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Essentials of Radiology

i
Essentials of Radiology

FOURTH EDITION

Fred A. Mettler, Jr., MD, MPH

Emeritus Professor
Department of Radiology
University of New Mexico
School of Medicine
Health Sciences Center
Albuquerque, New Mexico
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899

ESSENTIALS OF RADIOLOGY: FOURTH EDITION ISBN: 978-0-323-50887-2

Copyright © 2019 by Elsevier, Inc. All rights reserved.

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Preface
Radiology continues to get little attention in most medical
school curricula, expect perhaps as an elective. The classic
gross anatomy lab has been dead (so to speak) for decades,
and most health care providers learn human internal
anatomy through radiology or electronic formats. This text
is not meant you make you a radiologist, nor is it simply a
book for a medical student elective, although it has been
widely used for the latter. It is intended to be a text that
will provide you with a basis for radiologic anatomy, imaging
fundamentals, and appropriate imaging for most common
clinical problems and be useful for years in your practice.
The text is generally organized by clinical presentation (e.g.,
low back pain, headache) and discusses the imaging that is
initially appropriate and why. As such, this text has found
wide use among medical students, first year radiology resi-
dents, primary care physicians, nurse practitioners, physi-
cian’s assistants, and other health care professionals.
The fourth edition comes 13 years after the publica-
tion of the first edition. Why is a fourth edition needed?
CHAPTER    v
There remains rapid transition in the imaging field, with
changes in detector systems to solid state, development of
new techniques (e.g., breast tomosynthesis), and continuing
development of appropriateness criteria. In the last several
years almost 100 new criteria have been developed, which
are included in this text. Screening guidelines have been
changing, and “rules” have been developed to minimize
unnecessary examinations and radiation dose. These areas
have all been updated in this edition without expanding
the length of the text. While appropriate imaging soft-
ware is included in some hospital image procedure ordering
systems, this is neither widespread nor readily available to
you on your smart phone or tablet, but this text and its
images are.
I hope that this book fits your needs and wish you the
best in your career.
Fred A. Mettler, Jr.
v
Acknowledgments
I thank my colleagues who have helped me with this edition
and previous editions, including Blaine Hart, MD; Charles
Hickam, MD; Peter Humphrey, MD; and Josh Robertson,
MD. I also thank Gary Mlady, MD, and RuthAnne Bump
for their encouragement and help. And a particular note of
vi
gratitude goes out to all those who have worked very hard
over the years on many task groups to compile information
and recommendations for the American College of Radiol-
ogy Appropriateness Criteria, which have been essential for
this text.
1
Introduction
AN APPROACH TO IMAGE
INTERPRETATION
The first step in medical imaging is to examine the patient
and determine the possible cause of his or her problem.
Only after this is done can you decide which imaging study
is the most appropriate. A vast number of algorithms and
guidelines have been developed, but no definite consensus
exists on the “right” one for a given symptom or disease
because a number of imaging modalities have similar sen-
sitivities and specificities. In this text I provide tables of
appropriate initial imaging studies for various clinical situ-
ations. When possible, these tables are based on the pub-
lished literature and recommendations of professional
societies. When this is not possible, I give you my opinion
based on 45 years of clinical practice.
What should you expect from an imaging examination?
Typically one expects to find the exact location of a problem
and hopes to make the diagnosis. Although some diseases
present a characteristic picture, most can appear in a variety
of forms, depending on the stage. As a result, image inter-
pretation will yield a differential diagnosis that must be
placed in the context of the clinical findings.
Examination of images requires a logical approach. First
you must understand the type of image, the orientation,
and the limitations of the technique used. For example, I
begin by mentally stating, “I am looking at a coronal com-
puted tomography (CT) scan of the head done with intra-
venous contrast.” This is important, because intravenous
contrast can be confused with fresh blood in the brain.
Next I look at the name and age on the image label to
avoid mixing up patients, and this allows making a differen-
tial diagnosis that applies to a patient of that age and sex. You
would not believe the number of times that this seemingly
minor step will keep you from making dumb mistakes.
The next step is to determine the abnormal findings on
the image. This means that you need to know the normal
anatomy and variants of that particular part of the body, as
well as their appearance on the imaging technique used.
After this, you should describe the abnormal areas, because
it will help you mentally order a differential diagnosis. The
most common mistake is to look at an abnormal image and
immediately name a disease. When you do this, you will
find your mind locked on that diagnosis (often the wrong
one). It is better to say to yourself something like, “I am
going to give a differential diagnosis of generalized cardiac
enlargement with normal pulmonary vasculature in a
40-year-old man,” rather than to blurt out “viral cardiomy-
opathy” in a patient who really has a malignant pericardial
effusion.
After practicing for 20 years or so, a radiologist knows
the spots where pathology most commonly is visualized.
Throughout this text, I point out the high-yield areas for
the different examinations. Although no absolute rules
exist, knowing the pathology and natural history of differ-
ent diseases will help you. For example, colon cancer typi-
cally metastasizes first to the liver rather than the lungs,
whereas sarcomas preferentially metastasize to the lungs
rather than the liver.
After reviewing the common causes of the imaging find-
ings that you have observed, you should reorder the causes
in light of the clinical findings. At this point, you probably
