Professional Documents
Culture Documents
Student Consult eBooks give you the power to browse and find content,
view enhanced images, share notes and highlights—both online and offline.
4 Click “Redeem”
5 Log in or Sign Up
Place sticker here.
6 Go to “My Library”
It’s that easy!
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the Publisher. Details on how to seek permission, further information about
the Publisher’s permissions policies, and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods, they should be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered and to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge
of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence, or
otherwise or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein
Daniel J. Kowal, MD
Computed Tomography Division Director
Radiology Elective Director
Department of Radiology
Saint Vincent Hospital
Worcester, Massachusetts
Chapter 22: Magnetic Resonance Imaging: Understanding the Principles
and Recognizing the Basics
vii
This page intentionally left blank
Preface
I’ve checked, and most prefaces to a third edition or later start When pattern recognition doesn’t work, this text will try
out with something like, “It’s hard to believe that this is the third wherever possible to give you a logical approach to reaching
edition of…” Not this text. I know how much work it’s taken, a diagnosis. By learning an approach, you’ll have a method
so I definitely can believe it. But thank you if you have contrib you can apply to similar problems again and again. An
uted in any way, including reading this preface, to the success analytic approach will enable you to apply a rational solution to
of this book. diagnostic imaging problems.
In the first edition, I asked you to suppose for a moment This text was written to make complimentary use of the
that your natural curiosity drove you to wonder what kind of platform on which radiologic images are now almost universally
bird with a red beak just landed on your window sill. You could viewed: the digital display. Although digital displays may be ideal
get a book on birds that listed all of them alphabetically from for looking at images, some people do not want to read large
albatross to woodpecker and spend time looking through hundreds volumes of text from their digital devices. So we’ve joined
of bird pictures. Or you could get a book that lists birds by the the text in the printed book with photos, videos, quizzes,
colors of their beaks and thumb through a much shorter list to and tutorials—many of them interactive—and made them
find that your feathered visitor is a cardinal. available online at StudentConsult/Inkling.com in a series of
This book is a red beak book. Where possible, groups of web enhancements that accompany the book. I think you’ll
diseases are first described by the way they look rather than by really enjoy them.
what they’re called. Imaging diagnoses frequently, but not This text is not intended to be encyclopedic. Many wonderful
always, rest on a recognition of a reproducible visual picture of radiology reference texts are available, some of which contain
that abnormality. That is called the pattern recognition approach thousands of pages and weigh slightly less than a Mini Cooper.
to identifying abnormalities, and the more experience you have This text is oriented more toward students, interns, residents,
looking at imaging studies, the more comfortable and confident residents-to-be, and other health care professionals who are just
you’ll be with that approach. starting out.
Before diagnostic images can help you decide what disease This book emphasizes conventional radiography because
the patient may have, you must first be able to differentiate that is the type of study most patients undergo first and because
between what is normal in appearance and what is not. That the same imaging principles that apply to reaching the diagnosis
isn’t as easy as it may sound. Recognizing the difference between on conventional radiographs can frequently be applied to
normal and abnormal probably takes as much practice, if not making the diagnosis on more complex modalities.
more, than deciding what disease a person has. Let’s get started. Or, if you’re the kind of person (like I am)
Radiologists spend their entire lives performing just such who reads the preface after you’ve read the book, I hope you
differentiations. You won’t be a radiologist after you’ve com enjoyed it.
pleted this book, but you should be able to recognize abnor
malities and interpret images better and, by so doing, perhaps
participate in the care of patients with more assurance and William Herring, MD, FACR
confidence.
ix
This page intentionally left blank
Acknowledgments
I am again grateful to the many thousands of you whom I have supplying additional images for this edition. And thanks to
never met but who found a website called Learning Radiology Mindy Horrow, MD; Eric Faerber, MD; and Brooke Devenney-
helpful, making it so popular that it played a role launching the Cakir, MD, for reviewing chapters from this text.
first edition of this book, which itself was so popular that it led I certainly want to recognize and again thank Jim Merritt and
to this third edition. Katy Meert from Elsevier for their support and assistance.
For their help and suggestions, I thank David Saul, MD, one I also acknowledge the hundreds of radiology residents and
of our radiology residents, who made invaluable suggestions medical students who, over the years, have provided me with an
about how this edition could be changed. Daniel Kowal, MD, a audience of motivated learners, without whom a teacher would
radiologist who graduated from our program, did an absolutely have no one to teach.
wonderful job in simplifying the complexities of MRI again in Finally, I want to thank my wonderful wife, Pat, who has
the chapter he wrote. Jeffrey Cruz, MD, one of our residents, encouraged me throughout the project, and my family.
helped out with the online Radiation Safety and Dose module,
and Sherif Saad, MD, contributed an illustration.
I thank Chris Kim, MD; Susan Summerton, MD; Mindy William Herring, MD, FACR
Horrow, MD; Peter Wang, MD; and Huyen Tran, MD, for
xi
This page intentionally left blank
Contents
CHAPTER 1 CHAPTER 6
Recognizing Anything Recognizing the Causes of an Opacified Hemithorax
An Introduction to Imaging Modalities 1 Atelectasis of the Entire Lung 45
From Darkness … Light 2 Massive Pleural Effusion 46
Conventional Radiography 2 Pneumonia of an Entire Lung 47
The Five Basic Densities 2 Postpneumonectomy 48
Computed Tomography 3
Ultrasonography 4
Magnetic Resonance Imaging 5 CHAPTER 7
Fluoroscopy 5 Recognizing Atelectasis
Nuclear Medicine 5 What is Atelectasis? 50
Conventions Used in This Book 6 Types of Atelectasis 52
Patterns of Collapse in Lobar Atelectasis 55
How Atelectasis Resolves 56
CHAPTER 2
Recognizing a Technically Adequate Chest Radiograph CHAPTER 8
Evaluating the Chest Radiograph for Technical Adequacy 8
Recognizing a Pleural Effusion
Normal Anatomy and Physiology of the Pleural Space 58
Modalities for Detecting Pleural Effusions 58
CHAPTER 3 Causes of Pleural Effusions 58
Recognizing Normal Pulmonary Anatomy Types of Pleural Effusions 58
The Normal Frontal Chest Radiograph 14 Side-Specificity of Pleural Effusions 59
Normal Pulmonary Vasculature 15 Recognizing the Different Appearances of Pleural Effusions 59
The Normal Lateral Chest Radiograph 15
Normal CT Anatomy of the Chest 19
Normal CT Anatomy of the Lungs 19 CHAPTER 9
The Fissures 21 Recognizing Pneumonia
General Considerations 68
General Characteristics of Pneumonia 68
Patterns of Pneumonia 69
CHAPTER 4
Lobar Pneumonia 69
Recognizing Normal Cardiac Anatomy
Segmental Pneumonia (Bronchopneumonia) 69
Evaluating the Heart on Chest Radiographs 24
Interstitial Pneumonia 70
General Principles 25
Round Pneumonia 70
Evaluating the Heart on Cardiac CT 25
Cavitary Pneumonia 71
Normal Cardiac CT Anatomy 25
Aspiration 71
Uses of Cardiac CT 29
Localizing Pneumonia 72
Cardiac MRI 31
How Pneumonia Resolves 74
CHAPTER 5 CHAPTER 10
Recognizing Airspace versus Interstitial Lung Disease Recognizing Pneumothorax, Pneumomediastinum,
Classifying Parenchymal Lung Disease 35 Pneumopericardium, and Subcutaneous Emphysema
Characteristics of Airspace Disease 35 Recognizing a Pneumothorax 76
Some Causes of Airspace Disease 37 Recognizing Pneumomediastinum 81
Characteristics of Interstitial Lung Disease 38 Recognizing Pneumopericardium 82
Some Causes of Interstitial Lung Disease 39 Recognizing Subcutaneous Emphysema 82
xiii
xiv | Contents
CHAPTER 11 CHAPTER 15
Recognizing the Correct Placement of Lines and Tubes and Recognizing the Normal Abdomen and Pelvis on
Their Potential Complications: Critical Care Radiology Computed Tomography
Endotracheal and Tracheostomy Tubes 85 Introduction to Abdominal and Pelvic Computed
Intravascular Catheters 87 Tomography 140
Cardiac Devices—Pacemaker, AICD, IABP 91 Abdominal CT: General Considerations 141
GI Tubes and Lines—Nasogastric Tubes, Feeding Tubes 94
CHAPTER 16
CHAPTER 12 Recognizing Bowel Obstruction and Ileus
Recognizing Diseases of the Chest Abnormal Gas Patterns 147
