beside thee yet, I would that there our
kindred blood on Spain's free soil had met, —
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150 THE GOLDEN STAIRCASE Thou wouldst have known

my spirit then, — for thee my fields were won, — And thou hast
perish'd in thy chains, as though thou hadst no son ! ' Then, starting
from the ground once more, he seized the monarch's rein, Amidst
the pale and wilder'd looks of all the courtier train ; And with a
fierce, o'ermastering grasp, the rearing war-horse led, And sternly
set them face to face, — the king before the dead 1 ' Came I not
forth upon thy pledge, my father's hand to kiss ? Be still, and gaze
thou on, false king ! and tell me what is this ! The voice, the glance,
the heart I sought — give answer, where are they ? — If thou
wouldst clear thy perjured soul, send life through this cold clay ! '
Into those glassy eyes put Light — be still ! keep down thine ire, —
Bid these white lips a blessing speak — this earth is not my sire !
Give me back him for whom I strove, for whom my blood was shed,
— Thou canst not — and a king ! His dust be mountains on thy head
! ' He loosed the steed ; his slack hand fell, — upon the silent face
He cast one long, deep, troubled look — then turn'd from that sad
place : His hope was crush'd, his after-fate untold in martial strain,—
His banner led the spears no more amidst the hills of Spain FELICIA
HEMANS.
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THE GOLDEN STAIRCASE 151 BERNARDO AND ALPHONSO

WITH some good ten of his chosen men, Bernardo hath appeared,
Before them all, in the palace hall, the lying King to beard ; With cap
in hand and eye on ground, he came in reverent guise, But ever and
anon he frown'd, and flame broke from his eyes. ' A curse upon
thee,' cries the King, ' who com'st unbid to me; But what from
traitor's blood should spring save traitor like to thee ? His sire, lords,
had a traitor's heart; perchance our champion brave May think it
were a pious part to share Don Sancho's grave.' 'Whoever told this
tale, the King hath rashness to repeat,' Cries Bernard, ' here my
gage I fling before the liar's feet! No treason was in Sancho's blood,
no stain in mine doth lie — Below the throne, what knight will own
the coward calumny ? 'The blood that I like water shed, when
Roland did advance, By secret traitors hired and led, to make us
slaves of France ; — The life of King Alphonso I saved at Roncesval
— Your words, Lord King, are recompense abundant for it all!
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152 THE GOLDEN STAIRCASE ' Your horse was down, —

your hope was flown, — I saw the falchion shine That soon had
drunk your royal blood, had I not ventured mine ; But memory soon
of service done deserteth the ingrate, And you Ve thank'd the son
for life and crown by the father's bloody fate. ' You swore upon your
kingly faith to set Don Sancho free, But, curse upon your paltering
breath! the light he ne'er did see ; He died in dungeon cold and dim,
by Alphonso's base decree, And visage blind and stiffen'd limb were
all they gave to me. 1 The King that swerveth from his word hath
stain'd his purple blackNo Spanish lord will draw the sword behind a
liar's back ; But noble vengeance shall be mine ; an open hate I 'II
show — The King hath injured Carpio's line, and Bernard is his foe.'
1 Seize — seize him ! ' loud the King doth scream. ' There are a
thousand here — Let his foul blood this instant stream — what !
caitiffs, do you fear ? Seize — seize the traitor ! ' But not one to
move a finger dareth, — Bernardo standeth by the throne, and calm
his sword he bareth. He drew the falchion from the sheath and held
it up on high, And all the hall was still as death ; cries Bernard, '
Here am I;
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THE GOLDEN STAIRCASE 153 And here's the sword that

owns no lord, excepting Heaven and me ; Fain would I know who
dares its point — King, Conde", or Grandee ? ' Then to his mouth the
horn he drew — (it hung below his cloak) — His ten true men the
signal knew, and through the ring they broke ; With helm on head
and blade in hand, the knights the circle brake ; And back the
lordlings 'gan to stand, and the false King to quake. ' Ha ! Bernard,'
quoth Alphonso, ' what means this warlike guise ? You know full well
I jested — you know your worth I prize.' But Bernard turned upon
his heel, and smiling passed away; Long rued Alphonso and Castille
the jesting of that day. J. G. LOCKHART. BERNARDO'S REVENGE
WHAT tents gleam on the green hillside, like snow in the sunny
beam, What gloomy warriors gather there, like a surly mountain
stream ? These, for Bernardo's vengeance, have come like a stormy
blast, The rage of their long cherished hate on a cruel king to cast.
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154 THE GOLDEN STAIRCASE 'Smiters of tyranny!' cries