think that you are finished. Not so. Often a plethora of
information is contained in the patient’s image files or in
the hospital’s computer information system. This comes in
the form of previous findings and histories supplied for the
patient’s other imaging examinations. Reviewing the old
reports has directed me to areas of pathology on the current
image that I would have missed if I had not looked into the
medical information system. A simple example is a pneu-
monia that has almost but not completely resolved or a
pulmonary nodule that, because of inspiratory difference, is
hiding behind a rib on the current examination.
You probably think that you are finished now. Wrong
again. A certain number of entities could cause the findings
on the image, but you just have not thought of them all.
After I have finished looking at a case, I try to go through
a set sequence of categories in search of other differential
possibilities. The categories I use are congenital, physical/
chemical, infectious, neoplastic, metabolic, circulatory, and
miscellaneous.
X-RAY
Regular x-rays (plain x-rays, also sometimes called radio-
graphs) account for about 75% of imaging examinations.
X-ray examinations, or plain x-rays, are made by an x-ray
1
2 C HA P T E R 1 Introduction
beam passing through the patient. The x-rays are absorbed
in different amounts by the various tissues or materials in
the body. Most of the beam is absorbed or scattered. This
represents deposition of energy in the tissue but does not
cause the patient to become radioactive or to emit radiation.
A small percentage of the incident radiation beam exits the
patient and strikes a detector.
The historical imaging receptor was a film/screen com-
bination. The x-ray beam would strike a fluorescent screen,
which produced light that exposed the film, and then the
film was developed. Newer systems are called computed radi-
ography or digital radiography. In computed radiography, the
x-rays strike a plate that absorbs the x-rays and stores the
energy at a specific location. The plate is then scanned by a
laser, which releases a point of light from the plate. The
location is detected and stored in a computer. In digital
radiography detector systems, the x-ray hits a detector and
then is converted to light or an electrical charge immedi-
ately. Once either type of image is stored in the computer,
it can be displayed on a monitor for interpretation or trans-
mitted to remote locations for viewing.
Four basic tissue densities, or shades, are visible on plain
x-rays. These are air, fat, water (blood and soft tissue), and
bone. Air is black or very dark. On regular x-rays and CT
scans, fat is generally gray and darker than muscle or blood
(Fig. 1.1). Bone and calcium appear almost white. Items
that contain metal (such as prosthetic hips) and contrast
agents also appear white. The contrast agents generally used
are barium for most gastrointestinal studies and iodine for
most intravenously administered agents.
Remember that standard or plain x-rays are two-
dimensional presentations of three-dimensional informa-
tion. That is why frontal and lateral views are often needed.
Without these, mistakes can easily be made. You must
remember that an object visualized on a specific view is
somewhere in the path of the x-ray beam (not necessarily
in the patient). If an object projects outside the patient on
any view, it is outside the patient. However, even if an object
Soft tissue
Bone
• Fig. 1.1 The Four Basic Densities on an X-Ray. A lateral view of the forearm shows that the bones
are the densest, or white; soft tissue is gray; fat is somewhat dark; and air is very dark. The abnormality
in this case is the fat in the soft tissue of the forearm, which is due to a lipoma.
projects within the patient on two orthogonal views, it can
still be located outside the patient (Figs. 1.2 and 1.3). Each
additional view needed to make a diagnosis requires an
additional x-ray exposure and therefore adds to the patient’s
radiation dose. Radiation doses from various examinations
are given in the Appendix.
The terminology used to describe images is usually quite
straightforward. Chest and abdominal radiographs are
referred to as upright or supine, depending on the position
of the patient. In addition, chest x-rays are usually described
as posteroanterior (PA) or anteroposterior (AP) (Fig. 1.4).
These terms indicate the direction in which the x-ray beam
traversed the patient on its way to the detector. PA means
that the x-ray beam entered the posterior aspect of the
patient and exited anteriorly. AP means that the beam direc-
tion through the patient was anterior to posterior. A left
lateral decubitus view is one taken with the patient’s left side
down.
Position is important to note, because it can affect mag-
nification, organ position, and blood flow and therefore
significantly affect image interpretation. For example, the
heart appears larger on AP than on PA images because on
an AP projection the heart is farther from the detector and
is magnified more by the diverging x-ray beam. It also
appears larger on supine than on upright images because
the hemidiaphragms are pushed up, making the heart
appear wider. Portable chest images are taken not only in
the AP projection but also with the tube closer to the
patient than on standard upright images. This magnifies the
heart even more.
Use of contrast agents permits visualization of anatomic
structures that are not normally seen. For example, intrave-
nously or intra-arterially injected agents allow visualization
of blood vessels (Fig. 1.5). If imaging is done with standard
format, the blood vessels appear white. Digital imaging
allows subtraction or removal of unwanted structures, such
as the bones, from an image (see Fig. 1.5B). Often the
computer manipulation is done in such a way that the
Air
Fat
 CHAPTER 1 Introduction 3

Film
Anterior-posterior Lateral
• Fig. 1.2 Spatial Localization on an X-Ray. On both anteroposterior (AP) and lateral projections, the
square and round objects will be seen projecting within the view of the chest, even though the square
object is located outside the chest wall. If you can see an object projecting outside the chest wall on at
least one view (the triangle), it is outside the chest. If, however, an object looks as though it is inside the
chest on both views, it may be either inside or outside.

