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Medical Radiology · Diagnostic Imaging
Series Editors: H.-U. Kauczor · P. M. Parizel · W. C. G. Peh

Johny A. Verschakelen
Walter De Wever

Computed
Tomography of
the Lung
A Pattern Approach
Second Edition
Medical Radiology
Diagnostic Imaging

Series editors
Hans-Ulrich Kauczor
Paul M. Parizel
Wilfred C.G. Peh

For further volumes:

http://www.springer.com/series/4354
Johny A. Verschakelen • Walter De Wever

Computed Tomography
of the Lung
A Pattern Approach

Second Edition
Johny A. Verschakelen Walter De Wever
Department of Radiology Department of Radiology
UZ Leuven UZ Leuven
Leuven Leuven
Belgium Belgium

ISSN 0942-5373     ISSN 2197-4187 (electronic)

Medical Radiology
ISBN 978-3-642-39517-8    ISBN 978-3-642-39518-5 (eBook)
https://doi.org/10.1007/978-3-642-39518-5

Library of Congress Control Number: 2017955684

© Springer-Verlag Berlin Heidelberg 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
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Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer-Verlag GmbH Germany
The registered company address is: Heidelberger Platz 3, 14197 Berlin, Germany
Preface

Computed tomography is generally considered to be the best imaging modal-

ity for the assessment of the lung parenchyma. High-resolution computed
tomography (HRCT) is able to provide very high morphological detail of the
normal and abnormal lung parenchyma and has been widely accepted as the
imaging gold standard for the lung parenchyma. Many reports have con-
firmed the high diagnostic value of this technique, especially in the study of
widespread diffuse or generalised lung disease. Spiral CT and especially
multidetector-row spiral CT have brought about enormous change in the field
of cross-sectional imaging and have also significant potential for the detailed
study of the lung parenchyma. This procedure is indeed able to generate volu-
metric high-resolution CT which provides a contiguous detailed visualisation
of the entire lung parenchyma. This visualisation is also no longer limited to
the axial plane since multiplanar reformations and three-­dimensional volume
reconstructions can easily be performed. In addition, high-detail imaging of
the lung parenchyma is also no longer reserved for the less frequently occur-
ring diffuse and interstitial lung diseases, but has now become available for
the study of all lung diseases. Finally, continuous technical improvements
and the development of optimised imaging protocols are responsible for an
important reduction in radiation dose allowing to produce high detailed
images at a significantly lower dose than in the early days of CT.
Optimal use and interpretation of CT require good knowledge and under-
standing of how the normal lung parenchyma looks on CT, why and how this
lung parenchyma may be affected by disease and how these changes are visu-
alised on a CT image. Furthermore, in order to have a fruitful discussion with
the clinician taking care of the patient and, when appropriate, with the pathol-
ogist, it is important that the radiologist knows and understands why abnor-
malities appear as they do. This has become very important since nowadays a
multidisciplinary approach is considered mandatory for establishing a correct
diagnosis in patients with diffuse and interstitial lung disease.
Giving the readers a clear understanding of why abnormalities appear as
they do is indeed one of the main goals of this book, since this skill will
enable them to choose an appropriate differential diagnosis or even to suggest
a definitive diagnosis once the CT findings have been correlated with the
clinical situation.
We have opted for a concise and didactic approach reducing the vast
amount of information available on this topic to what we think is basic and
essential knowledge that allows to recognise and understand the CT signs of

v
vi Preface

lung diseases and of diseases with pulmonary involvement. We have used the
pattern approach because it is well established and is considered a good
method to accomplish the main goal of the book. Our approach also has a
practical orientation. For this reason, a large section of the book is dedicated
to the description of typical and less typical cases. Analysing these cases will
help the reader to exercise pattern recognition and to understand why diseases
present as they do.
Furthermore, we have decided to reduce the number of authors to ensure
that the specific concept and approach of this book are well respected through-
out the whole volume. However, we want to emphasise that this book could
never have been written without the many informative discussions we had on
this topic with radiologists and pulmonologists, both trainees and certified
specialists. We want to express our sincere gratitude to each of them. We
would specially like to thank Dr. Wim Volders and Dr. Johan Coolen for their
valuable suggestions. We also thank Professor Albert L. Baert, who gave us
the unique opportunity to write the first and also the second edition of this
book.
In this second edition, we have maintained the basic structure of the book
which is the pattern approach of lung disease. We have added new insights
that help to explain the CT features responsible for these patterns. We have
also replaced a large number of illustrations by more recent and more illustra-
tive ones. We hope the reader will enjoy this work and will find it helpful
when exploring the perhaps difficult but very exciting CT features of lung
diseases and diseases with a pulmonary component.

Leuven, Belgium Johny A. Verschakelen

 Walter De Wever
Contents

Introduction����������������������������������������������������������������������������������������������   1
Basic Anatomy and CT of the Normal Lung����������������������������������������   3
How to Approach CT of the Lung?�������������������������������������������������������� 21
Increased Lung Attenuation ������������������������������������������������������������������ 33
Decreased Lung Attenuation������������������������������������������������������������������ 55
Nodular Pattern��������������������������������������������������������������������������������������� 81
Linear Pattern������������������������������������������������������������������������������������������ 103
Combined Patterns���������������������������������������������������������������������������������� 125
Case Study������������������������������������������������������������������������������������������������ 137
Index���������������������������������������������������������������������������������������������������������� 223

vii
 Introduction
The use of computed tomography in the study of
lung diseases is well established. Many reports
have indeed emphasised its role not only in the
detection and diagnosis but also in the quantifica-
tion and follow-up of both focal and diffuse lung
diseases. Moreover, CT has helped to better
understand the clinical and pathological course
of some diseases, while some CT classifications
are used now to categorise disease.
CT interpretation, however, remains difficult.
CT findings are often not specific and can change
during the course of the disease. In addition, the
CT changes often have more than one pathologi-
cal correlate, abnormalities can occur before
clinical symptoms develop, and clinical symp-
toms may be present before CT abnormalities
become evident. That is why a final diagnosis,
especially in a patient with diffuse interstitial
lung disease, is often only possible when clini-
cians, pathologists and radiologists work closely
together. To make such multidisciplinary coop-
eration successful, it is very important that the
pathological correlate of the CT changes is very
well understood. In fact, when looking at the CT
features, at least at a submacroscopic level, one
should be able to predict the pathological
changes, but also vice versa, when reading the
report of the pathologist, one should be able more
or less to imagine how the CT scan could look.
Today’s CT techniques can offer such good
image quality that these correlations between CT
and pathology become easier. Not only the
© Springer-Verlag Berlin Heidelberg 2018
J.A. Verschakelen, W. De Wever, Computed Tomography of the Lung, Medical Radiology, Diagnostic Imaging,
https://doi.org/10.1007/978-3-642-39518-5_1
improved detail of high-resolution computed
tomography, but also the ability to produce highly
detailed reformatted images is responsible for
this.
CT is now able to study the lung anatomy and
pathology at the level of the secondary pulmo-
nary lobule, which is a unit of lung of about
0.5–3 cm. CT can discover different components
of this secondary pulmonary lobule, especially
when they are abnormal. This is particularly
helpful in the study of the distribution pattern of
the disease since the airway, vascular, lymphatic
and intestitial pathways of distribution can,
because of their specific relation to the secondary
pulmonary lobule, often be identified and differ-
entiated from each other. This explains why the
diagnosis of lung disease with CT is to a large
extent based on the study of the distribution of
the disease.
Another important element to diagnosing
lung disease with CT is the study of the disease
appearance pattern. Recognition of the appear-
ance pattern often allows developing an appro-
priate differential diagnosis list including all the
major categories of disease that might lead to the
identified pattern. Although the recognition of a
pattern may be easy and straightforward, some
lung changes are difficult to categorise because
patterns are very often mixed or change during
the course of the disease. Nevertheless, in order
to make a diagnosis or an adequate differential
diagnosis list, the exercise of trying to categorise
1
2 Introduction
the CT changes into one or more specific pat-
terns should always be done. This is certainly
true when diffuse lung disease is studied but is
often also very helpful when focal lung disease
or diseases involving only a few lung areas are
encountered.
The subtitle of this book is “A pattern
approach”. Indeed an important objective of this
book is to help the reader to identify the disease
pattern, i.e. the appearance and distribution pat-
tern of the disease. Tools and illustrations pro-
vided not only help to recognise these patterns
but also help to understand why disease can
present with a particular pattern. The book is
organised according to the different appearance
patterns that can be encountered on a CT scan of
the lungs. After an introductory chapter on how
a CT of the lung should be approached, several
chapters describe the different patterns in detail:
(1) increased lung attenuation, (2) decreased lung
attenuation, (3) the nodular pattern and (4) the lin-
ear pattern. Because some lung diseases typically
combine two ore more patterns simultaneously,
also a chapter is added that deals with combined
or mixed patterns. Once the appearance pattern(s)
is/are determined, the distribution pattern(s)
should be identified. In each chapter, a great deal
of attention is therefore provided on how combin-
ing disease pattern and distribution pattern can
lead to a diagnosis or a narrow differential diag-
nosis list. Diagrams are provided for this purpose.
A good understanding of the disease and distri-
bution pattern is only possible when the anatomy
of the lung is well known. That is why a chapter
on basic anatomical considerations is included
and precedes the chapters dealing with the differ-
ent patterns. Finally, the CT features of the most
frequently occurring focal and especially diffuse
lung diseases will be shown, and their appearance
and distribution patterns will be listed.
Basic Objectives of the Book
• Learn to detect and understand the CT
changes in patients with lung disease
• Learn to recognise and to determine the
different appearance and distribution
patterns of lung disease
• Learn to use these patterns to make a
diagnosis or to narrow the differential
diagnosis list
 Basic Anatomy and CT
of the Normal Lung