their chief, 'see yonder slavish host, We shall drench the field with
their craven blood, or freedom's hopes were lost ; You know I come
for a father's death, my filial vow to pay, Then let the "Murdered
Sancho!" be your battle-cry to-day. ' On, on ! for the death of the
tyrant king ! ' ' Hurrah 1 ' was the answering cry ; 1 We follow thee
to victory, or follow thee to die ! ' The battlefield, — the charge, —
the shock, — the quivering struggle now,— The rout, — the shout!
— while lightnings flash from Bernardo's angry brow. The chieftain's
arm has need of rest, his brand drips red with gore, But one last
sacrifice remains, ere his work of toil is o'er. The King, who looked
for victory from his large and well-trained host, Now flies for safety
from the field, where all his hopes are lost ; But full in front, with
blood-red sword, a warrior appears, And the war-cry, ' Murdered
Sancho ! ' rings in the tyrant's ears. ' Ha ! noble King, have we met
at last ? ' with scornful lip he cries : 'Don Sancho's son would speak
with you once more before he dies ; 'Your kindness to my sainted
sire is graven on my heart, And I would show my gratitude once
more before we part.
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THE GOLDEN STAIRCASE 155 Draw ! for the last of

Sancho's race is ready for your sword ; — Bernardo's blood should
flow by him, by whom his sire's was poured ! 'What wait you for,
vile, craven wretch? it was not thus you stood When laying out your
fiendish plans to spill my father's blood. Draw! for I will not learn
from thee the assassin's coward trade, I scorn the lesson you have
taught— unsheath your murderous blade ! ' Housed by Bernardo's
fiery taunts, the King at length engaged : He fought for life, but all
in vain ; unequal strife he waged ! Bernardo's sword has pierced his
side, — the tyrant's reign is o'er,— ' Father, I have fulfilled my vow, I
thirst for blood no more.' UNKNOWN. LOCHINVAR O, YOUNG
Lochinvar is come out of the west, Through all the wide Border his
steed was the best ; And save his good broadsword he weapons had
none, He rode all unarm'd, and he rode all alone. So faithful in love,
and so dauntless in war, There never was knight like the young
Lochinvar. He staid not for brake, and he stopp'd not for stone, He
swam the Esk river where ford there was none ;
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156 THE GOLDEN STAIRCASE But ere he alighted at

Netherby gate, The bride had consented, the gallant came late : For
a laggard in love, and a dastard in war, Was to wed the fair Ellen of
brave Lochinvar. So boldly he enter'd the Netherby Hall, Among
bride's-men, and kinsmen, and brothers, and all: Then spoke the
bride's father, his hand on his sword, (For the poor craven
bridegroom said never a word), ' O come ye in peace here, or come
ye in war, Or to dance at our bridal, young Lord Lochinvar ? ' 'I long
woo'd your daughter, my suit you denied ; — Love swells like the
Solway, but ebbs like its tide — And now am I come, with this lost
love of mine, To lead but one measure, drink one cup of wine. There
are maidens in Scotland more lovely by far, That would gladly be
bride to the young Lochinvar.1 The bride kiss'd the goblet : the
knight took it up, He quaff'd off the wine, and he threw down the
cup. She look'd down to blush, and she look'd up to sigh, With a
smile on her lips, and a tear in her eye. He took her soft hand, ere
her mother could bar, — ' Now tread we a measure ! ' said young
Lochinvar. So stately his form, and so lovely her face, That never a
hall such a galliard did grace ; While her mother did fret, and her
father did fume, And the bridegroom stood dangling his bonnet and
plume ; And the bride-maidens whisper'd, ' 'Twere better by far, To
have match'd our fair cousin with young Lochinvar.' One touch to her
hand, and one word in her ear, When they reach'd the hall-door, and
the charger stood near ; So light to the croupe the fair lady he
swung, So light to the saddle before her he sprung !
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HE TOOK HER SOFT HAHD, ERE HER MOTHER.