Mediastinal Masses 97 Laws of the Gut 147
Anterior Mediastinum 98 Functional Ileus: Localized Sentinel Loops 148
Middle Mediastinal Masses 100 Functional Ileus: Generalized Adynamic Ileus 148
Posterior Mediastinal Masses 101 Mechanical Obstruction: Small Bowel Obstruction 149
Solitary Nodule/Mass in the Lung 101 Mechanical Obstruction: Large Bowel Obstruction (LBO) 154
Bronchogenic Carcinoma 105 Volvulus of the Colon 155
Metastatic Neoplasms in the Lung 107 Intestinal Pseudoobstruction (Ogilvie Syndrome) 155
Pulmonary Thromboembolic Disease 107
Chronic Obstructive Pulmonary Disease 108
Blebs and Bullae, Cysts and Cavities 109
Bronchiectasis 110 CHAPTER 17
Recognizing Extraluminal Gas in the Abdomen
Signs of Free Intraperitoneal Air 158
Air Beneath the Diaphragm 158
CHAPTER 13 Visualization of Both Sides of the Bowel Wall 159
Recognizing Adult Heart Disease Visualization of the Falciform Ligament 161
Recognizing an Enlarged Cardiac Silhouette 114 Causes of Free Air 161
Pericardial Effusion 114 Signs of Extraperitoneal Air (Retroperitoneal Air) 162
Extracardiac Causes of Apparent Cardiac Enlargement 114 Causes of Extraperitoneal Air 162
Identifying Cardiac Enlargement on an AP Chest Radiograph 115 Signs of Air in the Bowel Wall 162
Recognizing Cardiomegaly on the Lateral Chest Radiograph 115 Causes and Significance of Air in the Bowel Wall 163
Recognizing Common Cardiac Diseases 115 Signs of Air in the Biliary System 164
Noncardiogenic Pulmonary Edema—General Considerations 119 Causes of Air in the Biliary System 165
Noncardiogenic Pulmonary Edema—Imaging Findings 120
Differentiating Cardiac from Noncardiac Pulmonary Edema 120
Hypertensive Cardiovascular Disease 121
Mitral Stenosis 121 CHAPTER 18
Pulmonary Arterial Hypertension 122 Recognizing Abnormal Calcifications and
Aortic Stenosis 123 Their Causes
Cardiomyopathy 123 Patterns of Calcification 167
Aortic Aneurysms—General Considerations 124 Rimlike Calcification 167
Recognizing a Thoracic Aortic Aneurysm 124 Linear or Tracklike Calcification 167
Thoracic Aortic Dissection 125 Lamellar or Laminar Calcification 169
Coronary Artery Disease 126 Cloudlike, Amorphous, or Popcorn Calcification 169
Location of Calcification 173
CHAPTER 14
Recognizing the Normal Abdomen: Conventional Radiology CHAPTER 19
Conventional Radiography 129 Recognizing the Imaging Findings of Trauma
What to Look For 129 Chest Trauma 174
Normal Bowel Gas Pattern 129 Rib Fractures 174
Normal Fluid Levels 131 Pulmonary Contusions 175
Differentiating Large from Small Bowel 131 Pulmonary Lacerations (Hematoma or Traumatic Pneumatocele) 175
Acute Abdominal Series: the Views and What They Show 131 Aortic Trauma 176
Calcifications 135 Abdominal Trauma 177
Organomegaly 135 Pelvic Trauma 180
Contents | xv
CHAPTER 20 How Fractures are Described—by the Direction of the Fracture Line 244
Recognizing Gastrointestinal, Hepatic, and Urinary How Fractures are Described—by the Relationship of One Fracture
Tract Abnormalities Fragment to Another 244
Esophagus 183 How Fractures are Described—by the Relationship of the Fracture to
Stomach and Duodenum 186 the Atmosphere 245
Duodenal Ulcer 186 Avulsion Fractures 245
Small and Large Bowel 186 Stress Fractures 246
Large Bowel 188 Common Fracture Eponyms 247
Pancreas 193 Some Easily Missed Fractures or Dislocations 248
Hepatobiliary Abnormalities 194 Fracture Healing 251
Space-Occupying Lesions of the Liver 196
Biliary System 199
Urinary Tract 199 CHAPTER 25
Pelvis 200 Recognizing Joint Disease: An Approach to Arthritis
Urinary Bladder 201 Anatomy of a Joint 254
Adenopathy 201 Classification of Arthritis 255
Hypertrophic Arthritis 256
Erosive Arthritis 260
CHAPTER 21 Infectious Arthritis 263
Ultrasonography: Understanding the Principles and Recognizing
Normal and Abnormal Findings
How It Works 204 CHAPTER 26
Doppler Ultrasonography 205 Recognizing Some Common Causes of Neck and Back Pain
Adverse Effects or Safety Issues 205 Conventional Radiography, Magnetic Resonance Imaging,
Medical Uses of Ultrasonography 205 and Computed Tomography 266
The Normal Spine 266
Back Pain 268
CHAPTER 22 Malignancy Involving the Spine 272
Magnetic Resonance Imaging: Understanding the Principles and MRI in Metastatic Spine Disease 273
Recognizing the Basics Spinal Trauma 273
Daniel J. Kowal, MD
How Magnetic Resonance Imaging Works 220
Hardware That Makes Up an MRI Scanner 220 CHAPTER 27
What Happens Once Scanning Begins 220 Recognizing Some Common Causes of Intracranial Pathology
How Can You Identify a T1-Weighted or T2-Weighted Image? 221 Normal Anatomy 279
MRI Contrast Agents: General Considerations 223 MRI and the Brain 281
MRI Safety Issues 225 Head Trauma 282
Diagnostic Applications of MRI 226 Intracranial Hemorrhage 285
Diffuse Axonal Injury 286
Increased Intracranial Pressure 289
CHAPTER 23 Stroke 290
Recognizing Abnormalities of Bone Density Ruptured Aneurysms 292
Normal Bone Anatomy 228 Hydrocephalus 294
The Effect of Bone Physiology on Bone Anatomy 229 Cerebral Atrophy 296
Recognizing a Generalized Increase in Bone Density 229 Brain Tumors 296
Recognizing a Focal Increase in Bone Density 230 Other Diseases 299
Recognizing a Generalized Decrease in Bone Density 233 Neuroimaging Terminology 300
Recognizing a Focal Decrease in Bone Density 235
Pathologic Fractures 238
CHAPTER 28
Recognizing Pediatric Diseases
CHAPTER 24 Conditions Discussed in This Chapter 303
Recognizing Fractures and Dislocations Newborn Respiratory Distress 303
Recognizing an Acute Fracture 240 Childhood Lung Disease 306
Recognizing Dislocations and Subluxations 242 Soft Tissues of the Neck 307
Describing Fractures 242 Ingested Foreign Bodies 309
How Fractures are Described—by the Number of Fracture Fragments 242 Other Diseases 310
xvi | Contents
xvii
This page intentionally left blank
CHAPTER 1
Recognizing Anything
AN INTRODUCTION TO IMAGING MODALITIES are here to learn. The answers are at the very end of this book
(Figs. 1-1 to 1-6).
It’s always exciting when a class starts out with a surprise quiz. ■ You are about to learn about each of the imaging modalities,
No pencils are necessary. Here are six images with brief histo- about how to approach imaging studies, about the six dis-
ries presented as unknowns. Each is diagnostic. If you don’t eases represented in the figures, and much more as you
know the answers, that is perfectly fine because that’s what you complete this text.
SUPINE
Compress
FIGURE 1-1 A 56-year-old patient with abdominal pain. FIGURE 1-2 A 49-year-old who fell off a ladder. FIGURE 1-3 A 22-year-old with sudden chest pain.
FIGURE 1-4 Incidental finding on abdominal ultrasound. FIGURE 1-5 Cystogram of a 56-year-old who was in an auto- FIGURE 1-6 A 4-month-old with irritability.
mobile accident.
1
2 | Recognizing Anything
FROM DARKNESS … LIGHT ■ We will look briefly at each of these modalities in the sections
that follow.
■ In 1895, Wilhelm Röntgen (or Roentgen), working in a dark-
ened laboratory in Würzburg, Germany, noticed that a CONVENTIONAL RADIOGRAPHY
screen painted with a fluorescent material in the same room,
but a few feet from a cathode ray tube he had energized ■ Images produced through the use of ionizing radiation (i.e.,
and made lightproof, started to glow (fluoresce). Sensing the production of x-rays, but without added contrast material
something important had happened, he recognized that such as barium or iodine) are called conventional radio-
the screen was responding to the nearby production of graphs or, more often, plain films.
an unknown ray transmitted invisibly through the room. ■ The major advantage of conventional radiographs is that the
He named the new rays “x-rays,” using the mathematical images are relatively inexpensive to produce, can be obtained
symbol “x” for something unknown. It didn’t take long almost anywhere by using portable or mobile machines, and
before almost everyone was taking x-rays of almost every- are still the most widely obtained imaging studies.
thing imaginable. ■ They require a source to produce the x-rays (the “x-ray
■ For about 100 years after that, radiographic images survived machine”), a method to record the image (a film, cassette,
their brief birth as a burst of ionizing radiation nestled com- or photosensitive plate), and a way to process the recorded
fortably on a piece of film. In some places, film is the image (using either chemicals or a digital reader).
medium still used, but it’s much less common. ■ Common uses for conventional radiography include the
■ Today, like in 1895, conventional radiographic images (usually ubiquitous chest x-ray, plain films of the abdomen, and virtu-
shortened to x-rays) are produced by a combination of ion- ally every initial image of the skeletal system to evaluate for
izing radiation and light striking a photosensitive surface, fractures or arthritis.
which, in turn, produces a latent image that is subsequently ■ The major disadvantages of conventional radiography are
processed. At first, the processing of film was carried out the limited range of densities it can demonstrate and that
in a darkroom containing trays with various chemicals; the it uses ionizing radiation.
films were then, literally, hung out and then up to dry.