A B
• Fig. 1.3 What Is the Location of the Keys? On both the posteroanterior (PA) view of the chest (A) and
the lateral view (B), the keys seem to be within the center of the chest. Actually, if you look carefully, you
will notice that the keys do not change position at all, even though the patient has rotated 90 degrees.
The keys are located on the receptor cassette and are not in the patient.

arteries may appear black instead of white, although this
usually does not present a problem in interpretation.
Contrast agents are used to fill either a hollow viscus
(such as the stomach) or anatomic tubular structures that
can be accessed in some way (such as blood vessels, ureter,
and common bile duct). When you see an abnormality on
one of these studies, you must determine whether the loca-
tion is intraluminal, mural, or extrinsic. This usually requires
seeing the abnormality in perpendicular views (Fig. 1.6).
Unless you are careful about this determination, you will
make errors in diagnosis.
Contrast agents instilled orally, rectally, or retrograde
into the ureter or bladder incur little or no risk unless
aspiration or perforation occurs. With the intravenously or
intra-arterially administered agents, a small but real risk for
contrast reaction exists. This is something that you should
consider before ordering a contrast-enhanced CT scan.
About 5% of patients will experience an immediate mild
reaction, such as a metallic taste or a feeling of warmth;
some experience nausea and vomiting, wheeze, or get hives
as a result of these contrast agents. Some of these mild reac-
tions can be treated with 50 mg of intramuscular diphenhy-
dramine (Benadryl). Because contrast agents also can reduce
renal function, they should not generally be used in patients
with compromised renal function (estimated glomerular
filtration rate [eGFR] < 50 to 60 mL/min).
4 C HA P T E R 1 Introduction

About 1 in 1000 patients have a severe reaction to intra-
vascular contrast. This may be a vasovagal reaction, laryn-
geal edema, severe hypotension, an anaphylactic-type
reaction, or cardiac arrest. A vasovagal reaction can be
treated with 0.5 to 1.0 mg of intravenous atropine. The
most important initial therapeutic measures for these severe
reactions are to establish an airway, ensure breathing and
circulation, and give intravenous fluids. Other drugs
Detector
Anterior-posterior Posterior-anterior
• Fig. 1.4 Typical X-ray Projections. X-ray projections are typically
listed as anteroposterior (AP) or posteroanterior (PA). This depends on
whether the x-ray beam passed through the patient from anterior to
posterior or the reverse. Lateral (LAT) and oblique (OBL) views also are
commonly obtained.
obviously also may be necessary. The risk for death from a
study using intravenously administered contrast agents is
between 1 in 40,000 and 1 in 100,000.
COMPUTED TOMOGRAPHY
CT is accomplished by passing a rotating fan beam of x-rays
through the patient and measuring the transmission at
thousands of points. The data are handled by a computer
that calculates exactly what the x-ray absorption was at any
given spot in the patient. The data can be manipulated in
a number of ways, displayed on a screen, or photographed.
Because the data points are in the computer memory, it is
possible to “window” the data and obtain a number of
images without additional radiation exposure (Fig. 1.7).
The computers can even display the data as a three-
dimensional rotating image, although this is rarely necessary
for diagnosis. Compared with plain x-rays, CT uses about
10 to 100 times more radiation.
On early CT scanners the x-ray tube rotated around the
patient to obtain a single “slice,” and then the table was
moved incrementally before another slice was obtained.
Newer scanners allow the x-ray tube to stay on and rotate
at the same time that the table is moving. This is called a
spiral scanner or helical scanner. The most modern scanners
not only have the helical motion but also have multiple rows
of detectors and can obtain more than 100 image data slices
at once.
The appearance of tissues on CT scan depends to some
extent on the computer manipulation, but in general the

A B
• Fig. 1.5 Pulmonary Angiogram. (A) A conventional view of blood vessels can be obtained by injecting
iodinated contrast material into the vessels. On these images the vessels will appear white and the bones
will be seen as you would normally expect (white). A digital subtraction technique with a computer may
show the vessels either as black (B) or as white, but the bones will have been subtracted from the image.
 CHAPTER 1 Introduction 5

AP Lateral AP Lateral AP Lateral

A Intraluminal lesion B Intramural lesion C Extramural lesion

• Fig. 1.6 Appearances of Different Lesions Depending on Their Location When Using Contrast.
Contrast medium is used to visualize tubular structures, including the spinal canal, blood vessels,
gastrointestinal tract, ureters, and bladder. (A) Intraluminal lesions, such as stones or blood clots within
the lumen of the given structure, produce a central defect on both anteroposterior (AP) and lateral projec-
tions. On the AP and lateral views the contrast will show acute angles on both sides and in both projec-
tions. (B) Intramural lesions will produce a defect that indents the column of contrast. When seen
tangentially, an acute angle will appear between the normal wall and the beginning of the indentation. (C)
Extramural lesions also can indent the wall, but at the point of indentation, the angle will be somewhat
blunted as compared with the intramural lesion.