Contents Abstract
1 Introduction 3 A good knowledge of the lung anatomy in
general and a good understanding of the anat-
2 Basic Anatomical Considerations 4
2.1 Anatomic Organisation of the Airways omy of the secondary pulmonary lobule in
and Airspaces 4 particular is mandatory to understand the CT
2.2 Anatomic Organisation of the features of the normal and the diseased lung.
Blood Vessels 5
In the first section of this chapter, the basics of
2.3 Anatomic Organisation of the Lymphatics 7
2.4 The Pulmonary Interstitium 8 lung anatomy will be discussed. In the second
2.5 The Subsegmental Structures of the Lung section, a description will be given on the rela-
and the Secondary Pulmonary Lobule 9 tionship between lung anatomy and distribu-
3 Relationship Between Anatomy tion of disease while in the third section the
and Distribution of Disease 12 CT features of the normal lung will be
4 CT Features of the Normal Lung 13 explained.
4.1 Large Arteries and Bronchi 13
4.2 Secondary Pulmonary Lobule 15
4.3 Lung Parenchyma 16
References 17 1 Introduction

Good knowledge of lung anatomy is mandatory

to understand the CT features of lung diseases,
not only because it permits a better understand-
ing of the CT features of the disease (appearance
pattern), but also because it helps to understand
the specific distribution in the lung of the dis-
ease (distribution pattern). Comprehensive
knowledge of the lobes and segments of the
lung has of course always been a very impor-
tant part of a radiologist’s armamentarium, but
it was the introduction of CT and especially
thin-slice CT that made the significance of the

© Springer-Verlag Berlin Heidelberg 2018 3

J.A. Verschakelen, W. De Wever, Computed Tomography of the Lung, Medical Radiology, Diagnostic Imaging,
https://doi.org/10.1007/978-3-642-39518-5_2
4 Basic Anatomy and CT of the Normal Lung
subsegmental lung anatomy apparent. Indeed,
the high anatomic detail obtained with thin-
slice CT allows the recognition of anatomical
structures at a subsegmental level and the iden-
tification of lung units as small as the secondary
pulmonary lobule. These secondary pulmonary
lobules have turned out to be very important in
the interpretation of lung changes seen on CT
and abnormalities of these units are more or less
the building blocks of which the CT patterns are
constructed. In addition, good knowledge of the
anatomy of the secondary pulmonary lobule is
also very useful to determine the distribution
pattern of the disease. Differential diagnosis of
lung disease can indeed be narrowed when one
is able to decide whether the disease very likely
is located in or around the airways, the blood
vessels, the lymphatics, the alveolar airspace or
the lung interstitium.
The first section of this chapter will discuss
the basics of lung anatomy. In the second section,
a short description will be given on the relation-
ship between lung anatomy and distribution of
disease, while the third section discusses the CT
features of the normal lung.
Segmental bronchus
Subsegmental bronchus
Bronchi
Secondary
Pulm Lobule
Large Airways
Fig. 1 Anatomic (2 mm) Bronchioles
organisation of the Small Airways
tracheobronchial tree
2 Basic Anatomical
Considerations
This section starts with a discussion on those
aspects of the anatomical organisation of the air-
ways and airspaces, the pulmonary blood vessels
and the lymphatics, that are important in using
and interpreting CT scans of the lungs.
Subsequently, the anatomy of the interstitium
will be discussed and finally attention will be
given to the subsegmental structures of the lung,
particularly the anatomy of the secondary pulmo-
nary lobule.
2.1 Anatomic Organisation
of the Airways and Airspaces
Airways divide by dichotomous branching with a
maximum of approximately 23 generations of
branches identifiable from the trachea to the alve-
oli (Fig. 1; Table 1). This dichotomy is asymmet-
ric, which implies that although division of the
bronchus into two branches is usual, variation in
both number and size of the branches is common
Bronchus
Lobular Bronchiole
Terminal bronchioles
Respiratory bronchiole
Alveolar Duct
Alveolar sac
Ac
nu
i
s + alveoli
2 Basic Anatomical Considerations
Table 1 In this table the different generations of airways
with their approximate diameter are listed
Structure Diameter (mm)
Trachea 25
Main bronchi 11–19
Lobar bronchi 4–13
Segmental bronchi 4–7
Subsegmental bronchi 3–6
Bronchi 1.5–3
Terminal bronchi 1 rise to the respiratory bronchioles, which are so
Bronchioles 0.8–1
Lobular bronchioles 0.8
Terminal bronchioles 0.6–0.7
Respiratory bronchioles 0.4–0.5
Alveolar ducts and sacs 0.4
Alveoli 0.2–0.3
(Horsfield and Cumming 1968). The initial belief
that the distance along the airways from the tra-
chea to terminal gas exchanging units is approxi-
mately the same for the entire lung is probably a
gross oversimplification (Weibel 2009). Indeed,
the number of generations is different throughout
the lung and varies between approximately 9–23
making the distance along the airways from the
trachea to the terminal gas exchanging units also
variable. The trachea divides into main bronchi
that divide into lobar bronchi. The lobar bronchi
divide into segmental bronchi that in turn divide
into subsegmental bronchi. These bronchi divide
into several generations of smaller bronchi and
finally the terminal bronchi are reached. These
terminal bronchi divide into bronchioles.
Bronchioles differ from the bronchi in that the
bronchi contain cartilage and glands in their walls,
whereas the bronchioles do not. The bronchioles
include two categories: the membranous bron-
chioles (lobular and terminal) and the respiratory
bronchioles. The term “small airways” is often
also used to describe the bronchioles and small
airway disease is then defined as the pathological
condition in which the bronchioles are affected.
At this point, it should be emphasised, however,
that an internal diameter of 2 mm is another often
used division between small and large airways.
Although both definitions do not correspond
because cartilage may be found in some peripheral
airways less than 1 mm in diameter, the latter defi-
5
nition is more practical and more frequently used
in radiological literature. The lobular bronchioles
enter the core of the secondary pulmonary lobule
and divide into a number of terminal bronchioles
according to the size of the lobule. These termi-
nal bronchioles represent the most distal purely
conducting portion of the tracheobronchial tree;
that is, they conduct air without being involved
in gas exchange. The terminal bronchioles give
designated because alveoli bud directly from their
walls. Hence, respiratory bronchioles not only are
conducting but are also involved in gas exchange.
The respiratory bronchioles give rise to alveolar
ducts. In contrast to the respiratory bronchioles
where alveoli only rise occasionally from the
wall, these alveolar ducts have so many alveoli
originating from their wall that there is virtually
no wall structure between the alveolar orifices.
The alveolar ducts finally lead into the alveolar
sacs containing several alveoli (Boyden 1971).
The lobular bronchioles enter the core of
the secondary pulmonary lobule and divide
into a number of terminal bronchioles
according to the size of the lobule.
Adjacent alveoli originating from different air
sacs are known to communicate directly with one
another through the pores of Kohn. Familiarity
with these tiny communications is necessary to
understand the pathology of diseases involving
the alveoli (Culiner and Reich 1961; Hogg et al.
1969; Liebow et al. 1950; Van Allen and Lindskog
1931). The canals of Lambert communicate dis-
tal bronchioles, particularly preterminal bronchi-
oles with alveoli (Lambert 1955).
2.2 Anatomic Organisation
of the Blood Vessels
The arteries of the human lung accompany the air-
ways and their pattern of division is similar to the
branching of the airways; hence for each airway
branch there is a corresponding artery (Elliott and
6 Basic Anatomy and CT of the Normal Lung
Fig. 2 Anatomic
organisation of the blood
vessels
Arteries
Secondary
Pulm Lobule
Reid 1965) (Fig. 2). However, there are many
artery branches that do not accompany any portion
of the airway and that are sometimes called super-
numerary arteries (Fraser and Pare 1977). This is
especially seen at the most distal part of the bron-
chovascular tree. The vessels accompanying the
bronchi are considered to be elastic arteries
because they have well-developed elastic laminae.
The vessels accompanying the bronchioles down
to the level of the terminal bronchioles are gener-
ally considered to be muscular arteries because
they contain fewer elastic laminae. The vessels
distal to the terminal bronchioles lose their con-
tinuous muscular coat and have a single elastic
lamina; they are called pulmonary arterioles. The
capillary network originates from the arterioles
and surrounds the alveoli. The high number of
individual very small vessels make this capillary
network look like a thin, continuous layer of blood
covering alveoli interrupted by columns of con-
nective tissue that act as supports (Weibel 1979).
The arteries of the human lung accompany
the airways and their pattern of division
is—except for the most distal part—simi-
lar to the branching of the airways.
Veins
Venules
Ac
nu
i
s Capillary
Arterioles network
Distal to the capillary network, the pulmo-
nary venules are formed, which merge into pul-
monary veins at the periphery of the secondary
pulmonary lobule. These pulmonary veins run
through the interlobular septa and then through
more central connective tissue sheaths to the left
atrium.
The pulmonary veins are formed by conflu-
ence of pulmonary venules at the periphery
of the secondary pulmonary lobule and run
through the interlobular septa and through
more central connective tissue sheets.
The bronchial arteries belong to a different
arterial system that originates from the systemic
circulation. Except for those distributed to the
pleura, these bronchial arteries accompany the
bronchi to the level of the terminal bronchiole. At
this point they ramify into a capillary plexus,
which is intimately integrated into the bronchiolar
wall. In the lung periphery, the bronchial arteries
also anastomose and are drained by the pulmo-
nary venous system (Lauweryns 1971; Miller
1947). The bronchial veins exist as a distinct set
of vessels only in the hilar region, where they
2 Basic Anatomical Considerations
drain blood from the hilar structures and walls of
the major bronchi into the azygos and hemiazygos
system. It is not clear whether there are also bron-
chial veins at the periphery of the lung that drain
blood from the bronchial capillary bed into pul-
monary veins. However, it is generally accepted
that the final drainage of the bronchial arterial
flow is by way of the pulmonary veins.
2.3 Anatomic Organisation
of the Lymphatics
The pulmonary lymphatics absorb the normal
transudate from the capillary bed and carry it
from the interstitial space to the central circula-
tion (Fig. 3). There are two intercommunicating
networks of lymph flow. First there is the rich
subpleural plexus, which is connected to and
drained by the septal lymphatic channels. These
channels follow interlobular septa and progress
into axial connective tissue sheaths around veins
as they progress centrally. Another system of
lymphatic channels is found in the axial connec-
tive tissue around arteries, bronchi and bronchi-
oles with the terminal bronchiole and its
accompanying arteriole as the most distal airway
Secondary
Pulm Lobule
Fig. 3 Anatomic
organisation of the
lymphatics
7
and blood vessel surrounded by lymphatics. No
lymphatics are found in alveolar walls. This is
curious considering that their job is to mobilise
fluid that is escaping from the capillaries. So this
fluid has to migrate towards the pulmonary lym-
phatics, which are located in the peribronchiolar
and the perivascular spaces, the interlobular septa
and the pleural network (Weibel and Bachofen
1979). Consequently, one part of the lymph fluid
is removed first centrifugally and then centripe-
tally while another part is removed directly
towards the hilum. It is not clear whether the cap-
illary pressure forces this fluid through the alveo-
lar walls to the lymphatics that act as efficient
sumps or whether the fluid is sucked into the
lymphatics by more negative interstitial pressure
(Weibel and Bachofen 1979). Probably both
mechanisms are operational.
There are two intercommunicating net-
works of lymph flow:
• The subpleural plexus connected to sep-
tal lymphatic channels
• The axial plexus around arteries, bron-
chi and bronchioles
Lymphatics
Ac
nu
i
s
8 Basic Anatomy and CT of the Normal Lung