COUl_DBAJtr "MOV/TREAD WE AMEASUREfSAlD YOUNG
LOCH1NVAR.
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fI
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THE GOLDEN STAIRCASE 157 1 She is won I we are gone,

over bank, bush, and scaur ; They'll have fleet steeds that follow,'
quoth young Lochinvar. There was mounting 'mong Graemes of the
Netherby clan; Forsters, Fenwicks, and Musgraves, they rode and
they ran: There was racing, and chasing, on Cannobie Lee, But the
lost bride of Netherby ne'er did they see. So daring in love, and so
dauntless in war, Have ye e'er heard of gallant like young Lochinvar ?
SIR WALTER SCOTT. YE MARINERS OF ENGLAND YE Mariners of
England ! That guard our native seas, Whose flag has braved a
thousand years The battle and the breeze ! Your glorious standard
launch again, To match another foe ! And sweep through the deep,
While the stormy tempests blow ; While the battle rages loud and
long, And the stormy tempests blow. ii The spirits of your fathers
Shall start from every wave ! For the deck it was their field of fame,
And Ocean was their grave : Where Blake and mighty Nelson fell,
Your manly hearts shall glow,
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158 THE GOLDEN STAIRCASE As ye sweep through the

deep, While the stormy tempests blow ; While the battle rages loud
and long, And the stormy tempests blow. in Britannia needs no
bulwark, No towers along the steep ; Her march is o'er the
mountain-waves. Her home is on the deep. With thunders from her
native oak, She quells the floods below — As they roar on the shore,
When the stormy tempests blow : When the battle rages loud and
long, And the stormy tempests blow. IV The meteor-flag of England
Shall yet terrific burn, Till danger's troubled night depart, And the
star of peace return. Then, then, ye ocean-warriors 1 Our song and
feast shall flow To the fame of your name, When the storm has
ceased to blow ; When the fiery fight is heard no more, And the
storm has ceased to blow. THOMAS CAMPBELL. THE PILGRIM
FATHERS THE breaking waves dashed high On a stern and rock-
bound coast, And the woods against a stormy sky Their giant
branches tossed ;
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THE GOLDEN STAIRCASE 159 And the heavy night hung

dark The hills and waters o'er, When a band of exiles moored their
bark On the wild New England shore. Not as the conqueror conies,
They, the true-hearted, came ; Not with the roll of stirring drums,
And the trumpet that sings of fame ; Not as the flying come, In
silence and in fear ; — They shook the depths of the desert gloom
With their hymns of lofty cheer. Amidst the storm they sang, And the
stars heard and the sea ; And the sounding aisles of the dim woods
rang To the anthem of the free 1 The ocean eagle soared From his
nest by the white wave's foam ; And the rocking pines of the forest
roared— This was their welcome home ! There were men with hoary
hair Amidst that pilgrim band ; Why had they come to wither there,
Away from their childhood's land ? There was woman's fearless eye,
Lit by her deep love's truth ; There was manhood's brow serenely
high, And the fiery heart of youth. What sought they thus afar ?
Bright jewels of the mine? The wealth of seas, the spoils of war ?—
They sought a faith's pure shrine I
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160 THE GOLDEN STAIRCASE Ay, call it holy ground, The

soil where first they trod. They have left unstained what there they
found — Freedom to worship God. FELICIA HEMANS. INCIDENT OF
THE FRENCH CAMP You know, we French stormed Ratisbon : A mile
or so away, On a little mound, Napoleon Stood on our storming-day ;
With neck out-thrust, you fancy how, Legs wide, arms locked
behind, As if to balance the prone brow Oppressive with its mind. n
Just as perhaps he mused, ' My plans That soar, to earth may fall,
Let once my army-leader Lannes Waver at yonder wall,'Out 'twixt the
battery-smokes there flew A rider, bound on bound Full-galloping ;
nor bridle drew Until he reached the mound. in Then off there flung
in smiling joy, And held himself erect By just his horse's mane, a boy
; You hardly could suspect—
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THE GOLDEN STAIRCASE 161 (So tight he kept his lips

compressed, Scarce any blood came through) — You looked twice
ere you saw his breast Was all but shot in two. IV ' Well,' cried he, '
Emperor, by God's grace We 've got you Ratisbon ! The Marshal 's in
the market-place, And you '11 be there anon To see your flag-bird
flap his vans Where I, to heart's desire, Perched him ! ' The chief's
eye flashed ; his plans Soared up again like fire. The chief's eye
flashed ; but presently Softened itself, as sheathes A film the
mother-eagle's eye When her bruised eaglet breathes ; ' You 're
wounded ! ' 'Nay,' the soldier's pride Touched to the quick, he said :
1 1 'm killed, Sire ! ' And his chief beside Smiling the boy fell dead.
ROBERT BROWNING. HORATIUS BUT the Consul's brow was sad,
And the Consul's speech was low, And darkly looked he at the wall,
And darkly at the foe.
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162 THE GOLDEN STAIRCASE ' Their van will be upon us