R L basic four densities on CT images are the same as those in

plain x-rays: air is black, fat is dark gray, soft tissue is light
gray, and bone or calcium and contrast agents are white.
B B One advantage of CT is that actual x-ray absorption of a
Liver B
B specific tissue can be displayed. The units used are Houns­
field units. The Hounsfield density of water is zero. The
greater sensitivity of CT compared with plain x-rays allows
Sp
B areas of tiny punctate calcification to be seen.
K CT scans are presented as a series of slices of tissue. The
method is similar in principle to slicing a loaf of bread and
A pulling up one slice at a time to examine it. Thus CT is a
two-dimensional display of two-dimensional information,
R L and objects appear where they really are in space. The scans
B or slices are shown as if you were viewing the patient from
B
the foot of the patient’s bed. Thus the individual’s right side
B is on your left (Fig. 1.8). This also is the convention used
Liver
for transverse images of ultrasound and magnetic resonance
imaging (MRI).
Sp
Contrast agents, frequently used in CT scans, are usually
K K the same water-soluble oral, rectal, or intravenous iodinated
agents used in other imaging studies. Intravenous contrast
B agents are common, being used in probably 75% of all CT
studies, and obviously carry the risk for contrast reactions
• Fig. 1.7 Computed Tomography (CT). Images of the abdomen are discussed previously. Rapid acquisition of images allows the
presented here. (A) The image was made by using relatively wide
windows during viewing, and no intravenous contrast was used. (B)
intravenously administered contrast to be displayed and
The windows have been narrowed, producing a rather grainy image, images acquired in arterial, venous, or delayed phases with
and intravenous contrast has been administered so that you can see only a single injection.
enhancement of the aorta, abdominal vessels, and both kidneys (K). The appeal of CT is that a large number of structures
In both images, contrast has been put in the bowel (B) to differentiate are visualized simultaneously. In a patient with abdominal
bowel from solid organs and structures. L, Left; R, right; Sp, spine.
pain, one CT examination shows the liver, adrenal glands,
kidneys, spleen, aorta, pancreas, and other structures. This
allows the clinician to identify macroscopic pathology
quickly.
6 C HA P T E R 1 Introduction
• Fig. 1.8 Orientation of Computed Tomography (CT) and Magnetic
Resonance (MR) Images. CT and MR usually present images as
transverse (axial) slices of the body. As you stand and look at the
patient from the foot of the bed, if you think of these images as slices
lifted out of the body, you will have the orientation correct.
Head Anterior Feet
Liver
Kidney
Posterior
• Fig. 1.9 Ultrasound Examination of the Liver and Kidney. This is
a longitudinal image, and you are essentially looking at the patient from
the right side. The patient’s head is to your left. The liver has rather
homogeneous echoes, and the kidney is easily seen as a bean-shaped
object posterior to the right lobe of the liver.
ULTRASOUND
Ultrasound examination uses high-frequency sound waves
to make images. The technology is that of sonar or a glori-
fied fish finder used by fishermen. The image is made by
sending high-frequency sound into the patient and assessing
the magnitude and time of returning echoes. Echoes are the
result of interfaces or changes in density. Typically a cyst has
few if any echoes, because it is mostly water. Tissues such
as liver and spleen give a picture with rather homogeneous
small echoes caused by the fibrous interstitial tissue (Fig.
1.9). High-intensity echoes are caused by calcification, fat,
and air.
The technology of ultrasound is attractive because it does
not use ionizing radiation and the machines are relatively
Anterior
Head Feet
Liver Gallbladder
Portal vein
• Fig. 1.10 Color Doppler Ultrasound. In addition to displaying
anatomy, ultrasound can analyze blood flow direction and velocity. In
this longitudinal image of the liver, the red is blood in the portal vein
flowing toward the transducer (located on the anterior aspect of the
abdomen) and the blue represents blood flowing away from the
transducer.
inexpensive. For these reasons, ultrasound has found wide-
spread use in obstetrics. The use of so-called real-time ultra-
sound allows the images to be seen in sequential frames
just as in a movie. This capability has proved popular
for imaging rapidly moving structures, such as the heart.
Ultrasound images can be quite dependent on operator-
set parameters, and the field of view within the patient
is limited. Thus unless clear labels are placed relative to
orientation, the images can be difficult or impossible for
the novice to interpret. Ultrasound images are usually pre-
sented as white echoes on a black background. In addi-
tion to using echoes to generate images, the ultrasound
equipment can analyze the returning echo frequencies.
This Doppler analysis allows for identification of moving
blood, as well as its direction and velocity. Examples
of its use are to identify and quantitate stenoses of the
carotid arteries or the direction of blood flow in the portal
vein (Fig. 1.10).
NUCLEAR MEDICINE
Nuclear medicine images are made by giving the patient a
short-lived radioactive material. The most commonly used
radionuclides decay rapidly and have half-lives of only
minutes or hours. Most materials administered are not
detectable within a day or so after administration. With the
attachment of a radionuclide (such as technetium 99m) to
specific carrier compounds, concentration of the radioactiv-
ity can be imaged and measured in a chosen organ or tissue,
such as the thyroid, bone, lung, heart, abscess, or tumor.
Few, if any, significant patient reactions are found to radio-
pharmaceuticals used for diagnosis.
Nuclear medicine images are made by a gamma camera
or positron emission scanner that records radiation emanat-
ing from the patient and makes an image of the distribution