the acini (Weibel 1979) inducing “fibrous” intra-

The terminal bronchiole and its accompa- lobular septa or whether the space in between
nying arteriole are the most distal airway the acini is only a “virtual” interstitial space
and blood vessel surrounded by lymphatics between two unit structures (Johkoh et al. 1999).
So the pleura is in anatomic continuity with the
different lung septa including the interlobular
2.4 The Pulmonary Interstitium septa and the septa between the acini. A more
detailed description of the secondary pulmonary
The pulmonary interstitium is the supporting lobule, the acinus and the interlobular septa, as
tissue of the lung and can be divided into three well as the border between acini will be given
component parts that communicate freely: (1) the in Sect. 2.5.
peripheral connective tissue; (2) the axial connec-
tive tissue, and (3) the parenchymatous connec-
(1)
tive tissue (Weibel and Gil 1977) (Figs. 4 and 5). (3)
(3) (3) (3)
2.4.1 Peripheral Connective Tissue
(3) (3)
The peripheral connective tissue includes the Acinus
subpleural space and the lung septa. The septa (3)
Pulmonary lobule (3)
are fibrous strands that penetrate deeply as
incomplete partitions from the subpleural space
into the lung not only between lung segments Acinus (3) (3)
and subsegments but also between secondary
pulmonary lobules and hence are responsible Acinus (2)
for the distal border of the secundary pulmo-
Fig. 5 The pulmonary interstitium can be divided into
nary lobules (Weibel 1979, 2009). It is not clear three component parts that communicate freely: (1) the
whether fibrous strands also penetrate from peripheral connective tissue; (2) the axial connective tis-
these interlobular septa into the lobule between sue; (3) the parenchymatous connective tissue