Before the bridge goes down ; And if they once may win the bridge,
What hope to save the town ? ' Then out spake brave Horatius, The
Captain of the Gate : ' To every man upon this earth Death cometh
soon or late. And how can man die better Than facing fearful odds,
For the ashes of his fathers, And the temples of his Gods. ' Hew
down the bridge, Sir Consul, With all the speed ye may ; I, with two
more to help me, Will hold the foe in play. In yon strait path a
thousand May well be stopped by three. Now who will stand on
either hand, And keep the bridge with me ? ' Then out spake Spurius
Lartius ; A Ramnian proud was he : 1 Lo, I will stand at thy right
hand, And keep the bridge with thee.' And out spake strong
Herminius ; Of Titian blood was he : * I will abide on thy left side,
And keep the bridge with thee/ ' Horatius,' quoth the Consul, ' As
thou sayest, so let it be.' And straight against that great array Forth
went the dauntless Three.
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THE GOLDEN STAIRCASE 163 For Romans in Rome's

quarrel Spared neither land nor gold, Nor son nor wife, nor limb nor
life. In the brave days of old. Now while the Three were tightening
Their harness on their backs, The Consul was the foremost man To
take in hand an axe : And Fathers mixed with Commons, Seized
hatchet, bar, and crow, And smote upon the planks above, And
loosed the props below. Meanwhile the Tuscan army, Right glorious
to behold, Came flashing back the noonday light, Rank behind rank,
like surges bright Of a broad sea of gold. Four hundred trumpets
sounded A peal of warlike glee, As that great host, with measured
tread, And spears advanced, and ensigns spread, Rolled slowly
towards the bridge's head, Where stood the dauntless Three. The
Three stood calm and silent, And looked upon the foes, And a great
shout of laughter From all the vanguard rose : And forth three chiefs
came spurring Before that deep array ; To earth they sprang, their
swords they drew, And lifted high their shields, and flew To win the
narrow way.
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164 THE GOLDEN STAIRCASE But meanwhile axe and lever

Have manfully been plied ; And now the bridge hangs tottering
Above the boiling tide. 1 Come back, come back, HoratiusI' Loud
cried the Fathers all. ' Back, Lartius ! back, Herminius ! Back, ere the
ruin fall 1 ' Back darted Spurius Lartius ; Herminius darted back :
And, as they passed, beneath their feet They felt the timbers crack.
But when they turned their faces, And on the farther shore Saw
brave Horatius stand alone, They would have crossed once more.
But with a crash like thunder Fell every loosened beam, And, like a
dam, the mighty wreck Lay right athwart the stream : And a long
shout of triumph Rose from the walls of Rome, As to the highest
turret-tops Was splashed the yellow foam. Alone stood brave
Horatius, But constant still in mind ; Thrice thirty thousand foes
before, And the broad flood behind. ' Down with him ! ' cried false
Sextus, With a smile on his pale face. 1 Now yield thee,' cried Lars
Porsena, ' Now yield thee to our grace.'
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THE GOLDEN STAIRCASE 165 Round turned he, as not

deigning Those craven ranks to see ; Nought spake he to Lars
Porsena, To Sextus nought spake he ; But he saw on Palatinus The
white porch of his home ; And he spake to the noble river That rolls
by the towers of Rome. 'O Tiber! father Tiber! To whom the Romans
pray, A Roman's life, a Roman's arms, Take thou in charge this day !
' So he spake, and speaking sheathed The good sword by his side,
And with his harness on his back, Plunged headlong in the tide. No
sound of joy or sorrow Was heard from either bank ; But friends and
foes in dumb surprise, With parted lips and straining eyes, Stood
gazing where he sank; And when above the surges They saw his
crest appear, All Rome sent forth a rapturous cry, And even the ranks
of Tuscany Could scarce forbear to cheer. But fiercely ran the
current, Swollen high by months of rain : And fast his blood was
flowing ; And he was sore in pain,
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