ANT POST
R L
i e
g f
h t
t the magnet, and cost. The major safety problem with these
• Fig. 1.11 Nuclear Medicine Bone Scan. Radioactivity has been
introduced intravenously and localizes in specific organs. In this case
a tracer makes the radioactivity localize in the bone and kidneys.
Nuclear medicine can obtain images of a number of organs, including
lungs, heart, and liver. ANT, Anterior view; POST, posterior view.
of the radioactive material (Fig. 1.11). The radiation dose
to the patient is determined by the amount of radioactive
material initially injected into the body. Therefore once
the radiopharmaceutical has been given, additional images
can be obtained without increasing the radiation dose.
Images are usually obtained as planar images that, like plain
x-rays, display three-dimensional data in two dimensions.
These images are labeled as anterior, lateral, and so forth.
Computer technology (similar to CT) has been applied to
nuclear medicine and allows images to be displayed as slices
of the tissue of interest. The major advantage of nuclear
medicine is its ability to obtain an image of physiologic
function. For example, virtually no other imaging technique
can assess regional pulmonary ventilation or hepatobiliary
function.
MAGNETIC RESONANCE IMAGING
MRI generates images by applying a varying magnetic field
to the body. The magnetic field aligns atoms. When the field
is released, radio waves are generated. The frequency of the
emitted radio waves is related to the chemical environment
of the atoms and their location. With computer analysis of
CHAPTER 1 Introduction 7
these data, magnetic resonance (MR) images (which are
essentially hydrogen maps) can be generated.
Although many MRI techniques exist, the two basic
types of images are T1 and T2. T1 images show fat as a
white or bright signal, whereas water (or cerebrospinal fluid
[CSF]) is dark. On a T2 image, fat is dark, and blood,
edema, and CSF appear white (Fig. 1.12). Unfortunately,
calcium and bone are difficult to see on MR images. What
people think are the (white) bones is really visualization of
fat in the marrow. Computer manipulation of MR images
allows slices similar to those of CT orientation to be used.
An intravenous contrast agent (gadolinium) is often used in
conjunction with MRI. Significant patient reactions are rare
with this agent, although nephrogenic systemic fibrosis has
occasionally been reported in patients with severely impaired
renal function (eGFR < 30 mL/min).
The primary advantages of MRI are that it obtains exqui-
site images of the central nervous system and stationary soft
tissues (such as the knee joint). It also does not use ionizing
radiation. Recent developments and shorter imaging times
have allowed images of the heart and blood vessels to be
generated without the need to inject anything into the
patient (Fig. 1.13).
Disadvantages of MRI have been artifacts caused by
patient motion, the inability to bring ferrous objects near
magnets is that they are so strong that if you bring a fer-
romagnetic object (such as a wrench) into the room, it can
accelerate to 150 miles per hour as it is ripped out of your
hand and flies into the bore of the magnet. Large floor
polishers have been sucked into magnets (Fig. 1.14). If a
patient is in the machine at the time, lethal consequences
will result. Be aware that some “sandbags” used for neck
stabilization actually contain small BBs and can destroy
magnets.
HYBRID IMAGING
Increases in computer power and advances in equipment
manufacturing have allowed data imaging sets from various
modalities to be combined and the images coregistered. The
most popular use of this has been integration of positron
emission tomography (PET) functional nuclear medicine
data with CT anatomic data (PET/CT) (Fig. 1.15). This
currently has wide use in the imaging of cancer. Other
forms of hybrid imaging exist, including PET combined
with MRI.
NONINTERPRETATIVE SKILLS, QUALITY,
AND PATIENT SAFETY
In addition to diagnosing and treating illness, physicians
and other medical professionals need to have additional
knowledge and skills to ensure that medical care is carried
out in a safe, efficient, and high-quality environment. There
are a number of methods to achieve these goals.
8 C HA P T E R 1 Introduction

T1 T2

Fat
CSF

CSF

CSF

A B
• Fig. 1.12 Magnetic Resonance (MR) Imaging of the Brain. A wide variety of imaging parameters can
make tissues appear vastly different. (A) The two most common presentations are T1 images, in which
fat appears white, water and cerebrospinal fluid (CSF) appear black, and brain and muscle appear gray.
In almost all MR images, bone gives off no signal and will appear black. (B) With T2 imaging, fat is dark,
and water and CSF have a high signal and will appear bright or white. The brain and soft tissues still
appear gray.

ACA

• Fig. 1.14 Floor Polisher in a Magnet. The high magnetic field

strength of a magnetic resonance machine is shown by a heavy floor
polisher sucked into the scanner. The polisher was inadvertently
brought into the room by cleaning personnel. (Courtesy T. Haygood,
MCA MD.)