Peripheral Connective Tissue

Axial Connective Tissue

Secondary
Pulm Lobule

Parenchymatous
Connective Tissue
Fig. 4 The pulmonary
interstitium
2 Basic Anatomical Considerations
2.4.2 Axial Connective Tissue
The axial connective tissue is a system of fibres
that originates at the hilum, surrounds the bron-
chovascular structures and extends peripherally.
It terminates at the centre of the acini in the form
of a fibrous network that follows the wall of the
alveolar ducts and sacs (Weibel 1979). The alve-
oli are formed in the meshes of this fibrous
network.
2.4.3 Parenchymal Connective Tissue
At their peripheral limits, the alveoli and the cap-
illaries are in close contact in order to allow gas
diffusion. Nevertheless, elastic and collagen
fibres are present also and are part of the paren-
chymatous connective tissue. These fibres appear
at the side of the capillaries; in fact, the capillary
is wound around these fibres like a snake around
a pole. In this way, on one side of the capillary
the basement membrane of this capillary is fused
to the alveolar basement membrane to form a thin
sheet across which diffusion takes place, while
on the other side a septal fibre separates both
structures. These fibres extend from the axial to
the peripheral connective tissue and are short and
thin (Weibel 1979).
The pulmonary interstitium is the support-
ing tissue of the lung and can be divided
into three component parts that communi-
cate freely:
• the peripheral connective tissue
• the axial connective tissue
• the parenchymal connective tissue
2.5  he Subsegmental Structures
T for CT interpretation conceptually appropriate,
of the Lung and the
Secondary Pulmonary Lobule
Three units of lung structure have been described
at the subsegmental level of the lung: the primary
pulmonary lobule, the acinus and the secondary
pulmonary lobule (Gamsu et al. 1971; Lui et al.
1973; Miller 1947; Pump 1964, 1969; Recavarren
9
et al. 1967; Sargent and Sherwin 1971; Weibel
and Taylor 1988; Ziskind et al. 1963).The pri-
mary pulmonary lobule cannot be demonstrated
by CT in normal states, but its borders may some-
times be suggested. Also the acinus can some-
times be identified with CT in diseased lung. But
especially the secondary pulmonary lobule or
parts of it are very often seen with this technique,
even when the lung is only mildly diseased or
normal. That is why the secondary pulmonary
lobule is the ideal unit of subsegmental lung
organisation with which the CT and pathologic
abnormality can be correlated and why a basic
understanding of its anatomy is mandatory to
understand the CT patterns seen in various dis-
ease states.
The secondary pulmonary lobule is the
ideal unit of subsegmental lung organisa-
tion with which the CT and pathologic
abnormality can be correlated.
2.5.1 Primary Pulmonary Lobule
Miller originally described the primary pulmo-
nary lobule and defined it as the lung unit distal to
the respiratory bronchioles (Miller 1947). The
primary pulmonary lobule consists of alveolar
ducts, alveolar sacs and alveoli. According to
Wyatt et al., approximately 30–50 primary pul-
monary lobules can be found in one secondary
pulmonary lobule (Wyatt et al. 1964).
2.5.2 Acinus
Although several different definitions of the aci-
nus can be found, a commonly accepted, and also
definition describes the acinus as the portion of
lung distal to a terminal bronchiole and supplied
by a first-order respiratory bronchiole or bronchi-
oles (Gamsu et al. 1971; Recavarren et al. 1967;
Reid and Simon 1958). Because respiratory bron-
chioli contain alveoli in their wall, the acinus is
the largest unit in which all airways participate in
gas exchange. The reported number of acini in
10
a b
Fig. 6 a–c. (a) Sagittal section through the lung. Several
interlobular septa can be recognised both in the lung
parenchyma and at the lung surface (arrows) demarcating
secondary pulmonary lobules. (b) The secondary pulmo-
nary lobule has three principal components: (1) the inter-
lobular septa, (2) the centrilobular region and (3) the
lobular lung parenchyma. (c) The interlobular septa con-
tain pulmonary veins (blue) and lymphatics (green) sur-
rounded by connective tissue (white). The centrilobular
region contains bronchiolar branches (yellow) with their
one secondary pulmonary lobule varies consider-
ably in different studies and numbers are found
between 3 and 12. The diameter of an acinus has
been reported to be between 5 and 10 mm (Pump
1969; Sargent and Sherwin 1971) (Figs. 6 and 7).
2.5.3 Secondary Pulmonary Lobule
The secondary pulmonary lobule is defined as the
smallest unit of lung structure marginated by
connective tissue septa (Heitzman 1984) (Fig. 6).
It is supplied by a group of terminal bronchioles,
is irregularly polyhedral in shape and is approxi-
mately 1–2.5 cm on each side (Reid and Simon
1958). Although the overall configuration of the
secondary pulmonary lobule and its relationship
to other lobules appears to be almost entirely ran-
dom, the organisation of the individual anatomic
Basic Anatomy and CT of the Normal Lung
1
3
3
1
3
2
1
3
1
accompanying arteries (red) with adjacent to them some
supporting connective tissue (not indicated) and some
lymph vessels (green). The lobular parenchyma consists
of functioning lung supported by connective tissue septa
(white) and stroma. Figure 6a appears courtesy of
B. Vrugt (Institute for Pathology, University Hospital
Zürich, Switzerland). Part of Fig. 6b and c appear cour-
tesy of E. Verbeken (Dept. of Pathology, University
Hospitals Leuven, Belgium)
components of the lobule is quite precise and is
similar from lobule to lobule.
The secondary pulmonary lobules are demar-
cated from each other by interlobular connective
tissue septa: the interlobular septa. As mentioned
earlier, it is not clear whether fibrous strands also
penetrate from these interlobular septa into the
lobule between the acini (Weibel 1979) inducing
“fibrous” intralobular septa or whether the space
in between the acini is only a “virtual” interstitial
space between two unit structures (Johkoh et al.
1999). The interlobular septa are clearly continu-
ous peripherally with the pleura (Fig. 6a). They
are, however, not homogeneously developed in
the lung. The septa in the upper lobes tend to be
longer and more randomly arranged, whereas in
the lower lung fields they appear to be shorter
2 Basic Anatomical Considerations
a b
Fig. 7 (a) Detail of a secondary pulmonary lobule show-
ing one acinus. TB terminal bronchiole, RB respiratory
bronchiole, AD alveolar ducts, AS/ALV alveolar sacs/
alveoli. (b) MicoCT of a part of the secondary pulmonary
and more horizontally oriented perpendicular to
the pleural surfaces.
These connective tissue septa are also better
developed at the lung periphery than in the cen-
tral portions of the lung. But even at the lung
periphery, the interlobular septa do not always
constitute a totally intact connective tissue enve-
lope surrounding the secondary pulmonary lob-
ule. There are indeed occasional defects in the
septa allowing communication between lobules
(Heitzman 1984). These defects have radiologi-
cal significance for the concept of collateral air-
flow on a segmental level. Indeed collateral
airflow can maintain lung segments in an inflated
state despite obstruction of their bronchi. It is
believed that the pores of Kohn and the canals of
Lambert are responsible for this phenomenon. If
there were no defect in the interlobular septa col-
lateral airflow would only be possible within the
secondary pulmonary lobule.
As mentioned earlier, the airway component of
the lobule is supplied by a group of terminal bron-
chioles. However, it is difficult to define which
bronchial structures precisely supply the lobules
(Itoh et al. 1993). Branching of the lobular bron-
chiole is irregular dichotomous, which means that
11
lobule. TB terminal bronchiole, RB respiratory bronchi-
ole, AD alveolar duct, IV interlobular septal vein; arrows
interlobular septa
when it divides, it most often divides into two
branches of different sizes, with one branch nearly
the same as the one it arose from and the other
smaller (Itoh et al. 1993). This lobular bronchiole
is distributed with the accompanying artery, which
has the same irregular dichotomous branching into
the central portion of the lobule. Thus on CT, there
often appears to be a single dominant bronchiole
and artery in the centre of the lobule, which gives
off smaller branches at intervals along its length.
These bronchioles progress through the lobule,
dividing progressively from terminal to respira-
tory bronchioles, alveolar ducts, alveolar sacs and
alveoli. Although the arteries accompany the bron-
chioles until the centre of the lobule, their branch-
ing pattern throughout the lobule is somewhat
different from the bronchiolar branching pattern.
However, finally these vessels terminate in the
capillary bed, which is distributed throughout the
alveolar wall. Blood then flows from the capillary
bed into venules, which drain to the periphery of
the lobule where they join to form the pulmonary
vein. These pulmonary veins course centrally
through the interlobular septa.
So branching continues until ultimately the
entire lobulus is supplied. Most of the lobular
12
volume is thus airway and airspace. When a sec-
ondary pulmonary lobule is cut across, macro-
scopically numerous small holes are seen at the
cut surface (Fig. 6). These holes represent respi-
ratory bronchioles as well as some portions of
the airway distal to this respiratory bronchiole.
Alveolar ducts, alveolar sacs and alveoli are too
small to be identified macroscopically but fill up
the areas between the holes and are together with
the small holes responsible for the porous
sponge-­like character of the cut surface. At the
core of the lobule, a larger airway can be seen
corresponding with a terminal bronchiole, either
presenting as a larger hole or as a branching
tubular structure.
The lymphatics are on one hand found adja-
cent to the pulmonary artery and airway branches
and stop more or less at the level of the respira-
tory bronchioles and on the other hand in the
interlobular septa. No pulmonary lymphatics are
found in the alveolar walls.
The secondary pulmonary lobule has three
principal components (Fig 6 b, c):
• The interlobular septa that marginate
the lobule and that contain the pulmo-
nary veins and lymphatics surrounded
by connective tissue.
• The centrilobular region containing the
bronchiolar branches that supply the
lobule, their accompanying pulmonary
arteries and adjacent to them support-
ing connective tissue and lymph vessels.
• The lobular lung parenchyma is the part
of the secondary lobule surrounding the
lobular core and contained within the
interlobular septa. It consists of func-
tioning lung grouped in 3–12 acini that
contain alveoli (organised in alveolar
ducts and sacs) and their associated
pulmonary capillary bed together with
their supplying small respiratory air-
ways and arterioles and with draining
veins. This parenchyma is supported by
connective tissue stroma.
Basic Anatomy and CT of the Normal Lung
3 Relationship Between
Anatomy and Distribution
of Disease
A good understanding of the lung anatomy in
general and of the anatomy of the secondary pul-
monary lobule in particular is extremely useful in
understanding the pathology and pathogenesis of
most pulmonary disease states.
Inhaled disease particles can, depending on
their size, deposit everywhere in the tracheobron-
chial tree. However, often there is a preferential
deposition along the respiratory bronchioles.
This is explained by the fact that the cross-­
sectional area of the total of the airways of the
lung increases sharply at the level of the respira-
tory bronchiole. This large number of branches
causes laminar air-flow to slow down markedly.
The respiratory bronchioles are branches from
the terminal bronchioles. Recognition that these
terminal bronchioles are distributed to the central
core portion of the secondary pulmonary lobule
helps to understand why processes that involve
the terminal airways, such as pneumonias, rap-
idly spread out from the centre to the periphery of
the lobule when they involve the more distal air-
spaces leaving, certainly in a first stage, the septal
structures unaffected.
On the other hand, because of the sequential
organisation of the alveoli, the most centrally
located alveoli in the wall of the respiratory bron-
chioles and in the alveolar ducts will be venti-
lated first and see fresh air first while the more
peripheral alveoli will see air that has already lost
some O2 (Weibel 2009). So destruction and dys-
function of the proximal more centrilobular
located airways may have a larger repercussion
on gas-exchange than when the more peripheral
areas of the secondary pulmonary lobule are
involved. This sequentional organisation of the
alveoli may also be responsible for the unequal
distribution of intra-alveolar fluid. Fresh air
arriving in the respiratory bronchioles and the
alveolar ducts may push the fluid towards the
peripheral part of the acini.
Intra-alveolar processes can spread not only
through the more proximal airway, but also from
alveolus to alveolus through the pores of Kohn.
4 CT Features of the Normal Lung
These structures are also believed to be respon-
sible for the collateral air drift. This collateral air
drift is thought to prevent or to minimise atelec-
tasis secondary to obstruction of terminal por-
tions of the airway by providing an alternate
route for air to reach the lung distal to the obstruc-
tion. The air that reaches the alveoli by collateral
air drift, however, shows relatively little move-
ment during respiration and the oxygen in this
stagnant air becomes absorbed, leading to low
oxygen concentrations in alveoli and secondary
to hypoxic vasoconstriction. It should be empha-
sised that collateral air drift not only occurs
between adjacent alveoli within one secondary
pulmonary l­obule but occurs also between lob-
ules, segments and even lobes. This can be
explained by the well-known incompleteness of
fissures and by the presence of defects in the
interlobular septa. The canals of Lambert offer
another pathway by which diseases can be dis-
tributed and by which collateral airflow can
occur.
The unequal size of the airspaces may be
responsible for another phenomena that can
explain the distribution pattern of some diseases.
Small alveoli are located in the walls of the larger
alveolar ducts and alveolar sacs. Alteration in
pulmonary surfactant can cause increase in sur-
face tension in the alveoli which may, due to
Laplace law, be responsible for collapse of small
alveoli onto the larger alveolar ducts and sacs.
Since small alveoli are predominantly located in
the peripheral parts of the acini, this collapse will
predominantly take place at the borders of the
acini (Galvin et al. 2010).
Also the arterial supply is distributed to the
central core portion of the secondary pulmonary
lobule, which explains why some pathologic pro-
cesses involving the pulmonary arterial and cap-
illary bed such as pulmonary infarction and
pulmonary haemorrhage initially can present
findings of alveolar disease that again involve the
secondary pulmonary lobule from its core to its
peripheral parts leaving the septal structures
unaffected.
On the other hand, diseases that cause intersti-
tial abnormalities and fibrosis will produce thick-
ening of the septa, the alveolar wall and the
13
perivascular and peribronchial connective tis-
sues. Similarly, diseases of the pulmonary lym-
phatics that run in the interlobular septa and
along the vessels and airways will cause thicken-
ing of these structures. Since pulmonary veins
run in the interlobular septa, it is to be anticipated
that disease processes involving the pulmonary
veins also initially will appear as interstitial
abnormalities.
As we will see further on in this book, the CT
interpretation of lung disease is in part based on
the recognition of the location of the diseases in
relation to these different components of the sec-
ondary pulmonary lobule structures.
4  T Features of the Normal
C
Lung
4.1 Large Arteries and Bronchi
The large pulmonary arteries normally appear
as rounded or elliptic opacities on CT when
imaged at an angle to their longitudinal axis and
roughly cylindrical when imaged along their
axis (Fig. 8). These arteries are accompanied by
thin-walled bronchi of which the appearance is
also defined by the angle between the scan plane
and the axis of the bronchi. When imaged along
their axis, bronchi and vessels can show a slight
tapering as they branch. The diameter of the
artery and its neighbouring bronchus should be
approximately equal. However, in the depen-
dent areas vessels are usually slightly larger
(Fig. 8a). It should be emphasised that in normal
subjects, bronchi may appear larger than their
adjacent arteries (Lynch et al. 1993). This is cer-
tainly true when the scan traverses the bronchus
just before it branches (Fig. 8b). The outer walls
of both the vessels and the bronchi should be
smooth and sharply defined. Also the inner wall
of the bronchi should appear smooth and of uni-
form thickness. Whether a normal airway is vis-
ible or not on a CT scan depends on its size and
on the CT technique that is used. As a general
rule, airways less than 2 mm in diameter or
closer than 1–2 cm to the pleural surface are
below the resolution of even HRCT images
14
a b
Fig. 8 HRCT of the normal lung at suspended deep inspi-
ration. Notice that the vessels are slighter larger in the
dependent areas than in the non-dependent areas (a).
(Kim et al. 1997; Murata et al. 1986, 1988;
Webb et al. 1988) (Table 1). The presence of
visible bronchial structures in the lung periph-
ery (within 2–3 cm of the chest wall) signifies
pathologic bronchial wall thickening or ectasia
of the small airways.
Assessment of the bronchial wall thickness
is often considered a difficult task because it is
subjective and depends on the window settings.
In addition, what is seen as bronchial wall also
includes the peribronchovascular interstitium;
consequently, thickness is always a little over-
estimated. In general and for bronchi distal to
the segmental level, the wall thickness of the
airways is approximately proportional to their
diameter measuring from one-sixth to one-tenth
of their diameter (Matsuoka et al. 2005; Weibel
and Taylor 1988). The ability to visualise air-
ways also reflects the choice of appropriate
window settings. These window settings have a
marked effect on the apparent size of structures
Basic Anatomy and CT of the Normal Lung
Some bronchi appear larger than their adjacent arteries
because the scan traverses the bronchus just before it
branches (arrow in b)
and inappropriate window settings can alter
the thickness of the bronchial wall (Webb et al.
1984). No absolute window settings can be rec-
ommended because of variation between CT
machines and individual preferences; however,
for diagnostic purposes consistent window
settings from patient to patient are advisable
and a window centre between –300 and –950
Hounsfield Units (HU) with corresponding
window widths between 1000 and 1500 HU
has been recommended (Bankier et al. 1996;
Grenier et al. 1993; Kang et al. 1995; Seneterre
et al. 1994).
Although expiration has an important effect
on the diameter of the trachea—the anteroposte-
rior diameter can decrease up to 32% between
deep inspiration and deep expiration due to the
invagination of the posterior tracheal mem-
brane—the diameter of the main and lobar bron-
chi appears only slightly reduced on full
expiration CT scans (Stern et al. 1993).
4 CT Features of the Normal Lung
The presence of visible bronchial struc-
tures in the lung periphery (within 2–3 cm
of the chest wall) signifies pathologic bron-
chial wall thickening or ectasia of the small
airways.
4.2 Secondary Pulmonary Lobule
Although the identification of secondary pulmo-
nary lobules in normal patients may be difficult
with CT, some features that help to identify this
anatomical structure are often present (Webb
2006). A few septa can be visible in the lung
periphery in normal subjects, mostly anteriorly
and along the mediastinal pleural surfaces (Aberle
et al. 1988; Zerhouni 1989). The location of the
a b
Fig. 9 (a) CT of the normal lung (coronal reconstruc-
tion). Interlobular septa can often be inferred by locating
septal pulmonary vein branches (arrows) presenting as
linear, arcuate or branching structures approximately
5–10 mm from the centrilobar arteriole (white arrow-
15
interlobular septa can also often be inferred by
locating septal pulmonary vein branches. They
present as linear, arcuate or branching structures
about 5–10 mm from the centrilobular arteriole.
This centrilobular arteriole presents as a dot-like,
linear or branching opacity within the centre of the
lobule or for lobules abutting the pleura at about
1 cm from the pleural surface. Some smaller intra-
lobular vascular branches may be visible between
the septa and the centrilobular arteriole, again pre-
senting as small dots or branching lines, but this
time about 3–5 mm from the septa (Fig. 9a).
When disease affects the secondary pulmonary
lobule one or more of its components can become
better visible. Recognising these abnormal com-
ponents will be helpful to determine the distribu-
tion pattern of the disease and is an important step
in the diagnosis of the disease (Fig. 9b).
heads) (b) CT of the lung (coronal reconstruction) of a
patient with lymphangitic spread of cancer and thickening
of the interlobular septa in the right lower lobe. Because
of this thickening the secondary pulmonary lobules can be
better recognised
16 Basic Anatomy and CT of the Normal Lung