♦ When an immediate reading was requested, the films THE FIVE BASIC DENSITIES
were interpreted while still dripping with chemicals, and
thus the term wet reading for a “stat” interpretation ■ Conventional radiography is limited to demonstrating
was born. five basic densities, arranged here from least to most
♦ Films were then viewed on lighted view boxes (almost dense (Table 1-1):
always backward or upside-down if the film placement ♦ Air, which appears the blackest on a radiograph
was being done as part of a movie or television show). ♦ Fat, which is shown in a lighter shade of gray than air
■ This workflow continued for many decades, but it had two ♦ Soft tissue or fluid (because both soft tissue and fluid
major drawbacks: appear the same on conventional radiographs, it’s
♦ It required a great deal of physical storage space for impossible to differentiate the heart muscle from the
the ever-growing number of films. Even though each blood inside of the heart on a chest radiograph)
film is very thin, many films in thousands of patients’ ♦ Calcium (usually contained within bones)
folders take up a great deal of space (eFig. 1-1). ♦ Metal, which appears the whitest on a radiograph
♦ The other drawback was that the radiographic films • Objects of metal density are not normally present in
could physically be in only one place at a time, which the body. Radiologic contrast media and prosthetic
was not necessarily where they might be needed to help knees or hips are examples of metal densities
in the care of a patient. artificially placed in the body (Fig. 1-7).
■ So, eventually, digital radiography came into being, in ■ Although conventional radiographs are produced by ionizing
which the photographic film was replaced by a photosensi- radiation in relatively low doses, radiation has the potential
tive cassette or plate that could be processed by an elec-
tronic reader and the resulting image could be stored in a
digital format. This electronic processing no longer required
a darkroom to develop the film or a large room to store the
TABLE 1-1 FIVE BASIC DENSITIES SEEN ON
films. Countless images could be stored in the space of one
CONVENTIONAL RADIOGRAPHY
spinning hard disk on a computer server. Even more impor-
tant, the images could be viewed by anyone with the right to Density Appearance
do so, anywhere in the world, at any time. Air Absorbs the least x-ray and appears “blackest” on
■ The images were maintained on computer servers, where conventional radiographs
they could be stored and archived for posterity and from
Fat Gray, somewhat darker (blacker) than soft tissue
which they could be communicated to others. This system
is referred to as PACS, which stands for picture archiving, Fluid or soft Both fluid (e.g., blood) and soft tissue (e.g., muscle)
communications, and storage. tissue have the same densities on conventional radiographs
■ Using PACS systems, images created using all modalities can Calcium The most dense, naturally occurring material
be stored and retrieved. Conventional radiography, com- (e.g., bones); absorbs most x-rays
puted tomography (CT), ultrasonography, magnetic reso- Metal Usually absorbs all x-rays and appears the “whitest”
nance imaging (MRI), fluoroscopy, and nuclear medicine are (e.g., bullets, barium)
examples of images that can be stored in this way.
Recognizing Anything | 2.e1
eFIGURE 1-1 Film file room. When medical images were stored on film, they occupied a tremendous
amount of space at each facility. This is one aisle containing several thousand patient films among
many dozens of similar aisles in a cavernous room that was needed to store all of the images. Today,
all of these images can be stored in the space of computer servers and are viewable, with permission,
from any location.
Recognizing Anything | 3
A B
FIGURE 1-7 Bullet in the chest. A, The dense (white) metallic foreign body overlying the right lower lung field (white arrow) is a bullet. It is much denser (whiter) than the bones (calcium density), represented
by the ribs, clavicles, and spine. Fluid (such as the blood in the heart) and soft-tissue density (such as the muscle of the heart) have the same density, which is why we cannot differentiate the two using con-
ventional radiography. The air in the lungs is the least dense (blackest). B, Two views at 90° angles to each other, such as these frontal and lateral chest radiographs, are called orthogonal views. With only
one view, it would be impossible to know the location of the bullet. On the lateral view, the bullet can be seen lying in the soft tissues of the back (black arrow). Orthogonal views are used throughout conven-
tional radiography to localize structures in all parts of the body.
to produce cell mutations, which could lead to many forms 400 HU to 600 HU. Fat is −40 to −100 HU, water is
of cancer or anomalies. Public health data on lower levels of 0, and soft tissue is 20 HU to 100 HU.
radiation vary with regard to assessment of risk, but it is ■ CT images are displayed or viewed using a range of Houns
generally held that only medically necessary diagnostic exam- field numbers preselected to best demonstrate the tissues
inations should be performed and that imaging using x-rays being studied (e.g., from −100 to +300), and anything within
should be avoided during potentially teratogenic times, such that range of CT numbers is displayed over the levels of
as pregnancy. (More information about radiation dose and density in the available gray scale. This range is called the
safety is available at StudentConsult.com.) window.
Measurements of Radiation
RADIATION DOSE AND SAFETY ■ The absorbed radiation is measured by the absorbed dose.
Ionizing Radiation in Radiology The unit for absorbed dose is the gray (Gy), which is the
■ In the modalities of conventional radiography, CT, and fluo- energy absorbed per unit of mass (kilogram). The older unit
roscopy, images are produced using ionizing radiation. for absorbed dose is the rad, where 1 Gy = 100 rads.
Besides producing the image, this radiation can also have Absorbed dose does not take into account the biological
harmful effects if used in excess. All health care providers effect of that radiation.
should understand the risks associated with radiation expo- ■ The equivalent and effective doses attempt to correlate the
sure and limit exposure when possible. absorbed dose with the potential biological effects on
different types of tissues. The unit for these doses is the
Three Fates of Radiation During Sievert (Sv) or rem, where 1 Sv = 100 rem.
an Imaging Procedure
■ Transmitted radiation is the radiation that passes through Biological Effects of Radiation
the patient and interacts with the detector to create the image ■ Radiation causes biological effects on a cellular level either
(wavy white line in eFig. 1-2). Unfortunately, only about 5% (1) by directly damaging molecules or (2) by indirectly
to 15% of the radiation produced by the source becomes creating free radicals to disrupt cellular metabolism.
transmitted radiation.
■ The majority of radiation produced by the source becomes Types of Biological Effects
either absorbed radiation or scatter radiation. ■ Deterministic effects (nonrandom): This is damage that
♦ Absorbed radiation is the radiation that interacts with occurs when a threshold level is met. Both the probability
the tissues of the patient, depositing its energy in those and the severity of the effect are proportional to increas-
tissue; it is the source of the patient radiation exposure ing dose, where the dose is usually given in one exposure
(wavy black line in eFig. 1-2). or several exposures over a very short period of time. These
♦ Scatter radiation is not transmitted or absorbed by the effects occur when the level of radiation-induced cell damage
patient. As radiation passes through the patient, some exceeds the cell’s ability to repair the damage. Some examples
of the radiation changes its original path, with the of deterministic effects and threshold doses are shown in
scatter leaving the patient along a different course. eTable 1-1.
Scatter radiation can degrade the quality of the ■ Stochastic effects (random): Damage that may occur at
image and can be an exposure source to personnel any level of exposure, without a threshold dose. These
(wavy yellow line in eFig. 1-2). effects occur by chance, and while their probability
increases with an increasing dose, their severity is inde-
pendent of the dose. These effects are due to damage of
cellular components, usually DNA, by free radicals, leading
to abnormal cell function if repair is incomplete or incorrect.
Stochastic effects are “invisible damage” and may not mani-
fest until many years after exposure.
■ The probability of cell damage is due in part to the radio-
sensitivity of the type of tissue irradiated. In general, slowly
dividing mature cells, such as bone cells, have a low sen-
sitivity to radiation damage, whereas undifferentiated,
rapidly dividing cells, such as intestinal epithelial cells, have
a higher sensitivity. The most radiosensitive organs are
bone marrow, colon, lung, female breast, stomach, and
childhood thyroid.
■ Radiation-induced DNA mutations that occur in somatic
cells can lead to the development of cancers. Mutations
that occur in the germ cells may be passed on to the off-
spring, causing heritable genetic or chromosomal abnor-
malities, although none has ever been documented in
humans.
Adapted from International Commission on Radiological Protection (ICRP), Pregnancy and Medical Radiation (ICRP Publication 84), Ann. ICRP 30 (1), 2000; and ICRP, Biological Effects after Prenatal Irradiation
(Embryo and Fetus) (ICRP Publication 90), Ann. ICRP 33 (1-2), 2003.
*Stochastic risks are suspected, but data are not consistent.
VIDEO 1-1 Spinning gantry of a computed tomography scanner. This is a view few people see. This
is the gantry containing the computed tomography scanner x-ray sources and detectors that spin at
an incredibly rapid number of rotations (between 180 and 240 rotations/min) around the patient and
capture the volumetric data that allow today’s scanners to scan from head to toe in less than 10
seconds and display the images in three dimensions, in any plane. (Courtesy Philips Healthcare.)
4 | Recognizing Anything
A B C
FIGURE 1-8 Windowing the thorax. Chest computed tomography scans are usually “windowed” and displayed in several formats to optimize anatomical definition. A, Lung windows are chosen to maximize
the ability to image abnormalities of the lung parenchyma and to identify normal and abnormal bronchial anatomy (black circle). B, Mediastinal windows are chosen to display the mediastinal, hilar, and pleural
structures to best advantage (white circle). C, Bone windows are utilized as a third way of displaying the data to visualize the bony structures to their best advantage (white oval and arrow). It is important to
recognize that the displays of these different windows are manipulations of the data obtained during the original scan and do not require rescanning the patient.