• Fig. 1.13 Magnetic Resonance Angiogram. An anterior view of the
head showing intracerebral vessels, including the anterior cerebral
artery (ACA) and the middle cerebral artery (MCA). These images were
obtained without injection of any contrast agent.
Informed Consent. All patients have a right to know
what type of procedure is being suggested or ordered and
to be able to ask questions regarding the procedure or
examination. For simple procedures a short discussion or
note in the chart may be all that is necessary. However, for
most complex procedures a written informed consent is
obtained by a qualified assistant or by the physician (who
is ultimately responsible in any case). The contents of an
informed consent include expected benefits and risks, alter-
native procedures, and the risk of not having the recom-
mended procedure. The consent can be granted by the
patient or, if this is not possible due to mental issues or
being underage, by a guardian or legal representative. If
there is an emergency that may cause life-threatening condi-
tions or serious disability and informed consent cannot be
obtained, it may still be possible to proceed.

C
• Fig. 1.15 Positron Emission Tomography (PET)/Computed Tomography (CT) Hybrid Imaging. PET
nuclear medicine data (A) and CT data (B) can be coregistered to provide a single image combining both
functional and anatomic information (C). In this case the patient has colon cancer with hepatic metastases,
which were not easily seen on the CT scan alone.
Medical Errors and Adverse Events
The National Academy of Sciences has estimated that
44,000 to 98,000 deaths per year can be attributable to
medical errors and that about half of these are preventable.
A medical error can be defined either as the failure of a
planned action to be completed as intended or as the use
of a wrong plan to achieve an aim. Factors contributing to
medical errors are multiple. They may involve human
factors such as fatigue, ambient noise, poor lighting, confus-
ing or nonstandardized controls on equipment, decentral-
ized delivery, or poor systems design. Errors in radiology
and nuclear medicine have been described as perceptual
(60%–80%) versus cognitive/interpretative (20%–40%). A
perceptual error is one where a lesion can be seen in retro-
spect but was not identified by the initial interpreter. Gener-
ally, the cause of such errors is not clear, but it is hypothesized
that they might be due to a number of factors, including
poor conspicuity of the lesion, reader fatigue, rapid pace in
performing interpretations, distractions, and “satisfaction of
search” (one lesion is seen and the interpreter is happy and
stops looking). A cognitive error is when the lesion is identi-
fied but interpreted to be something that it is not (e.g.,
interpreting a lung mass as a cancer when it really is an
infectious process).
CHAPTER 1 Introduction 9
Common tools for evaluating medical errors include the
“root cause analysis” (RCA) to analyze events that have hap-
pened within the timeline. Very often, multiple causes are
identified; some of these may be quickly fixed, but others
may require system changes. Other tools include a fishbone
(Ishikawa) or Pareto diagram.
The Institute of Medicine (IOM) has embodied six
quality improvement (QI) aims for health care: safety, time-
liness, effectiveness, efficiency, equity, and patient-centered
care. There also are national patient safety goals issued by
the Joint Commission. These include two patient identifi-
ers, timely reporting of critical results, marking of procedure
site, hand hygiene, and time-out before procedure. Medica-
tion reconciliation is a process to prevent unintended medi-
cation discrepancies and is a complete review of all
medications at points of transition, including admission,
transfer, and discharge. It is required for patients admitted
to a hospital or who have changes made to their existing
medications. The review process for medication administra-
tion includes information regarding the right patient, right
medication, right route, right dose, right time, and right
documentation.
Universal protocol is also a way to prevent errors. This
involves a preprocedure verification process (preferably)
involving the patient to determine the correct procedure
10 C HA P T E R 1 Introduction
and site, as well as using a standardized list to determine
the availability of items needed for the procedure and rele-
vant documentation. The process also includes “time-outs,”
where all team members agree on identification of the site
and procedure to be performed. A time-out is usually per-
formed separately for each procedure if multiple procedures
are being performed. Attention to hand washing is crucial
for most patient care and for invasive procedures (such as
central venous catheter insertion). The use of a cap, mask,
sterile gown, sterile gloves, large sterile sheet, hand hygiene,
and cutaneous antisepsis is required.
Quality control (QC) is an ongoing review of the quality
of all factors involved in producing an item. In radiology
or nuclear medicine this would include a daily check on
machine performance or review of images by the physician
to make sure that they do not need to be repeated. Quality
assurance (QA) is a term not often used today. It is a static
process that typically is a reactive retrospective process to
determine who was at fault after a medical error. Quality
improvement (QI) involves both prospective and retrospec-
tive reviews and is a continuous process that attempts to
avoid placing blame but rather to create systems that prevent
errors from happening.
There are a number of methods used to measure and
improve quality and to develop best practices. Benchmark-
ing is used to compare portions of the system to results
derived from peers or standards. An example of this would
be comparing the exposure or dose parameters used in your
practice. These can be compared to online recommenda-
tions of groups such as the American College of Radiology
Image Wisely Program (http://www.imagewisely.org/) or the