4.3 Lung Parenchyma Normal lung on CT

The density of the lung parenchyma should be CT

of greater opacity than air. This density is deter- presentation
mined by three components: lung tissue, blood Lung tissue and (capillary)
in small vessels beyond the resolution of CT and blood
air (Fig. 10). These components are not homo-
Large blood vessel
geneously distributed over the lung and the Large airway
relative proportion is continuously changing in
Air
function of normal physiological events. Lung
density decreases when lung volume is increased
(Robinson and Kreel 1979). Although seen in all Fig. 10 The density of the lung as seen on a CT scan is
lung zones, this decrease is not uniform. Due to determined by three components: lung tissue, blood in the
gravitational effects, lung density is higher in the small vessels beyond the resolution of CT and air. The
dependent areas compared to the nondependent relative proportion of these components is continuously
changing as a function of normal physiological events
areas (Fig. 11). This density difference is similar

a b

c d

Fig. 11 (a–f) HRCT of the normal lung at upper and dient between the dependent and the nondependent lung,
middle levels in supine and at lower level in prone body which is larger on expiratory scans than on inspiratory
position (a, b, c, suspended deep inspiration; d, e, f same scans
levels, suspended deep expiration). Notice the density gra-
References 17

e f

Fig. 11 (continued)

in both lungs and throughout the lungs. However,

this density gradient is strongly affected by lung
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regions becomes very small near total lung capac-
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the dependent areas compared to the nondepen-
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rounding normal areas and appears relatively involved (arrows)
lucent. This relative lucency is most typically seen
in the superior segments of the lower lobes, poste-
rior to the major fissures, and in the anterior part of
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 How to Approach CT of the Lung?

Contents Abstract
1 Introduction 21 This chapter introduces the three pillars on
which the diagnosis of lung disease on a chest
2 Analysis of Patient Data 23
CT is based: the recognition of the appearance
3 Appearance Pattern of Disease 23 pattern, the study of the location and distribu-
3.1 Increased Lung Attenuation 23
tion pattern of the abnormalities in the lung
3.2 Decreased Lung Attenuation 25
3.3 Nodular Pattern 28 (distribution pattern) and the careful analysis
3.4 Linear Pattern 28 of the patient data.
3.5 Combination of Patterns 29
4 Localisation and Distribution of Disease:
Distribution Pattern 31
References 32 1 Introduction

The diagnosis of diffuse and interstitial lung dis-

ease often requires a multidisciplinary approach
correlating the findings of the clinician, the radi-
ologist and, when a lung biopsy has been per-
formed, the pathologist (Wells 2003; Flaherty
et al. 2004). This is especially true for the group
of idiopathic interstitial lung diseases. The find-
ings of the radiologist and the pathologist can be
considered as “complimentary”. While CT offers
a submacroscopic view of the entire lung, will
pathology provide a microscopic view of a small
part of the lung. It is obvious that the CT exami-
nation usually will precede the pathological
examination, but ideally the discussion whether
or not a biopsy is necessary should also be hold
before this biopsy is taken. In fact, at that point,
the multidisciplinary discussion should define the
settings where biopsy is more informative than
CT and those where biopsy is not needed. During