ULTRASONOGRAPHY
F
■ Ultrasound probes utilize acoustic energy above the audible
frequency of humans to produce images, instead of using
FIGURE 1-9 Three-dimensional computed tomography rendering of normal rib cage. This x-rays as both conventional radiography and CT scans do
grayscale version (color online) of a three-dimensional surface rendering of the rib cage is made (see Chapter 21).
possible by the acquisition of multiple, thin computed tomographic sections through the body. These ■ An ultrasound probe or transducer both produces the ultra-
sections can then be reconstructed to demonstrate surface anatomy, as in this illustration. The same sonic signal and records it. The signal is processed for its
data set could have been manipulated to show the heart or lungs (which are digitally removed here) characteristics by an onboard computer. Ultrasound images
and not the rib cage. Such renderings are especially helpful in demonstrating the exact anatomic are recorded digitally and are easily stored in a PACS system.
relationships of structures, especially for surgical planning. F, Foot; L, left; H, head; R, right. Images are displayed either as static images or in the form
of a movie (or “cine”) (Video 1-3).
■ Ultrasound scanners are relatively inexpensive com-
pared with CT and MRI scanners. They are widely avail-
scans can be shown in any plane: axial, sagittal, or coronal. able and can be made portable to the point of being
Volumetric data consist of a series of thin sections that can handheld.
be reassembled for a three-dimensional reconstruction. ■ Because ultrasonography utilizes no ionizing radiation, it is
Surface and volume rendering in three dimensions can particularly useful in obtaining images of children and
produce CT images of amazing, realistic quality (Fig. 1-9). women of childbearing age and during pregnancy.
■ One of the major benefits of CT scanning over conventional ■ Ultrasonography is widely used in medical imaging. It
radiography is its ability to expand the gray scale, which is usually the study of first choice in imaging the female
enables differentiation of many more than the five basic pelvis and in pediatric patients, in differentiating cystic versus
densities available on conventional radiographs. solid lesions in patients of all ages, in noninvasive vascular
Recognizing Anything | 4.e1
VIDEO 1-2 Virtual bronchoscopy. This is a three-dimensional surface rendering series of images of VIDEO 1-3 Color Doppler scan of carotid artery. In this split-screen image, the ultrasonographer is
the interior of the trachea obtained from a computed tomography scan of the chest. Its line of flight sweeping the transducer (probe) back and forth along the side of the neck to acquire images of the
is down the trachea to the carina at the bifurcation into the right and left main bronchi. The video is carotid artery (flow shown in red on the accompanying scan). The blue represents flow in the jugular
looped to display twice. Such reconstructions can aid in the location of lesions and planning for vein. To produce the best contact between the probe and the skin, a coupling gel is applied to the
interventions. skin surface first.
Recognizing Anything | 5
VIDEO 1-4 Normal swallowing function captured by fluoroscopy. The barium appears black in this VIDEO 1-5 Fluoroscopy used for angiography. Fluoroscopic imaging is essential in the performance
video. The patient is facing your left and has a cup of barium, which he is instructed to swallow at of interventional radiologic procedures to allow the operator to observe the location of the catheter
varying intervals. Then the patient turns to face you on the next set of swallows. Swallowing is and the course and appearance of the vessels and to assess the efficacy of interventional treatments.
captured with rapid sequence images that are played here as a cine. The colors in the video could have This is a cerebral angiogram. Contrast is injected via a catheter inserted from the groin into the right
been digitally inverted, and the barium could have been displayed as white rather than black. internal carotid artery, in this case, and outlines the arterial, capillary, and finally, venous structures
on the right side of the carotid artery’s distribution. The vascular supply of aneurysms, vascular
malformations, and tumors can be visualized with this technique.
6 | Recognizing Anything
A B
eFIGURE 1-3 Orientation of images. By convention, images are viewed as if the patient were facing you. A, When you view a chest radiograph, the patient’s right (labeled right) is on your left. B, Likewise,
when you view a computed tomographic scan (of any body part), the patient’s right is on your left. With today’s digital displays automatically orienting almost all images correctly, it is more difficult to view
an image backward.
6.e2 | Recognizing Anything
■ Dye: This is the lay term for contrast. Although contrast is ♦ This is not an easy concept to grasp, because it involves
the better term, many patients, and some radiologists in making a mental reconstruction of a three-
explaining tests to patients, use the term dye. Do not use the dimensional object from the two-dimensional
word dye unless you are explaining a test to a patient; use projections conventional radiographs provide.
the term contrast or contrast agent. In fact, if you can use ♦ For example, a disk-shaped object (one that looks like a
the words contrast and image in the same sentence, people playing piece used in the game of checkers), such as an
will think you are a genius. ingested coin, will appear circular when viewed en face
■ Flat plate: This is an archaic but still used term meaning a but rectangular when viewed in perfect profile
conventional radiograph or plain film of the abdomen, (eFig. 1-5).
almost always obtained with the patient lying supine. It is left ■ Horizontal versus vertical x-ray beams: These terms are
over from the pioneer days of radiology when the image was used to describe the orientation of x-ray beams.
produced on a flat glass plate, before film was used as the ♦ Horizontal and vertical beam orientation is an
recording medium. important concept to understand because it will help
■ White and black: These are not radiologic terms, but almost
every modality displays its images in white, black, and various
shades of gray.
♦ Remember, the denser an object is, the more x-rays it
absorbs and the “whiter” it appears on radiographic
images. The less dense an object is, the fewer x-rays it
absorbs and the “blacker” it will appear on radiographs.
♦ Unfortunately, the specific terms used to describe what
appears as white or black on an image change from
one modality to another. eTable 1-4 is a handy chart
that lists the terms used to describe what shows as
black or white using various modalities.
■ “En face” and “in profile”: These terms are used primarily
in describing conventional radiography and barium studies.
♦ When you look at a lesion directly “head-on,” you are
seeing it en face. A lesion seen tangentially (sideways) is
seen in profile.
♦ Only a sphere, which, by definition, is perfectly round
in every dimension, will appear exactly the same shape
no matter in which plane it is viewed (e.g., a nodule in
the lung) (eFig. 1-4). A
♦ Naturally occurring structures, whether normal or
abnormal, of any shape other than a sphere will appear
slightly different in shape if viewed en face or in profile.
A B
eFIGURE 1-5 Coin in the esophagus. Both the frontal (A) and lateral (B) images of this child’s upper thorax demonstrate a radiopaque metallic density in the region of the upper esophagus. The child
swallowed a quarter, which is temporarily lodged in the esophagus just above the aortic arch. Notice how different the coin looks when viewed en face in (A) (white arrow), where it is seen as a circle, and in
profile (B), when it is seen on end (black arrow).
A B
eFIGURE 1-6 Vertical versus horizontal x-ray beams. The same patient with a hydropneumothorax is shown imaged a few hours apart, first with a vertical x-ray beam (supine chest) (black arrow) (A)
and then with a horizontal x-ray beam (upright chest) on the right (B). In both images, the patient has both air and fluid in the left hemithorax, but only in image (B), taken with a horizontal beam, can the
distinctive flat, air–fluid interface be seen (white arrow). An air–fluid interface will only be visible with an x-ray beam that is parallel to the floor (horizontal), no matter what position the patient is in.
you in interpreting all kinds of conventional horizontal, regardless of the position of the patient
radiographic studies and in understanding their (eFig. 1-6).
limitations. This may, in turn, prevent you from falling • An air-fluid or fat-fluid level is an interface between
for a diagnostic pitfall. two substances of different density in which the
♦ An x-ray beam is usually directed either horizontally lighter substance rises above, and forms a straight-
between the tube and the cassette (as in an upright edge interface with, the heavier substance below.
chest examination) or vertically between the tube
and the cassette (as in a supine radiograph of the You usually do not have to specify whether you want
abdomen with the patient lying on the examining the x-ray beam to be horizontal or vertical when
table). ordering a study; by convention, certain types of imaging
♦ Horizontal x-ray beams are usually parallel to the studies are always done using one method or the other
floor of the examining room (unless the room was built (eTable 1-5). In general, any study with the terms erect,
by do-it-yourselfers on weekends). upright, cross-table, or decubitus is always done with a
♦ In conventional radiography, an air-fluid or fat-fluid horizontal beam. You can see fluid levels (if present)
level will be visible only if the x-ray beam is with any of these types of studies.
6.e4 | Recognizing Anything
VIDEO 1-6 Spinning positron emission tomography scan. The most commonly used target molecule
in PET scanning is an analogue of glucose called fluorodeoxyglucose (FDG); thus this type of imaging
is called FDG-PET. The concentration of this glucose analogue in bodily tissues gives a measure of
metabolic activity. Lung, breast, and colon cancers are among some tumor types that take up the
tracer and can be seen on the scans. The FDG will normally be seen in the organs shown here: the
heart (red arrow), the kidney (yellow arrow), and the urinary bladder (green arrow).
Recognizing Anything | 7
TAKE-HOME POINTS
RECOGNIZING ANYTHING: AN INTRODUCTION TO IMAGING MODALITIES
Today, almost all images are stored electronically on a picture Ultrasonography units are less expensive, are in widespread use, and
archiving, communications, and storage system called PACS. have been produced as small as handheld devices.