Society of Nuclear Medicine and Molecular Imaging Prac-
tice Guidelines (http://www.snmmi.org/ClinicalPractice/
content.aspx?ItemNumber=6414). Another tool is mea-
surement of key performance (dashboard) indicators, which
allows visual analysis of variation. A chart can be used
to measure variability over time and set upper and lower
control values (sometimes called an investigation level) to
distinguish signal from noise and to enable reduction of
unnecessary variation. An example might be analysis of the
time it takes for a particular diagnostic test to be interpreted
or complication rates from specific procedures.
Once an area for QI has been identified, a hypothesis is
formed, changes are made, and a reanalysis is performed to
see if things have been fixed or if additional changes are
necessary. This has been referred to as the Plan-Do-Study-
Act (PDSA) cycle. Other methodologies for process
improvement involve engaging all workers involved in the
process. These include the “Lean” method, which in radiol-
ogy and nuclear medicine can avoid inventory pileup and
standardization of procedures. A “Six Sigma” method is
based on analysis of standard deviation from a mean for a
particular measure.
Special noninterpretative skills in radiology include
being able to assess the appropriateness of an examination
(justification) for a particular patient and managing to get
the needed diagnostic information with the lowest radiation
dose. Remember that too little a dose is a problem since
you will not have enough image quality to make the diag-
nosis. You should be able to explain alternative nonradiation
procedures to the patient as well as some concept of radia-
tion risks. You need to know that there has been new equip-
ment acceptance testing and periodic calibration (sometimes
daily) as required. Of course, you also need to know how
to manage emergencies, especially contrast reactions. Most
of this material can be located on the website of the Ameri-
can College of Radiology.
Suggested Textbooks and Website
General Radiology
Brant WE, Helms C. Fundamentals of Diagnostic Radiology. Philadel-
phia: Lippincott, Williams & Wilkins; 2012.
Nuclear Medicine
Mettler F, Guiberteau M. Essentials of Nuclear Medicine and Molecular
Imaging. 7th ed. Philadelphia: Elsevier; 2018.
Ultrasound
Rumack CM, Levine D. Diagnostic Ultrasound. 5th ed. Philadelphia:
Elsevier; 2018.
Computed Tomography and Magnetic Resonance
Haaga JR, Boll DT. CT and MRI of the Whole Body. 6th ed. Phila-
delphia: Elsevier; 2016.
Appropriateness Criteria for Ordering Studies
American College of Radiology. ACR Appropriateness Criteria.
Available at: http://acr.org/Clinical-Resources/ACR-Appropriate-
ness-Criteria. Accessed May 7, 2018.
2
Head and Soft Tissues of Face
and Neck
SKULL AND BRAIN
The appropriate initial imaging studies for various clinical
problems are shown in Table 2.1.
Normal Skull and Variants
Normal anatomy of the skull is shown in Fig. 2.1. The
most common differential problem on plain skull x-rays
is distinguishing cranial sutures from vascular grooves
and fractures. The main sutures are coronal, sagittal, and
lambdoid. A suture also runs in a rainbow shape over
the ear. In the adult, sutures are symmetric and very
wiggly and have sclerotic (very white) edges. Vascular
grooves are usually seen on the lateral view and extend
posteriorly and superiorly from just in front of the ear.
They do not have sclerotic edges and are not perfectly
straight.
A few common variants are seen on skull x-rays.
Hyperostosis frontalis interna is a benign condition of
females in which sclerosis, or increased density, is seen
in the frontal region and spares the midline (Fig. 2.2).
Large, asymmetric, or amorphous focal intracranial cal-
cifications should always raise the suspicion of a benign
or malignant neoplasm. Occasionally, areas of lucency
(dark areas) are found where the bone is thinned. The
most common normal variants that cause this are vascular
lakes or biparietal foramen. Asymmetrically round or ill-
defined holes should raise the suspicion of metastatic disease
(Fig. 2.3).
Paget disease can affect the bone of the skull. In the early
stages, very large lytic, or destroyed, areas may be seen. In
later stages, increased density (sclerosis) and marked over-
growth of the bone, causing a cotton wool appearance of
the skull, may be seen (Fig. 2.4). Always be aware that both
prostate and breast cancer can cause multiple dense metas-
tases in the skull and that both diseases are more common
than Paget disease.
BRAIN
Normal Anatomy
Box 2.1 gives a methodology to follow or checklist of items
to use when examining a computed tomography (CT) scan.
Both CT and magnetic resonance imaging (MRI) are
capable of displaying anatomic slices in a number of differ-
ent planes. The identical anatomy of the brain can appear
quite different on CT and magnetic resonance (MR) images
(Fig. 2.5). The normal anatomy of the brain on CT and
MR images is shown in Figs. 2.6 and 2.7. You should be
able to identify some anatomy on these images. There are
many very complex imaging sequences used during MRI,
depending upon the clinical question or suspected pathol-
ogy. You are not expected to be familiar with all of these,
but you should realize that success in making a diagnosis
depends on your indicating the clinical problem accurately
so that the radiologist can prescribe the correct imaging
sequences.
Intracranial Calcifications
Intracranial calcifications can be seen occasionally on a skull
x-ray, but they are seen much more often on CT. Intra-
cranial calcifications may be due to many causes. Normal
pineal and ependymal calcifications may occur. Scattered
calcifications can occur from toxoplasmosis, cysticercosis,
tuberous sclerosis (Fig. 2.8), or granulomatous disease. Uni-
lateral calcifications are very worrisome because they can
occur in arteriovenous malformations, gliomas, and
meningiomas.
Headache
Headaches are among the most common of human ail-
ments. They can be due to a myriad of causes and should
Text continued on p. 19
11