© Springer-Verlag Berlin Heidelberg 2018 21

J.A. Verschakelen, W. De Wever, Computed Tomography of the Lung, Medical Radiology, Diagnostic Imaging,
https://doi.org/10.1007/978-3-642-39518-5_3
22
Fig. 1 Three basic elements on which diagnosis of lung disease with CT is based
this discussion the radiologist should give the
most likely radiological diagnosis or differential
diagnosis which is based on the CT presentation
and on the clinical data available at that moment.
Generally the diagnosis of lung disease on a
chest CT is based on three elements (Fig. 1):
• Recognition of the appearance pattern of dis-
ease, i.e. classifying the abnormalities in a cat-
egory that is based on their appearance
• Determination of location and distribution of
the abnormalities in the lung: the distribution
pattern
• Careful analysis of the patient data that are
available at the time the CT scan is performed
In a first step, the reader should try to recog-
nise the appearance pattern of the lung changes
because recognising this pattern makes it pos-
sible to develop a first and appropriate dif-
ferential diagnosis list, including the major
categories of disease that might lead to this
identified pattern.
In a second step, this list should be refined by
trying to determine the exact location of these
abnormalities. The location of abnormalities
should be as precise as possible and is performed
by deciding whether these abnormalities are focal
or diffuse, predominantly peripheral or central or
in the upper, middle or lower parts of the lung,
whether the airspaces or the interstitium are
affected and if disease seems to be distributed
along the blood vessels, the bronchi or the lym-
phatics. Combining the appearance pattern and
the distribution pattern of the abnormalities can
How to Approach CT of the Lung?
give detailed macroscopic and submacroscopic
insight into how the lung is affected by the dis-
ease and usually further reduces the differential
diagnosis list and sometimes even allows making
a specific diagnosis.
In a third step, a careful analysis of the patient
data that are available is necessary and includes
first the study of additional radiological informa-
tion that is available on this and on previous radio-
logical exams. Examining the present CT scan for
other than lung changes can indeed be very help-
ful to further narrow the differential diagnosis. For
example, the simultaneous detection of osteolytic
lesions in the ribs and nodules in the lung could
suggest metastatic disease. In addition, the exami-
nation of serial CT examinations, when available,
is very helpful when, for example, examining
lesion growth. It can, however, also be interest-
ing to wait for follow-up images before decid-
ing on the diagnosis. In an intensive care patient,
when airspace opacities disappear rapidly after
the administration of diuretics, a different diagno-
sis is suggested than when these opacities would
remain unchanged or increase in size. Careful
analysis of the patient data that are available also
includes the correlation with clinical, and patho-
logical and laboratory data. The knowledge that a
patient is immunocompromised will often change
the differential diagnosis list.
Although a stepwise analysis of these three
elements can result in a diagnosis or a narrow
differential diagnosis list, it is often not possible
to make a definitive diagnosis because one or
more of the elements discussed are unclear or
missing: patterns can overlap and can change
3 Appearance Pattern of Disease
over time, disease can show an aberrant locali-
sation and distribution, additional findings can
be misleading, previous examinations can be
missing or clinical history may be nonspecific.
Nevertheless, even if a diagnosis cannot be
made, it should be possible to suggest additional
(imaging or other) procedures that may lead to
the precise diagnosis.
Finally, it should be emphasised that checking
the quality of the examination is very important.
Incorrect positioning of the patient, insufficient
image collimation, the presence of life-­supporting
devices and especially incorrect exposure param-
eters are often responsible for a reduction in
image quality and for a possible misinterpreta-
tion of the CT findings.
2 Analysis of Patient Data
More than in any other part of the chest, the
abnormalities seen in the lung on a CT should be
carefully correlated with observations made on
other radiological examinations and with all the
relevant clinical data (presentation, exposure,
smoking status, associated diseases, lung
­function, laboratory findings) that are available at
the time of the CT examination. Particularly the
group of the idiopathic diffuse and interstitial
lung diseases is often very difficult to diagnose
when the interpretation is only based on the CT
presentation. Cooperation needs to be established
between the clinician who is responsible for the
patient, the radiologist and, when pathological
information is present or probably required, the
pathologist (Wells 2003; Flaherty et al. 2004).
Indeed, the historical gold standard of histologic
diagnosis has been replaced by an approach that
is based on a multidisciplinary discussion. An
important topic in this discussion is to define
when a biopsy is more informative than a CT or
when a biopsy is not needed to make the diagno-
sis (Quadrelli et al. 2010). So, as mentioned ear-
lier, the radiologist and the pathologist play a
complementary role. That is why it is mandatory
for the radiologist to understand why abnormali-
ties appear as they do and where they likely are
located both at a macroscopic and at a submacro-
23
scopic level. Only then is a fruitful discussion
possible and are radiology and pathology
complimentary.
3 Appearance Pattern
of Disease
Generally, CT findings can be classified into four
large categories based on their appearance:
• Abnormalities associated with an increase in
lung density, i.e. increased lung attenuation
• Abnormalities associated with a decrease in
lung density, i.e. decreased lung attenuation
• Abnormalities presenting as nodular opacities
• Abnormalities presenting as linear opacities
3.1 Increased Lung Attenuation
Generally, the increased lung attenuation pattern
is caused by an increase in density of the lung
parenchyma. As mentioned in chapter “Basic
Anatomy and CT of the Normal Lung”, the nor-
mal lung density on CT is slightly higher than air
and is determined by three components: lung tis-
sue, blood in small vessels beyond the resolution
of CT and air. Lung opacity will increase:
• When the amount of lung tissue increases or
when this tissue becomes denser or larger in
size
• When the amount of blood in the small vessels
increases, which is usually associated with an
expansion of these vessels
• When the relative amount of air decreases,
which can be the result of lung volume loss or
of replacement of air in the airspaces by fluid
and/or cells
The increase in lung attenuation is often the
result of two or more of these processes. Knowing
these different mechanisms that cause increased
lung attenuation, one can expect that the lung
architecture as observed within the resolution of
CT remains more or less intact. Indeed, although
the disease can of course also affect the large and
Another random document with
no related content on Scribd:
Perhaps, of all the occupants of the whaleboat, the calamity to their
leader hit the cowpuncher the hardest. The strongest natures feel
the most, especially for others, and no one could say that there was
any strain of weakness in Bucking Broncho.
Jack's bandages were constantly renewed, and fresh soaked in salt
water. He proved a good and tractable patient, and no one heard any
complaint leave his lips.
Only an occasional fleeting look of agony in his sightless eyes
showed the chafing of the restless spirit within.
Soon after midday, Jim, who was standing up in the bows taking a
glance round the horizon, suddenly gave a shout of surprise.
"Land ho!" he cried.
Right ahead, where the horizon grew indefinite and seemed to melt
away into the midst of the tropical heat, there lay an island, clear cut
and distinct. The black reef, the low beach, the very palms showed
up in dark clusters of straight stems and bushy foliage.
"Hurrah! An island right ahead!" he went on.
Tari and Broncho scrambled up and clambered forward.
After a long look, Tari said quietly,
"Dat am ghost-island!"
"Ghost-island? Precious little ghost about that," asserted Jim
confidently.
"It's an atoll, I expect," called Jack from under the awning. "Surely
we can't have drifted as far north yet as the Paumotus! By my
reckoning the nearest island is over a hundred miles off."
"It's a coral island—I can see the cocoanut trees," the boy sang out
excitedly.
"I'm afraid Tari's right, son," said Broncho, after a long scrutiny. "It's a
mirage!"
"A mirage?" exclaimed Jim incredulously, in tones of deep
disappointment.
It was a wonderful sight. There lay the island, plain to see, and no
one but a trained observer could have detected that it was a sham.
But Tari and Broncho were right. Many a mile had the cowpuncher
ridden in chase of just such a lifelike image on the prairie without
getting any nearer.
"These here mirages is just a deadfall, an' many a poor cowman has
panned out through trailin' after them," observed Broncho.
"Well, the island that mirage reflects is somewhere down under the
horizon," said Jack. "Just take its bearings, one of you, and we'll
shape our course for it directly the wind condescends to blow."
"It's north-a-half-west," said Jim, after a look at the compass.
All that long afternoon, whilst they drifted helplessly, the fairy island
hung over the horizon in the north.
Soon after darkness had fallen Jack startled the whole boat's crew
by saying very quietly,
"Boys, it's my watch on deck now. I've got my sight back."
There was a wild, hoarse cheer, a buzz of congratulations, and night
set in.
 CHAPTER VI
"THE ATOLL"
During the night the south-east trades came upon them in a
squall, and the whaleboat was soon bowling along merrily.
In a short while they found themselves in the midst of a choppy,
foam-flecked sea, making good headway before the gradually
strengthening breeze.
As daylight crept over the east, Jack, with a horrible sinking feeling
of dismay, felt his returned eyesight gradually fail again.
As the deep indigo of the night gave way before the rosy beams of
the morning sun and the moon lost its glitter, Jack saw a mist of grey
slowly spreading before him; then, as the light of day increased, the
grey merged into a black, which grew darker and darker, until the
rover felt as if he was being pressed down by an awful pall of ink,
pierced by tiny shafts, glinting flickers, and hovering waves of
flashing, scintillating light, which splashed through the black curtain
for all the world like the Northern Lights.
Great was the distress of his companions on hearing of this return of
the evil.
Jack took his misfortune very quietly, and stretched himself in the
bottom of the boat with a great show of fortitude and resignation.
"Keep a look-out for the island," he murmured, and then lay silent
with closed eyelids, which he found afforded him some relief from
the shafts of light which leaked in through the black shroud of his
blindness and burnt his aching eyeballs.
A heavy feeling of depression weighed down upon the boat's crew,
and Broncho's many attempts to break it only served to increase it.
Jim felt cowed and frightened; Tari, always of a singularly silent
disposition, remained mute in the bows, and whilst Jack tried hard to
respond to Broncho's sallies, his tortured brain refused to follow the
thread of the discourse, and he found himself answering at random
and listening without hearing.
About noon, Jim, who was on look-out duty forward, sang out
excitedly that he saw something ahead, sticking out of the sea.
"Looks like a ship's mast," he cried, "but there don't seem no yards
or sails on it, 'cept what looks like a flag flying at the truck."
Eagerly they all, except Jack, strained their eyes on the distant
object.
"Appears to me like one o' them Sitka Indian totem-poles," called
Broncho to the rover. "It's a cert it ain't got no fixin's."
"No hull in sight yet?" asked Jack, with the low, subdued voice which
had come upon him with his blindness.
"Nary a thing. It shore looks some queer an' lonely out thar, a-stickin'
out o' the scenery like a burnt pine."
Suddenly Jim began shouting with all the strength of his lungs.
"Land ho! Land! Land! Land! Hurray! The island at last!"
Sure enough the boy was right. Away a point to starboard of the
mysterious mast a long clump of palms was appearing in view.
"Him Low Island" asserted Tari, after a short look.
"An atoll, certainly," said Jack from aft; "but we're rather far south for
the Low Archipelago. It must be one of the Gambier group."
"Why, it's quite close," cried Jim. "I can see the surf now all along,
and the mast is sticking right out of the middle of it."
"Inhabited, then!" exclaimed Jack uneasily. "Get those Winchesters
loaded, Broncho. One can't trust Paumotu Islanders; they're a
treacherous lot, and have cut off many a ship before now."