Conventional radiographs (plain films) are produced using ionizing Magnetic resonance imaging (MRI) produces images based on the
radiation generated by x-ray machines and viewed on a monitor or energy derived from hydrogen atoms placed in a very strong
light box. magnetic field and subjected to radiofrequency pulsing. The data
thus derived are analyzed by powerful computer algorithms to
Such x-ray machines are relatively inexpensive and widely available,
produce images in any plane.
and they can be made portable. The images are limited as to the
sensitivity of findings they are capable of displaying. MRI units are relatively expensive, require site construction for their
placement, and are usually relatively high in cost to operate. They
There are five basic radiographic densities, arranged in order from
have become the cornerstone of neuroimaging and are of particular
that which appears the whitest to that which appears the blackest:
use in studying muscles, ligaments, and tendons.
metal, calcium (bone), fluid (soft tissue), fat, and air.
Fluoroscopy utilizes ionizing radiation to produce real-time
Computed tomography (CT) utilizes rapidly spinning arrays of x-ray
visualization of the body that allows for evaluation of motion,
sources and detectors and sophisticated computer processing to
positioning, and the visualization of barium or iodine contrast agents
increase the sensitivity of findings visible and display them in any
moving through the gastrointestinal and genitourinary tracts and
geometric plane.
blood vessels.
CT scanners have become the foundation of cross-sectional imaging.
Nuclear medicine utilizes radioisotopes that have been given the
They are moderately expensive and also use ionizing radiation to
property to “target” different organs of the body to evaluate the
produce their images.
physiology and anatomy of those organs. Unlike other modalities
Ultrasonography produces images using the acoustic properties of that use ionizing radiation, the patient can briefly be the source of
tissue and does not employ ionizing radiation. It is thus safe for use radiation exposure in nuclear medicine studies.
in children and in women of childbearing age and during pregnancy.
It is particularly useful in analyzing soft tissues and blood flow.
WEBLINK
Visit StudentConsult.Inkling.com for videos and more
information.
For your convenience, the following QR code may be used
to link to StudentConsult.com. You must register this title
using the PIN code on the inside front cover of the text to
access online content.
CHAPTER 2
Recognizing a Technically
Adequate Chest Radiograph
■ You have to be able to quickly determine if a study is techni- ♦ You can tell if a frontal chest radiograph is
cally adequate so that you don’t mistake technical deficien- underpenetrated (too light) if you are not able to see
cies for abnormalities. We will focus on the chest radiograph the thoracic spine through the heart.
in this chapter. This chapter will enable you to evaluate the ♦ Underpenetration can introduce at least two errors into
technical adequacy of a chest x-ray by helping you become your interpretation:
more familiar with the diagnostic pitfalls certain technical • First, the left hemidiaphragm may not be visible on
artifacts can introduce. the frontal film because the left lung base may
appear opaque. This technical artifact could either
mimic or hide true disease in the left lower lung field
EVALUATING THE CHEST RADIOGRAPH FOR
(e.g., left lower lobe pneumonia or left pleural
TECHNICAL ADEQUACY
effusion) (Fig. 2-2).
■ Evaluating five technical factors will help you to determine ■ Solution: Look at the lateral chest radiograph to
if a chest radiograph is adequate for interpretation or confirm the presence of disease at the left base
whether certain artifacts may have been introduced that can (see “The Lateral Chest” in Chapter 3).
lead you astray (Table 2-1): • Second, the pulmonary markings, which are mostly
♦ Penetration the blood vessels in the lung, may appear more
♦ Inspiration prominent than they really are. You may mistakenly
♦ Rotation think the patient is in congestive heart failure or has
♦ Magnification pulmonary fibrosis.
♦ Angulation ■ Solutions: Look for other radiologic signs of
congestive heart failure (see Chapter 13). Look at
Penetration
■ Unless x-rays adequately pass through the body part being
studied, you may not visualize everything necessary on the
image produced. 1 c
♦ To determine if a frontal chest radiograph is adequately
penetrated, you should be able to see the thoracic
spine through the heart shadow (Fig. 2-1).
8
Recognizing a Technically Adequate Chest Radiograph | 9
FIGURE 2-2 Underpenetrated frontal chest radiograph. The spine (solid black arrow) is not
visible through the cardiac shadow. The left hemidiaphragm is also not visible (dotted black arrows), FIGURE 2-3 Overpenetrated frontal chest radiograph. The overpenetration makes lung mark-
and the degree of underpenetration makes it impossible to differentiate between actual disease at ings difficult to see, mimicking some of the findings in emphysema or possibly suggesting a pneu-
the left base versus nonvisualization of the left hemidiaphragm due to underpenetration. A lateral mothorax. How lucent (dark) the lungs appear on a radiograph is a poor way of evaluating for the
radiograph of the chest would help to differentiate between artifact of technique and true disease. presence of emphysema because of artifacts introduced by technique. In emphysema, the lungs are
frequently hyperinflated and the diaphragm flattened (see Chapter 12). To diagnose a pneumothorax,
you should see the pleural white line (see Chapter 10).
the lateral chest film to confirm the presence of
increased markings, airspace disease, or effusion at
the left base that you suspected on the basis of BOX 2-1 DIFFERENTIATING BETWEEN
the frontal radiograph. ANTERIOR AND POSTERIOR RIBS
Posterior ribs are immediately more apparent to the eye on
Pitfall of overpenetration frontal chest radiographs.
The posterior ribs are oriented more or less horizontally.
■ If the study is overpenetrated (too dark), the lung markings
Each pair of posterior ribs attaches to a thoracic vertebral body.
may seem decreased or absent (Fig. 2-3). You could mistak-
enly think the patient has emphysema or a pneumothorax, or Anterior ribs are visible, but more difficult to see, on the frontal
chest radiograph.
if the degree of overpenetration is marked, it could render
Anterior ribs are oriented downward toward the feet.
findings such as a pulmonary nodule almost invisible.
♦ Solutions: Look for other radiographic signs of Anterior ribs attach to the sternum or to each other with cartilage
that usually is not visible until later in life, when the cartilage
emphysema (see Chapter 12) or pneumothorax (see may calcify.
Chapter 10). Ask the radiologist if the film should be
repeated.
Inspiration near the diaphragm (Fig. 2-5). This may lead you to
■ A full inspiration ensures a reproducible radiographic image mistakenly think the study shows lower lobe pneumonia.
for comparison from one time to the next and eliminates • Solution: Look at the lateral chest radiograph to
artifacts that may be confused for, or obscure, disease. confirm the presence of pneumonia (see “The
♦ The degree of inspiration can be assessed by Lateral Chest Radiograph” in Chapter 3).
counting the number of posterior ribs visible above
the diaphragm on the frontal chest radiograph. Rotation
• To help in differentiating the anterior from the ■ Significant rotation (the patient turns the body to one side
posterior ribs, see Box 2-1. or the other) may alter the expected contours of the
♦ If 10 posterior ribs are visible, it is an excellent heart and great vessels, the hila, and hemidiaphragms.
inspiration (Fig. 2-4). ■ The easiest way to assess whether the patient is rotated
♦ In many hospitalized patients, visualization of eight toward the left or right is by studying the position of the
to nine posterior ribs is a degree of inspiration usually medial ends of each clavicle relative to the spinous
adequate for accurate interpretation of the image. process of the thoracic vertebral body between the clavicles
(Fig. 2-6).
Pitfall: Poor inspiration ♦ The medial ends of the clavicles are anterior
structures.
♦ A poor inspiratory effort will compress and crowd ♦ The spinous process is a posterior structure
the lung markings, especially at the bases of the lungs (Fig. 2-7).
10 | Recognizing a Technically Adequate Chest Radiograph
♦ If the spinous process appears to lie equidistant ♦ These relationships hold true regardless of whether the
from the medial end of each clavicle on the frontal patient was facing the x-ray tube or facing the cassette
chest radiograph, there is no rotation (see Fig. 2-7, A). at the time of exposure.
♦ If the spinous process appears closer to the medial
end of the left clavicle, the patient is rotated toward Pitfalls of excessive rotation
his or her own right side (see Fig. 2-7, B).
♦ If the spinous process appears closer to the medial ♦ Even minor degrees of rotation can distort the normal
end of the right clavicle, the patient is rotated anatomic appearance of the heart and great vessels, the
toward her or his own left side (see Fig. 2-7, C). hila, and hemidiaphragms.
♦ Marked rotation can introduce errors in
interpretation:
• The hilum may appear larger on the side rotated
2
1 farther away from the imaging cassette, because
3
objects farther from the imaging cassette tend to be
more magnified than objects closer to the cassette.
4 ■ Solutions: Look at the hilum on the lateral
5 chest view to see if that view confirms hilar
enlargement (see “The Hilar Region” in Chapter 3).
6
10
FIGURE 2-5 Suboptimal inspiration. Only eight posterior ribs are visible on this frontal chest
FIGURE 2-4 Counting ribs. The posterior ribs are numbered in this photograph. Ten posterior ribs radiograph. A poor inspiration may “crowd,” and therefore accentuate, the lung markings at the
are visible above the right hemidiaphragm, an excellent inspiration. In most hospitalized patients, bases (black arrows) and may make the heart seem larger than it actually is. The crowded lung mark-
the presence of eight or nine visible posterior ribs in the frontal projection indicates an inspiration ings may mimic the appearance of aspiration or pneumonia. A lateral chest radiograph should help
that is adequate for accurate interpretation of the image. When counting ribs, make sure you do not eliminate the possibility, or confirm the presence, of basilar airspace disease suspected on the basis
miss counting the 2nd posterior rib, which frequently overlaps the 1st rib. of the frontal radiograph.
R L
R L
L R
A B C
FIGURE 2-6 How to determine if the patient is rotated. A, The patient is not rotated, and the medial ends of the right (orange dot) and left (black dot) clavicles are projected on the radiograph (black
line) equidistant from the spinous process (black triangle). B, The patient is rotated toward his own right side. Notice how the medial end of the left clavicle (black dot) is projected closer to the spinous process
than is the medial end of the right clavicle (orange dot). C, This patient is rotated toward his own left side. The medial end of the right clavicle (orange dot) is projected closer to the spinous process than is the
medial end of the left clavicle (black dot). The camera icon depicts this as an anteroposterior projection, but the same relationships would hold true for a posteroanterior projection as well. Figure 2-7 shows
how this applies to radiographs.
Recognizing a Technically Adequate Chest Radiograph | 11
A B C
FIGURE 2-7 How to evaluate for rotation. A, Close-up view of the heads of the clavicles demonstrates that each (white arrows) is about equidistant from the spinous process of the vertebral body
between them (black arrow). This indicates the patient is not rotated. B, Close-up view of the heads of the clavicles in a patient rotated toward his own right side. (Remember that you are viewing the
study as if the patient were facing you.) The spinous process (black arrow) projects much closer to the left clavicular head (dotted white arrow) than to the right clavicular head (solid white arrow). C, Close-up
view of the heads of the clavicles in a patient rotated toward his own left side. The spinous process (black arrow) is much closer to the right clavicular head (solid white arrow) than it is to the left (dotted
white arrow).
A B
FIGURE 2-9 Effect of positioning on magnification of the heart. A, Frontal chest radiograph done in the anteroposterior projection shows the heart to be slightly larger than in B, which shows the same
patient’s chest exposed minutes later in the posteroanterior projection. Because the heart lies anteriorly in the chest, it is farther from the imaging surface in (A) and is therefore magnified more than in (B), in
which the heart is closer to the imaging surface. In actual practice, there is very little difference in heart size between anteroposterior and posteroanterior exposures, as long as the patient’s inspiration was equal
in both.
TAKE-HOME POINTS
RECOGNIZING A TECHNICALLY ADEQUATE CHEST RADIOGRAPH
There are five parameters that define an adequate chest examination, inspiratory efforts may mimic basilar lung disease and may make the
and recognition of them is important to accurately differentiate heart appear larger.
abnormalities from technically produced artifacts. The spinous process should fall equidistant between the medial ends
These parameters are penetration, inspiration, rotation, of the clavicles to indicate the patient is not rotated. Rotation can
magnification, and angulation. introduce numerous artifactual anomalies affecting the contour of
the heart and the appearance of the hila and diaphragm.
If the chest is adequately penetrated, you should be able to see the
spine through the heart. Underpenetrated (too light) studies obscure Anteroposterior (AP) films (mostly portable chest x-rays) will magnify
the left lung base and tend to spuriously accentuate the lung the heart slightly compared with the standard posteroanterior (PA)
markings; overpenetrated studies (too dark) may mimic emphysema chest radiograph (usually done in the radiology department).
or pneumothorax. Frontal views of the chest obtained with the patient semirecumbent
If the patient has taken an adequate inspiration, you should see at in bed (tilted backward) may produce apical lordotic images that
least eight or nine posterior ribs above the diaphragm. Poor distort normal anatomy.
WEBLINK
Visit StudentConsult.Inkling.com for more information and a
quiz on the Correct Chest X-ray Technique.
For your convenience, the following QR Code may be used
to link to StudentConsult.com. You must register this title
using the PIN code on the inside front cover of the text to
access online content.
CHAPTER 3
Recognizing Normal
Pulmonary Anatomy
In this chapter, you will learn the normal anatomy of the lungs
as depicted by conventional radiography and chest computed Trachea
3
tomography (CT). To become more comfortable with interpret-
ing images of the chest, you should first be able to recognize
fundamental, normal anatomy to enable you to differentiate it
from what is abnormal. Coracoid process- Head of clavicle
scapula
Aortic 3
knob
WHICH “SYSTEM” WORKS BEST Ascending Medial border-
aorta- scapula
What is the best system to look at an imaging study such as a
superior
chest x-ray? I am glad you asked. Pulmonary blood vena cava
Some folks systematically look at imaging studies, such as chest vessels Main
radiographs, from the outside of the image to the inside of the pulmonary Left hilum-
image; others look at them from the inside out or from top to artery Left pulmonary
bottom. Some systems for reminding you to examine every part artery
of an image have catchy acronyms and mnemonics. Right hilum-
Right pulmonary Right Descending
The fact is: It does not matter which system you use, as long as artery aorta
atrium
you look at everything on the image. So, use whichever system
works for you, but be sure to look at everything. “Looking at Left
everything,” by the way, includes looking at all of the views ventricle
available in a given study, not just everything on one view.
(Do not forget that lateral chest radiograph in a two-view study
of the chest.) Cardiophrenic
angle Cardiophrenic
Experienced radiologists usually have no system at all. Right breast angle
Right Left
Burned-in images are bad for computer monitors, but they are shadow
hemidiaphragm hemidiaphragm
great for radiologists. “Burned” into the neurons of a radiologist’s
Costophrenic Costophrenic
brain are mental images of what a normal frontal chest
angle angle
radiograph looks like, what thoracic sarcoidosis looks like, and so
on. They frequently use a “gestalt” impression of a study that FIGURE 3-1 Well-exposed frontal view of a normal chest. Notice how the spine is just visible
they see in their mind’s eye within seconds of looking at an
through the heart shadow. Both the right and left lateral costophrenic angles are sharply and acutely
image. If the image does or does not correspond to the mental
image that resides in their brains, then they systematically study angled. The white line demarcates the approximate level of the minor or horizontal fissure, which is
the images. This is not magic; this ability comes only with usually visible in the frontal view because it is seen on end. There is no minor fissure on the left side.
experience, so at least for now, you are probably not quite ready The white circle contains lung markings that are blood vessels. Note that the left hilum is normally
to use the gestalt approach. slightly higher than the right. The white “3” lies on the posterior 3rd rib, and the black “3” lies on the
The most valuable system to use in interpreting images is the anterior 3rd rib.
system in which you routinely increase your knowledge. If you
do not know what you are looking for, you can stare at an image
for hours or days, or in the case of the lateral chest radiograph,
you can ignore an image entirely, and the end result will be the
■ Vessels and bronchi—normal lung markings
same: You will not see the findings. There is an axiom in radiology: ♦ Virtually all of the “white lines” you see in the lungs
You only see what you look for, and you only look for what on a chest radiograph are blood vessels. Blood vessels
you know. So if you don’t know what to look for, you will never characteristically branch and taper gradually from the
recognize the finding, no matter what system you use or how hila centrally to the peripheral margins of the lungs.
long you stare at the image.
You cannot accurately differentiate between pulmonary
By reading this book, you will gain the knowledge that will
allow you to recognize what it is you are looking at—the best
arteries and pulmonary veins on a conventional
system of all. radiograph.
♦ Bronchi are mostly invisible on a normal chest
radiograph because they are normally very thin-walled,
they contain air, and they are surrounded by air.
THE NORMAL FRONTAL CHEST RADIOGRAPH ■ Pleura—normal anatomy
♦ The pleura is composed of two layers, the outer
■ Figure 3-1 displays some of the normal anatomic features parietal and inner visceral layers, with the pleural
visible on the frontal chest radiograph. space between them. The visceral pleura is adherent
14
Recognizing Normal Pulmonary Anatomy | 15
FIGURE 3-3 Normal left lateral chest radiograph. There is a clear space behind the sternum
(solid white arrow). The hila produce no discrete shadow (white circle). The vertebral bodies are
approximately of equal height, and their end plates are parallel to each other (double white arrows).
The posterior costophrenic angles (solid black arrow) are sharp. Notice how the thoracic spine appears
FIGURE 3-2 Normal pulmonary vasculature. The right lung is shown. In the upright position, to become blacker (darker) from the shoulder girdle (black star) to the diaphragm because there is
the lower-lobe vessels (black circle) are larger in size than the upper-lobe vessels (white circle), and less dense tissue for the x-ray beam to traverse at the level of the diaphragm. The heart normally
all vessels taper gradually from central to peripheral (white arrow). Alterations in pulmonary flow or touches the anterior aspect of the left hemidiaphragm and usually obscures (silhouettes) it. The
pressure may change these relationships. superior surface of the right hemidiaphragm is frequently seen continuously from back to front (dotted
black arrow) because it is not obscured by the heart. Notice the normal space posterior to the heart
to the lung and enfolds to form the major and minor and anterior to the spine; this will be important in assessing cardiomegaly (see Chapter 13). The black
fissures. line represents the approximate location of the major or oblique fissure; the white line is the approxi-
♦ Normally, there are several milliliters of fluid but no mate location of the minor or horizontal fissure. Both are frequently visible because they are seen on
air in the pleural space. end on a lateral view radiograph.