Swiftly the rushing whaleboat approached before the strong trades.
Here and there to right and left the white water, flashing in the
sunshine, swirled and thundered on half-covered reefs, round which
countless numbers of shrieking, swooping seabirds hovered and
darted as they fished.
Round these reefs the deep blue of the Pacific changed to a
translucent emerald green, such as is given to the submerged part of
an iceberg when the bright sun is upon it.
The island was evidently but the smallest of coral reefs, studded with
a thin growth of cocoanut palms, which seemed thickest at the point
where Jim had first sighted them.
Like all atolls, its highest point was but a few feet above the sea-
level, and it hung, but a floating speck of shining white sand and
green foliage, in the midst of the immense space of blue sea and
sky.
But for the screaming birds, no sign of life showed, no habitations,
no smoke, nothing but the green brush, the gleaming sand, and
shining, flashing surf.
And yet, set in the very midst, rose a gigantic palm, bare as a ship's
spare topgallant mast, entirely denuded of its cluster of yellow fruit
and waving, fernlike branches.
From its top fluttered a small, small flag, undistinguishable at the
distance, but without possible doubt a signal of some importance,
put there by human hands.
As the whaleboat drew nearer the hoarse grumble of the surf could
be heard as it cast itself in long rollers upon the narrow, fragile strip
of beach, with the whole weight of the Pacific behind it.
And now, as every feature of this fairy isle unrolled itself before their
anxious eyes, keenly they surveyed it all, watching grimly for the
dreaded human.
"Nary a sign o' man thar," muttered Broncho. "It shore looks
lonesome a whole lot."
"The inhabitants of atolls always live on the lagoon," explained Jack.
"They shun the sea strand and consider it the abode of evil spirits
and devils."
"Can we land through that surf?" asked Jim uneasily, as he scanned
the boiling white water ahead.
"Want a Pitcairn Islander to take us in if it looks as bad as it sounds,"
declared the rover.
"Me boat-steerer, go in allee-lightee," said Tari quietly.
"We'd better skirt round the island first, and see if we can't find an
opening into the lagoon," advised Jack.
The boat's head was turned, and skimming along just outside the
breakers, they commenced to circle the island.
All of a sudden as they came opposite the big palm, a man appeared
through the brush and walked slowly on to the beach.
He stopped at the water's edge, and stood there watching them, his
form standing clear-cut and lonely against the dazzling whiteness of
the sand.
Jim drew his breath with a long hiss of apprehension, and Broncho
fumbled his Winchester uncertainly as he gazed at the apparition.
Tari, at the steering-oar, gave a queer grunt of alarm, and with a
rapid gesture, murmured in dialect to the rolling-stone, who, helpless
in his blindness, lay silent and worried.
"Carryin' a war club!" exclaimed the cowpuncher significantly, in a
low voice.
It was a moment of great suspense. Who knew what lurking savages
lay hid behind the ambush of that brushwood, ready as the boat's
keel grated on the shore to shower a flight of poisoned arrows upon
the strangers?
What would be the next move of the decoy in the foreground? Was
he about to entice them ashore with friendly gestures? What blood-
thirsty design had he planned for their entrapping? They could not
tell. They could only trust to Providence and await the issue.
Suddenly the solitary figure moved, flourished an arm, and hailed
them.
"Boat ahoy!" came thundering down the wind.
The effect of the two English words was electrical.
Jim sprang wildly on to the thwart and cheered. The cowpuncher laid
down his Winchester, and bent his eagle eye upon the man with
renewed keenness.
"He's white, shore enough!" he exclaimed, and burst into a strange
laugh of relief.
The Kanaka gave a short, expressionless grunt, whilst Jack
clambered to his feet, and with one hand round the mast to balance
himself, shouted out the question:
"Can we get into the lagoon?"
"No; better land here. Look out for the surf, though. Where you
from?"
"Shipwrecked!" replied Jack.
Acting on the stranger's advice, Tari turned the boat's head
shorewards. The sail was lowered and mast unstepped, whilst Jim
and Broncho shipped two oars and prepared to pull or backwater,
according as the Kanaka should direct.
Skilfully Tari ran her in, and then waited just outside the broken water
for a good opportunity.
Picking out the last of three big waves, he signed to Jim and
Broncho to give way, and off went the whaleboat, swooping forward
on the crest of the roller.
Straight as an arrow Tari kept her head, and the boat danced along
without shipping more than a cupful or two of water; then, judging his
time to a nicety, the Kanaka backed her off as the breaker toppled
and fell crashing; again, with wild cries of encouragement, he bade
them pull, and the boat was hurled towards the beach in the midst of
a raging mass of foam, which kept Jack busy baling as it boiled
around and lipped in over the gunwale.
The beach shelved gradually, and the whaleboat was carried far up it
before the undertow began to take hold.
At a word from Tari, all hands leaped overboard, and, helped by the
big stranger, who had run into the surf to their aid, they ran the boat
high and dry.
Weakened and cramped by their long spell of hardships and
privations since leaving the Ocmulgee, this last effort used up every
remaining ounce of strength, and utterly exhausted, the castaways
threw themselves full length upon the sand and lay there.
Before them stood the stranger, tall and muscular. His burly figure
and square, resolute face were those of that unmistakable type, the
British bluejacket, and he hardly required the bell-bottomed navy
trousers to identify him.
Virile strength, trained and disciplined to a fine perfection, showed in
every line of his active form.
"You're on British soil, lads," he began, squatting down beside the
worn-out boat's crew, and he jerked his thumb up at the small flag
straining in the strong breeze from the top of the bare palm.
They now perceived it to be a very minute Union Jack, faded and
somewhat ragged.
"This island is called H.M.S. Dido," he went on. "I named her after
the gunboat I belong to. My name's Bill Benson, bosun's mate. I fell
overboard about a month back. Got picked up by that black-'arted
scoundrel 'Awksley, of the Black Adder."
At these words, Jack, who was listening indifferently, suddenly leant
forward to attention with a strange new look on his tired face;
noticing which the man exclaimed,
"Know him, governor?"
"I do," returned Jack slowly, with a deep note of sternness in his
voice.
"Know no good, I'll be bound; but he's ashore here somewheres. His
blighted crew o' yellow-skinned beachcombers got fed up with him,
an' they just popped the three of us ashore 'ere—marooned us, as
they say."
"Who was the third, do you say?" broke in Jack again, a strange
excitement in his eyes.
"Why, that pretty little wife o' his to be sure, who's a mighty sight too
good and 'andsome for the likes of 'im. We've been 'ere more'n a
week now. That's my yarn, an' when you've had your siesta, I'll hear
yours. Your landin' party was a kind o' surprise-packet to me, an' I
just piped to clear decks for action when I see'd you fust; an' you can
bet I just sweated pure joy when you hailed back in the old chin-
chin."
"Wall," said Broncho slowly, sitting up and looking round, "you shore
had us shorthorns some fretted an' scared likewise when you jumps
out on the scenery so gay an' easy; but it's that 'ere flag o' yours
which has us some distrustful an' on the scout for ambushes at the
first turn of the kyards."
"Oh, that's my pocket 'andkercher. I shinned up that old palm,
trimmed his spars offen him, an' nailed it wi' wooden pegs to the
masthead, when I fust takes possession o' the island in the name of
'Er Majesty, so as there shouldn't be no international hankypanky
diplomatin' round later," the navy man explained calmly.
"Where's this Hawksley gone to, do you say?" asked Jack, trying
hard to hide the excitement in his voice.
"Why, I h'expec' he's divin' in the lagoon fishin' up oysters, a-lookin'
for pearls; 'e puts in mos' of his time that way."
"And his wife?" queried Jack again, his voice shaking for all his
efforts to control it.
"Moonin' round somewheres, poor thing. I reckon he's mighty near
broke 'er heart. She don't seem to take no 'eed o' nothin', an' just
navigates along plumb indifferent; dumb as a bloomin' Thames
barge, with the look of a beaten dog in 'er big, mournful eyes."
A deep, half-smothered curse burst from Jack's pale lips, and
springing suddenly to his feet, he wandered off unsteadily with bent
head along the beach, feeling his way by the edge of the breakers.
The others watched him wonderingly. Jim got up, meaning to follow
him; but Broncho motioned him down again, saying:
"Let him be, sonny!" Then, turning to the bluejacket, explained, "Our
mate's blind, an' it kinder hits him on the raw at times."
But the anxiety in the cowboy's eyes robbed the easy tones of their
indifference. The man received his explanation with a nod of the
head.
"Sorter moody, eh? An' I don't wonder——"
"Seein' as you-alls wants to savvy why we comes a-pirootin' in
disturbin' the ca'm salubrity o' your peaceful layout so abrupt an'
precip'tite-like," broke in Broncho hurriedly, with a sudden change of
conversation, "I'll just paw round in my mem'ry an' enlighten you
some."
"Navigate ahead, governor, me ear-valves is open," said the bosun's
mate politely.
"It's this way," drawled Broncho. "My bunkie there"—pointing to
Jack's receding form—"me, an' the boy goes a-weavin' offen a ship
into this here toomultuous sea without stoppin' to count the chips,
we're in sech a hustle—some like the way you-alls vamooses the
war-boat, I surmise. That 'ere event occurs away down south,
crowdin' hard on two moons back. We-alls goes floatin' round in the
swirlin' vortex o' them tempestuous waters, till things begin to look
scaly; but finally we makes a landin' on what you-alls call a
whaleship.
"It's there we meets up with Tari here, and another saddle-coloured
gent who's locoed. This same saddle-coloured gent, which his name
is Lobu, puts up sech a fervent play that we-alls has to corral him in
a kind of calaboose forward; but it shore don't give him no bliss, an'
he's that enraged an' indignant that he starts in to light a camp-fire
down thar, allowin' as how he'll call the turn on us that-away, an' he
mighty near rakes in the pot with that desp'rate play o' his. Though
we-alls busts in an' tries to down the flames with wet sails an' liquid
goods, it ain't no use; the deal goes agin us, an' we has to make
tracks.
"We saves our skins by scoutin' off in this here boat, which same
play has that paltry Lobu plumb disgusted to the core, an' he finally
allows he'll shore pull his picket-pin for good an' quit this vale o'
tears.
"A-promotin' o' which idees, he goes jumpin' off into the sea, an'
though we-alls makes a sperited play to obstruct his little game, it's
no use; we're too late, an' the last the outfit sees of him is his blood,
whilst he goes p'intin' off under water a-wrastlin' with a shark.
"Right in the tracks o' this eepisode we-alls near bogs down likewise,
bein' some scarce in liquid refreshments, not to say entirely lackin' in
the same—our canteens havin' run out, an' things lookin' ugly an'
desp'rate, when rain comes.
"But we ain't out o' the wood yet, for Derringer Jack yonder, who's all
the time doin' range-boss an' playin' the leadin' hand with both sand
an' savvy, goes buttin' his head agin fate, an' one maunin' emerges
outer the racket plumb moon-blind.
"It's shore a low mean play the Fates puts up agin poor old Jack, but
I ain't out to give you-alls no sarmon tharon, nor yet to bewail the
abandoned an' ornery conduct o' Destiny.
"It's a paltry play it makes, for shore, a-debauchin' itself on Jack that-
away, an' plumb mortifies the whole outfit to death; but to resoome
this here narrative, it's yesti'd'y we-alls sees your island in a mirage
an' capers off on its trail, with what result you-alls knows."
"I'm a flat-foot if you unfort'nit jossers ain't been jammed in a clinch
proper," commented the naval Robinson Crusoe, as Broncho
ceased.
There was a short pause, and then Jim broke in:
"Got any fresh water here?"
"I ain't see'd none; but there's milk, er course."
"Milk!" ejaculated Broncho in astonishment. "I don't see no cows
around."
"No, there ain't no cows a-muckin' around; but the milk here grows
up aloft, on them trees."
"Cocoanuts!" exclaimed the boy eagerly, with a watering mouth.
"That's what," replied Bill Benson heartily. "Like one, young 'un?"
"Aye, that I would."
At which the bosun's mate got good-humouredly to his feet and
strolled off into the low brush. Presently he reappeared with his arms
full of ripe, juicy fruit.
"Wot oh, Aunt Sally!" he cried cheerfully. "Two shies a penny! 'minds
one er 'ome, don't it?"
In a few moments they were all quenching their thirst with the
delicious milky juice.