♦ Neither the parietal pleura nor the visceral pleura is
normally visible on a conventional chest radiograph, Recognizing Adult Heart Disease from the Frontal Chest
except where the two layers of visceral pleura enfold to Radiograph” online.
form the fissures. Even then, they are usually no
thicker than a line drawn with the point of a THE NORMAL LATERAL CHEST RADIOGRAPH
sharpened pencil.
■ As part of the standard two-view chest examination, an
upright, frontal chest radiograph and an upright, left
NORMAL PULMONARY VASCULATURE
lateral view of the chest are obtained.
In the upright position, the blood flow to the bases is ■ A left lateral chest x-ray (with the patient’s left side against
normally greater than the flow to the apices because of the detector) is of great diagnostic value but is sometimes
the effect of gravity. Therefore the size of the vessels at ignored by beginners because of their lack of familiarity
the base is normally larger than the size of the vessels with the findings visible in that projection.
at the apex of the lung. ■ Figure 3-3 displays some of the normal anatomic features
visible on the lateral chest radiograph.
■ Normally, blood vessels branch and taper gradually from ■ Why look at the lateral chest?
central (the hila) to peripheral (near the chest wall) (Fig. 3-2). ♦ It can help you determine the location of disease you
■ Changes in pressure or flow can alter the normal dynamics already identified as being present on the frontal image.
of the pulmonary vasculature, some of which are described ♦ It can confirm the presence of disease you may be
in Chapter 13. unsure of on the basis of the frontal image alone, such
■ For more on recognizing normal pulmonary vasculature and as a mass or pneumonia.
an imaging approach to diagnosing heart disease in adults, ♦ It can demonstrate disease not visible on the frontal
registered users can view “The ABCs of Heart Disease: image (Fig. 3-4).
Another random document with
no related content on Scribd:
qu’à Tristan, qu’ils peuvent sortir de leurs lits et venir céans.—Tu as
encouru la peine de mort, dit froidement Louis XI au Brabançon, qui
heureusement ne l’entendit pas, tu en as au moins dix sur la
conscience, toi! Là, Louis XI laissa échapper un rire muet, et fit une
pause:—Mais, rassure-toi, reprit-il en remarquant la pâleur étrange
répandue sur le visage de l’avare, tu es meilleur à saigner qu’à tuer!
Et, moyennant quelque bonne grosse amende au profit de mon
épargne, tu te tireras des griffes de ma justice; mais si tu ne fais pas
bâtir au moins une chapelle en l’honneur de la Vierge, tu es en
passe de te bailler des affaires graves et chaudes pendant toute
l’éternité.
—Douze cent trente et quatre-vingt-sept mille écus font treize
cent dix-sept mille écus, répondit machinalement Cornélius, absorbé
dans ses calculs. Treize cent dix-sept mille écus de détournés!
—Il les aura enfouis dans quelque retrait, dit le roi qui
commençait à trouver la somme royalement belle. Voilà l’aimant qui
l’attirait toujours ici. Il sentait son trésor.
Là-dessus Coyctier entra. Voyant l’attitude de Cornélius, il
l’observa savamment pendant que le roi lui racontait l’aventure.
—Sire, répondit le médecin, rien n’est surnaturel en cette affaire.
Notre torçonnier a la propriété de marcher pendant son sommeil.
Voici le troisième exemple que je rencontre de cette singulière
maladie. Si vous vouliez vous donner le plaisir d’être témoin de ses
effets, vous pourriez voir ce vieillard aller sans danger au bord des
toits, à la première nuit où il sera pris par un accès. J’ai remarqué,
dans les deux hommes que j’ai déjà observés, des liaisons
curieuses entre les affections de cette vie nocturne et leurs affaires,
ou leurs occupations du jour.
—Ah! maître Coyctier, tu es savant.
—Ne suis-je pas votre médecin, dit insolemment le physicien.
A cette réponse, Louis XI laissa échapper le geste qu’il lui était
familier de faire lorsqu’il rencontrait une bonne idée, et qui consistait
à rehausser vivement son bonnet.
—Dans cette occurrence, reprit Coyctier en continuant, les gens
font leurs affaires en dormant. Comme celui-ci ne hait pas de
thésauriser, il se sera livré tout doucement à sa plus chère habitude.
Aussi a-t-il dû avoir des accès toutes les fois qu’il a pu concevoir
pendant la journée des craintes pour ses trésors.
—Pasques Dieu! quel trésor, s’écria le roi.
—Où est-il? demanda Cornélius, qui par un singulier privilége de
notre nature, entendait les propos du médecin et du roi, tout en
restant presque engourdi par ses idées et par son malheur.
—Ah! reprit Coyctier avec un gros rire diabolique, les
noctambules n’ont au réveil aucun souvenir de leurs faits et gestes.
—Laissez-nous, dit le roi.
Quand Louis XI fut seul avec son compère, il le regarda en
ricanant à froid.
—Messire Hoogworst, ajouta-t-il en s’inclinant, tous les trésors
enfouis en France sont au roi.
—Oui, sire, tout est à vous, et vous êtes le maître absolu de nos
vies et de nos fortunes; mais jusqu’à présent vous avez eu la
clémence de ne prendre que ce qui vous était nécessaire.
—Écoute, mon compère? Si je t’aide à retrouver ce trésor, tu
peux hardiment et sans crainte en faire le partage avec moi.
—Non, sire, je ne veux pas le partager, mais vous l’offrir tout
entier, après ma mort. Mais quel est votre expédient?
—Je n’aurai qu’à t’épier moi-même pendant que tu feras tes
courses nocturnes. Un autre que moi serait à craindre.
—Ah! sire, reprit Cornélius en se jetant aux pieds de Louis XI,
vous êtes le seul homme du royaume à qui je voudrais me confier
pour cet office, et je saurai bien vous prouver ma reconnaissance
pour la bonté dont vous usez envers votre serviteur, en m’employant
de mes quatre fers au mariage de l’héritière de Bourgogne avec
monseigneur. Voilà un beau trésor, non plus d’écus, mais de
domaines, qui saura rendre votre couronne toute ronde.
—La la, Flamand, tu me trompes, dit le roi en fronçant les
sourcils, ou tu m’as mal servi.
—Comment, sire, pouvez-vous douter de mon dévouement?
vous qui êtes le seul homme que j’aime.
—Paroles que ceci, reprit le roi en envisageant le Brabançon. Tu
ne devais pas attendre cette occasion pour m’être utile. Tu me vends
ta protection, Pasques Dieu! à moi Louis le Onzième. Est-ce toi qui
es le maître, et suis-je donc le serviteur?
—Ah! sire, répliqua le vieux torçonnier, je voulais vous
surprendre agréablement par la nouvelle des intelligences que je
vous ai ménagées avec ceux de Gand; et j’en attendais la
confirmation par l’apprenti d’Oosterlinck. Mais, qu’est-il devenu?
—Assez, dit le roi. Nouvelle faute. Je n’aime pas qu’on se mêle,
malgré moi, de mes affaires. Assez! Je veux réfléchir à tout ceci.
Maître Cornélius retrouva l’agilité de la jeunesse pour courir à la
salle basse, où était sa sœur.
—Ah! Jeanne, ma chère âme, nous avons ici un trésor où j’ai mis
les treize cent mille écus! Et c’est moi! moi! qui suis le voleur.
Jeanne Hoogworst se leva de son escabelle, et se dressa sur
ses pieds, comme si le siége qu’elle quittait eût été de fer rouge.
Cette secousse était si violente pour une vieille fille accoutumée
depuis de longues années à s’exténuer par des jeûnes volontaires,
qu’elle tressaillit de tous ses membres et ressentit une horrible
douleur dans le dos. Elle pâlit par degrés, et sa face, dont il était si
difficile de déchiffrer les altérations parmi les rides, se décomposa
pendant que son frère lui expliquait et la maladie dont il était la
victime, et l’étrange situation dans laquelle ils se trouvaient tous
deux.
—Nous venons, Louis XI et moi, dit-il en finissant, de nous mentir
l’un à l’autre comme deux marchands de myrobolan. Tu comprends,
mon enfant, que, s’il me suivait, il aurait à lui seul le secret du trésor.
Le roi seul au monde peut épier mes courses nocturnes. Je ne sais
si la conscience du roi, tout près qu’il soit de la mort, pourrait résister
à treize cent dix-sept mille écus. Il faut le prévenir, dénicher les
merles, envoyer tous nos trésors à Gand, et toi seule...
Cornélius s’arrêta soudain, en ayant l’air de peser le cœur de ce
souverain, qui rêvait déjà le parricide à vingt-deux ans. Lorsque
l’argentier eut jugé Louis XI, il se leva brusquement, comme un
homme pressé de fuir un danger. A ce mouvement, sa sœur, trop
faible ou trop forte pour une telle crise, tomba roide; elle était morte.
Maître Cornélius saisit sa sœur, la remua violemment, en lui disant:
—Il ne s’agit pas de mourir. Après, tu en auras tout le temps. Oh!
c’est fini. La vieille guenon n’a jamais rien su faire à propos. Il lui
ferma les yeux et la coucha sur le plancher; mais alors il revint à
tous les sentiments nobles et bons qui étaient dans le plus profond
de son âme; et, oubliant à demi son trésor inconnu:—Ma pauvre
compagne, s’écria-t-il douloureusement, je t’ai donc perdue, toi qui
me comprenais si bien! Oh! tu étais un vrai trésor. Le voilà, le trésor.
Avec toi, s’en vont ma tranquillité, mes affections. Si tu avais su quel
profit il y avait à vivre seulement encore deux nuits, tu ne serais pas
morte, uniquement pour me plaire, pauvre petite! Eh! Jeanne, treize
cent dix-sept mille écus! Ah! si cela ne te réveille pas... Non. Elle est
morte!
Là-dessus, il s’assit, ne dit plus rien; mais deux grosses larmes
sortirent de ses yeux et roulèrent dans ses joues creuses; puis, en
laissant échapper plusieurs ha! ha! il ferma la salle et remonta chez
le roi. Louis XI fut frappé par la douleur empreinte dans les traits
mouillés de son vieil ami.
—Qu’est ceci? demanda-t-il.
—Ah! sire, un malheur n’arrive jamais seul. Ma sœur est morte.
Elle me précède là-dessous, dit-il en montrant le plancher par un
geste effrayant.
—Assez! s’écria Louis XI qui n’aimait pas à entendre parler de la
mort.
—Je vous fais mon héritier. Je ne tiens plus à rien. Voilà mes
clefs. Pendez-moi, si c’est votre bon plaisir, prenez tout, fouillez la
maison, elle est pleine d’or. Je vous donne tout...
—Allons, compère, reprit Louis XI, qui fut à demi attendri par le
spectacle de cette étrange peine, nous retrouverons le trésor par
quelque belle nuit, et la vue de tant de richesses te redonnera cœur
à la vie. Je reviendrai cette semaine...
—Quand il vous plaira, sire...
A cette réponse, Louis XI, qui avait fait quelques pas vers la
porte de sa chambre, se retourna brusquement. Alors, ces deux
hommes se regardèrent l’un l’autre avec une expression que ni le
pinceau ni la parole ne peuvent reproduire.
—Adieu, mon compère! dit enfin Louis XI d’une voix brève et en
redressant son bonnet.
—Que Dieu et la Vierge vous conservent leurs bonnes grâces!
répondit humblement le torçonnier en reconduisant le roi.
Après une si longue amitié, ces deux hommes trouvaient entre
eux une barrière élevée par la défiance et par l’argent, lorsqu’ils
s’étaient toujours entendus en fait d’argent et de défiance; mais ils
se connaissaient si bien, ils avaient tous deux une telle habitude l’un
de l’autre, que le roi devait deviner, par l’accent dont Cornélius
prononça l’imprudent—Quand il vous plaira, sire! la répugnance que
sa visite causerait désormais à l’argentier, comme celui-ci reconnut
une déclaration de guerre dans—l’Adieu, mon compère! dit par le
roi. Aussi, Louis XI et son torçonnier se quittèrent-ils bien
embarrassés de la conduite qu’ils devaient tenir l’un envers l’autre.
Le monarque possédait bien le secret du Brabançon; mais celui-ci
pouvait aussi, par ses relations, assurer le succès de la plus belle
conquête que jamais roi de France ait pu faire, celle des domaines
appartenant à la maison de Bourgogne, et qui excitaient alors l’envie
de tous les souverains de l’Europe. Le mariage de la célèbre
Marguerite dépendait des gens de Gand et des Flamands, qui
l’entouraient. L’or et l’influence de Cornélius devaient puissamment
servir les négociations entamées par Desquerdes, le général auquel
Louis XI avait confié le commandement de l’armée campée sur la
frontière de Belgique. Ces deux maîtres renards étaient donc
comme deux duellistes dont les forces auraient été neutralisées par
le hasard. Aussi, soit que depuis cette matinée la santé de Louis XI
eût empiré, soit que Cornélius eût contribué à faire venir en France
Marguerite de Bourgogne, qui arriva effectivement à Amboise, au
mois de juillet de l’année 1483, pour épouser le dauphin, auquel elle
fut fiancée dans la chapelle du château, le roi ne leva point
d’amende sur son argentier, aucune procédure n’eut lieu, mais ils
restèrent l’un et l’autre dans les demi-mesures d’une amitié armée.
Heureusement pour le torçonnier, le bruit se répandit à Tours que sa
sœur était l’auteur des vols, et qu’elle avait été secrètement mise à
mort par Tristan. Autrement, si la véritable histoire y eût été connue,
la ville entière se serait ameutée pour détruire la Malemaison avant
qu’il eût été possible au roi de la défendre. Mais si toutes ces
présomptions historiques ont quelque fondement relativement à
l’inaction dans laquelle resta Louis XI, il n’en fut pas de même chez
maître Cornélius Hoogworst. Le torçonnier passa les premiers jours
qui suivirent cette fatale matinée dans une occupation continuelle.
Semblable aux animaux carnassiers enfermés dans une cage, il
allait et venait, flairant l’or à tous les coins de sa maison, il en
étudiait les crevasses, il en consultait les murs, redemandant son
trésor aux arbres du jardin, aux fondations et aux toits des tourelles,
à la terre et au ciel. Souvent il demeurait pendant des heures
entières debout, jetant ses yeux sur tout à la fois, les plongeant dans
le vide. Sollicitant les miracles de l’extase et la puissance des
sorciers, il tâchait de voir ses richesses à travers les espaces et les
obstacles. Il était constamment perdu dans une pensée accablante,
dévoré par un désir qui lui brûlait les entrailles, mais rongé plus
grièvement encore par les angoisses renaissantes du duel qu’il avait
avec lui-même, depuis que sa passion pour l’or s’était tournée contre
elle-même; espèce de suicide inachevé qui comprenait toutes les
douleurs de la vie et celles de la mort. Jamais le vice ne s’était
mieux étreint lui-même; car l’avare, s’enfermant par imprudence
dans le cachot souterrain où gît son or, a, comme Sardanapale, la
jouissance de mourir au sein de sa fortune. Mais Cornélius, tout à la
fois le voleur et le volé, n’ayant le secret ni de l’un ni de l’autre,
possédait et ne possédait pas ses trésors: torture toute nouvelle,
toute bizarre, mais continuellement terrible. Quelquefois, devenu
presque oublieux, il laissait ouvertes les petites grilles de sa porte, et
alors les passants pouvaient voir cet homme déjà desséché, planté
sur ses deux jambes au milieu de son jardin inculte, y restant dans
une immobilité complète, et jetant à ceux qui l’examinaient un regard
fixe, dont la lueur insupportable les glaçait d’effroi. Si, par hasard, il
allait dans les rues de Tours, vous eussiez dit d’un étranger; il ne
savait jamais où il était, ni s’il faisait soleil ou clair de lune. Souvent il
demandait son chemin aux gens qui passaient, en se croyant à
Gand, et semblait toujours en quête de son bien perdu. L’idée la plus
vivace et la mieux matérialisée de toutes les idées humaines, l’idée
par laquelle l’homme se représente lui-même en créant en dehors
de lui cet être tout fictif, nommé la propriété, ce démon moral lui
enfonçait à chaque instant ses griffes acérées dans le cœur. Puis,
au milieu de ce supplice, la Peur se dressait avec tous les
sentiments qui lui servent de cortége. En effet, deux hommes
avaient son secret, ce secret qu’il ne connaissait pas lui-même.
Louis XI ou Coyctier pouvaient aposter des gens pour surveiller ses
démarches pendant son sommeil, et deviner l’abîme ignoré dans
lequel il avait jeté ses richesses au milieu du sang de tant
d’innocents; car auprès de ses craintes veillait aussi le Remords.
Pour ne pas se laisser enlever, de son vivant, son trésor inconnu, il
prit, pendant les premiers jours qui suivirent son désastre, les
précautions les plus sévères contre son sommeil; puis ses relations
commerciales lui permirent de se procurer les antinarcotiques les
plus puissants. Ses veilles durent être affreuses; il était seul aux
prises avec la nuit, le silence, le remords, la peur, avec toutes les
pensées que l’homme a le mieux personnifiées, instinctivement
peut-être, obéissant ainsi à une vérité morale encore dénuée de
preuves sensibles. Enfin, cet homme si puissant, ce cœur endurci
par la vie politique et la vie commerciale, ce génie obscur dans
l’histoire, dut succomber aux horreurs du supplice qu’il s’était créé.
Tué par quelques pensées plus aiguës que toutes celles auxquelles
il avait résisté jusqu’alors, il se coupa la gorge avec un rasoir. Cette
mort coïncida presque avec celle de Louis XI, en sorte que la
Malemaison fut entièrement pillée par le peuple. Quelques anciens
du pays de Touraine ont prétendu qu’un traitant, nommé Bohier,
trouva le trésor du torçonnier, et s’en servit pour commencer les
constructions de Chenonceaux, château merveilleux qui, malgré les
richesses de plusieurs rois, le goût de Diane de Poitiers et celui de
sa rivale Catherine de Médicis pour les bâtiments, reste encore
inachevé.
Heureusement pour Marie de Sassenages, le sire de Saint-Vallier
mourut, comme on sait, dans son ambassade. Cette maison ne
s’éteignit pas. La comtesse eut, après le départ du comte, un fils
dont la destinée est fameuse dans notre histoire de France, sous le
règne de François Ier. Il fut sauvé par sa fille, la célèbre Diane de
Poitiers, l’arrière-petite-fille illégitime de Louis XI, laquelle devint
l’épouse illégitime, la maîtresse bien-aimée de Henri II; car la
bâtardise et l’amour furent héréditaires dans cette noble famille!
INTRODUCTION.