"My! that's somethin' like a drink!" sighed Jim, drawing a long breath.
"It shore beats any bug-juice I ever pours down my throat,"
commented Broncho appreciatively.
"It 'as its good p'ints," observed Bill Benson. "You can lap it down till
y'r back teeth are awash without acquirin' a cordite mouth, but it falls
considerable flat on the palate after a week o' nothin' else. There
ain't no bite to it. It's good enough for babbies, but I'm gettin' that sick
of it I'd as soon suck bilgewater."
 CHAPTER VII
"LOYOLA"
Meanwhile Jack wandered off along the shore with bent head
and stumbling feet, not knowing nor caring where he went, for his
brain was seething in a ferment.
The news which Bill Benson had given him racked the distracted
man almost beyond the limit of endurance. His heart leaped at one
moment to a fierce, delirious joy, to be cast down the next into the
very depths of despair.
Then a rage seized him, a wild, ungovernable fury, which shook his
weak, overstrained body to the very core, till he was forced to sink
upon the sand from sheer physical inability to remain erect. Hot,
passionate words rushed in a low, hoarse whisper from his cracked
lips; the blind eyes sparkled with a gleam of almost madness, and
the emaciated hands clenched and unclenched ceaselessly.
Slowly the paroxysm passed; a look of dreadful sadness came into
the eyes, and a long, dry sob broke huskily from his lips.
"What shall I do? Oh, God! what shall I do?" he wailed miserably.
"Kill the devil!" whispered a voice within him.
"No! no!" interposed another. "Let him be. It's none of your business.
She made her bed and must lie on it. She cast you aside, and now
you have no right to interfere."
"But she loved me—I know she did. Even at that last meeting, when
I like a fool lost my temper, even then I saw the love in her eyes," he
whispered softly; then with a deep, bitter groan, "My God! why did
she do it? Why did she do it? And that beast, of all men. And now—
what now, I wonder?"
The rover sat silent in an unnatural calm. He was hidden from the
group of men round the whaleboat by a clump of cocoa-palms,
jutting down on to a sort of promontory from the main grove.
Suddenly his ears, sharpened by his blindness, caught the sound of
approaching footsteps. With his head on one side in the attitude of
listening, he waited, cool without, but a very whirlwind of excitement
within; for as they drew nearer he recognised the soft tread of those
unknown feet.
Yes, it was! At last she was coming! This one thought filled him and
set his heart beating to suffocation. The strangeness of the meeting
on this lonely atoll of the two who had separated under such tragic
circumstances, he did not realise at the time.
A great, overpowering longing to see her and touch her filled the
blind man. How slowly she was approaching! Would she never reach
him? What if she did not see him—should he shout? No, that might
bring the hated Hawksley from the lagoon, which would never do.
Jack desired of all things that this first meeting between the two
should be private. Besides, he mistrusted himself with Hawksley; he
knew there was murder in his heart crying for accomplishment, and
at the very thought his fingers crooked significantly.
No, assuredly it would not do to risk drawing Hawksley's attention.
Should he rise to his feet and stumble forward to meet her? The
knowledge of his blindness struck him like a blow. He dreaded the
moment when she should find it out. "How would she take it?" he
wondered miserably. No, he dared not blunder upon her like a
drunken beachcomber. His manhood rose in rebellion. He desired
most fervently to hide from her this tragedy which fate had put upon
him, this fearful calamity which destroyed his strength and nerve and
scourged his pride through his utter helplessness.
So the sorely-tried man waited, crouching on his knees.
Coming slowly through the clump of palms was a white woman, clad
in a creamy dress of some silken texture, with a wide-brimmed
panama perched upon a wavy mass of dark brown hair, which shone
like gold where the sunbeams kissed it.
Her face was of a dead white, and the beautiful features were thin
and drawn, whilst her brown eyes, ringed in black circles and filled
with a look of piteous sadness, seemed too big for the rest of the
face.
As she reached the edge of the sand and espied the rolling-stone,
an involuntary cry broke from her lips. For a second she stood stock
still, whilst a look of amazement crept into her eyes.
Then, satisfied that her vision was playing her no trick, she advanced
into the open, restraining with difficulty a passionate desire to rush
forward and throw herself at the blind man's feet.
And then, as she drew nearer to this man whom she had treated so
badly, though from no fault of her own, but through sheer force of
circumstances, a strange hesitation filled her. Her heart, beating
suffocatingly, urged her forward and yet dragged her back at the
same time; her feet lagged, then hurried, then lagged again, whilst
her hands twined themselves together nervous and shaking.
At last she stood before him, looking down upon his haggard, storm-
lined features, from which the blind eyes stared up vacantly with an
expression which even in her agitation she could not help but notice.
"You, Jack—you?" she began softly, and her voice trembled in spite
of a great endeavour to keep it steady.
"Yes, me, Loyola," came the reply; but how dull, how indifferent, how
hard and cold were the well-known tones.
An icy chill crept shuddering down her back at the sound of this
strange new voice, so different to the one she had been used to in
the old happy days, now so far away, so long ago, though not in
time.
The pallor of her face took on a greyish tinge and the sadness in her
eyes deepened.
There was no forgiveness, as there was no hope. Why should she
expect it? Ah! but what a difference it would have made to her! How
it would have helped her to bear her fate!
For a second she tottered on the verge of a breakdown, and then
rallied, drawing upon that splendid woman's courage which enables
such as her to stand and bear with fate where others would fall and
be crushed.
Bravely she forced herself to continue, beating down the misery and
despair which the cold tones of his voice had raised within her.
"And what are you doing here, Jack?"
"Tossed ashore by the capricious sea. I might ask you the same
question, had I not already heard your story."
"Not from—Hawksley?" She stumbled miserably over her husband's
name, and then with a sudden fear cast an uneasy look over her
shoulder.
"No; the bluejacket," said Jack's even voice, and he got slowly to his
feet.
"Won't you—won't you even shake hands, Jack?" pleaded the
woman in her low, sad voice. "I know you won't forgive me, and I
don't expect you to; but——"
It was the "but," the misery, the despair, the utter hopelessness, and
yet the passionate entreaty in that last little word which conquered
Jack's iron-bound soul and swept away his righteous indignation at a
treatment which had spoiled his life.
He was touched; that "but" weighed down the scales on the side of
his love, till his grievance, his outraged feelings, and the resultant
misery leaped from him lightly as a feather.
"Why, of course I will. And as for forgiving you, I've forgiven you long
ago."
The new warmth in his voice brought a bright flush of pleasure to the
woman's face.
"Oh, Jack," she began; but stopped, watching with slowly growing
amazement whilst the blind man tried to find her outstretched hand.
What was the matter with Jack? Why did he paw the air in that
uncertain fashion, instead of grasping the hand she extended to
him?
Anxiously she looked at him, unable to fathom his strange action;
then took his wavering hand in hers and held it, a great comfort and
a new joy springing up within her.
What surer sign of friendship, of love, of deep understanding than a
firm hand-grasp?
His bony fingers closed on her slender ones with a grip that made
her wince, and a sudden light lit up his dull eyes.
And so they stood for one long minute of time, hand in hand.
The sun played upon them, lighting the woman's hair with sparkles
of yellow fire, and warmed the tired bodies with its tender glow, just
as the content of this tardy but complete reconciliation warmed their
tired souls.
The long rollers boomed a deep note of approval as they surged
shorewards in snowy foam, and the gentle breath of the trade wind
touched them caressingly with its invisible fingers.
The very sands flashed their delight up at them, and the swaying
palm-tops rustled with a drowsy murmur of satisfaction.
Often thus does nature seem to tune herself in accord with the
feelings and emotions of mankind.
In that moment the sinister barrier of misunderstanding, which for so
long had stood gloomy, forbidding, impassable, had been removed
from between their hearts, and the very air, the sea, the earth, the
waving foliage, the shining sand rejoiced thereat.
But as the cowboy would say, "You can't buck against destiny."
Destiny had tied a knot—a huge, cruel, untieable knot—which held
the lives of these two apart, set though they were in the same web of
fate.
Bitterness, doubt, misery had been the direct result; but now, by the
aid of that little winged cherub who plays such pranks with most
lives, the bitterness, the doubt, the misery, all had been swept aside
—only the knot remained.
With a long sigh of thankfulness Loyola murmured gently,
"You do forgive me, Jack?"
"I do, I do, child," he replied, the hardness all gone from his voice. "I
don't know why you did it. Only this I know, it was no fault of yours.
Fate in some way stepped in between us, and—and—and I can feel
it in the air"—he lifted his head and drew a long, deep breath—"I feel
that we are still the friends, the——" he stopped, hesitating, flushed,
and a tender light glowed in the blind eyes.
"Yes, Jack?" she whispered, longing to hear the word he had left
unspoken.
"Who used to be so fond of each other," he ended lamely.
"But," cried the woman eagerly, "I must tell you why I did it. I did it
——"
"Don't tell me, Lolie; I don't want to hear. I know now you must have
had some good reason, that is enough for me. We can still be
friends."
"But I must, I must. I did it to save Big Harry, poor old dad. He was
caught in Hawksley's clutches and I sold myself to save him, and—
and—and it was all no use," she sobbed. "He had cheated the pair of
us. It broke dad's heart, and he died two months after you left the
schooner."
"My God! If I had only known!" groaned the man, with miserable self-
reproach. "And that's why! and that's why! I might have guessed
something of the sort if I hadn't been such a cursed, jealous fool."
"I treated you shamefully, Jack," she whispered brokenly. "I ought to
have given you a reason, but I couldn't. Shame held my tongue, and
I let you go away without a word; but—but God knows I've been
bitterly punished. No one could imagine what I have suffered with
that demon—aye, and must continue to suffer."
"Can't anything be done, Lolie?"
"I must brave it out to the end, I suppose, as others have done
before me," she muttered drearily.
"Something shall be done!" cried Jack cheeringly.
His old confidence was coming back to him. Now that the mystery of
Loyola's strange marriage was cleared up, and he was no longer in
doubt that she still loved him, a mighty flood of gladness was surging
up within him.
For the present this newly gained knowledge was sufficient. Who
knew what the future might not bring forth? At any rate her love was
his; that, Hawksley could have no part in.
As for Hawksley, he despised Hawksley. Let the ruffian take care.
Snakes were only fit for stamping on, and Jack began to see himself
stamping on Hawksley with a keen satisfaction.
So the rover mused, whilst Loyola stood by his side, watching him.
"And now," he proposed, "I'll give you a sketch of the events which
landed me on this coral spit, after which we'll plan out the future."
And, standing there in the glaring sunlight, Jack plunged into a recital
of his late adventures, whilst Loyola listened without comment until
he came to the part the moon had played.
At the news of his blindness an involuntary cry broke from her, the
shock of the quiet announcement struck her like a blow. Her Jack,
dear old Jack of the happy Moonbeam days, blind? No, it could not
be! Fate was cruel, as she well knew, but not as cruel as that.
Leaning forward, she placed her hands on his shoulders and peered
into the blind eyes, as if she would reassure herself by their
appearance.
She saw no difference in them, no difference from the eyes she used
to know. It could not be! Jack was mistaken, and yet, how could a
man be mistaken as to whether he could see or not?
Again she peered desperately, her face within an inch of his. Jack
could feel her soft breath on his cheek; her lips, half opened in her
excitement, seemed to be touching his moustache; the slightest
movement forward on his part and they would be against his.
Never had the man been so tempted. At the same moment a wolfish
head poked stealthily through the brushwood, and a pair of cruel,
cunning eyes glared forth angrily upon the scene.