ANT
R L
A
ANT
R L
B suspected stroke. A purely ischemic acute stroke is difficult
• Fig. 2.15 Acute Subarachnoid Hemorrhage. A noncontrast axial
computed tomography scan shows the blood as areas of increased
density. (A) A transverse view near the base of the brain shows blood
in the “Texaco star” pattern (arrows), formed by blood radiating from
the suprasellar cistern into the sylvian fissures and the anterior inter-
hemispheric fissure. (B) A higher cut shows blood as an area of
increased density in the anterior and posterior interhemispheric fis-
sures, as well as in the sulci on the right (arrows). ANT, Anterior.
Transient Ischemic Attack
A transient ischemic attack (TIA) is defined as a neurologic
deficit that has an abrupt onset and from which rapid
recovery occurs, often within minutes, but always within 24
hours. The imaging indications for patients with a new
neurologic deficit are shown in Box 2.4. A TIA indicates
that the patient may be at high risk for stroke. In the acute
setting, the initial test of choice is a CT scan to differentiate
an ischemic event from a hemorrhagic one. A second CT
scan can be obtained in 24 to 72 hours if the diagnosis is
in doubt, but an MRI is more sensitive in identifying early
ischemic damage and may establish the cause of the TIA. If
initial vertebrobasilar findings are seen, an MRI provides
CHAPTER 2 Head and Soft Tissues of Face and Neck 23
• BOX 2.4 Imaging Indications With a New
Neurologic Deficit
Acute onset or persistence of the following neurologic deficits is
an indication for computed tomography or magnetic resonance
imaging:
• New vision loss
• Cranial neuropathy
• Aphasia
• Mental status change (e.g., memory loss, confusion, impaired
level of consciousness)
• Sensory abnormalities (e.g., hemianesthesia/hypesthesia
including single limb)
• Motor paralysis (e.g., hemiparesis or single limb)
• Vertigo with headache, diplopia, motor or sensory deficit,
ataxia, dysarthria, or dysmetria
better evaluation of the posterior fossa than a CT scan.
Regardless of whether a carotid bruit is present in this
setting, a duplex Doppler ultrasound examination of the
carotid arteries is indicated if the patient would be a surgical
candidate for endarterectomy. MR angiography can be used
to visualize carotid stenosis.
Stroke
A stroke may be ischemic or associated with hemorrhage.
An acute hemorrhagic stroke is most easily visualized on a
noncontrast CT scan because fresh blood is quite dense
(white). A diagnosis of stroke cannot be excluded, even with
normal results on a CT scan taken within 12 hours of a
to visualize on a CT scan unless mass effect is present. This
is noted as compression of the lateral ventricle, possible
midline shift, and effacement of the sulci on the affected
side. One key to identification of most strokes is that they
are usually confined to one vascular territory (such as the
middle cerebral artery). An acute ischemic stroke is very
easy to see on an MRI study, because the edema (increased
water) can be identified as a bright area on T2 images. In
spite of this, an MRI scan is not needed for a patient with
an acute stroke. Because anticoagulant therapy is often con-
templated, a noncontrast CT scan can be obtained to
exclude hemorrhage (which would be a contraindication to
such therapy).
After about 24 hours, the edema associated with a stroke
can be seen on a CT scan as an area of low density (darker
than normal brain). If a contrast CT scan is done 1 to
several days after a stroke, enhancement (increased density
or whiteness) may be seen at the edges of the area (so-called
luxury perfusion). During the months after a stroke, atrophy
of the brain occurs, which can be seen as widened sulci and
a focally dilated lateral ventricle on the affected side (Fig.
2.16). Different specific MRI imaging sequences are per-
formed when an acute ischemic, hemorrhagic, or chronic
stroke is suspected (Fig. 2.17).
Another random document with
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Rio Negro, (Arg.), 283, 299, 304, 309;
(Urug.), 356, 361;
(Brazil), 393, 410
Rivera, 356, 362, 366, 370;
General, 355
Rockstone, 104
Rocha, 356, 363, 366, 367
Roosevelt R., 383
Ropeway Line, 35
Roraima Mt., 61, 101, 380
Rosario, 285, 289, 297, 301, 304, 307, 308, 310, 312, 316, 322,
326, 331;
(Urug.), 366, 367
Rubber, 43, 89, 106, 143, 192, 242, 419, 420
Rurenabaque, 224, 227

Sabana Ry., 34, 37

Sacramento, Pampa del, 160, 183
Saenz Peña, Dr. Roque, 282
Safety Isls., 112
St. George Gulf, 304, 313
St. Laurent, 113
St. Roque Cape, 381
Salado del Norte R., 289, 295
Salaverry, 164, 165, 175, 186
Salt, 64, 69, 94, 201, 275, 325
Salta, 269, 283, 292, 306, 307, 312, 313, 321, 322, 326
Salto, 356, 357, 362, 365, 367, 370
Salto Grande Falls, 331
Sama R., 255
Samanco, 167, 186, 188
San Andrés, 10, 12
San Antonio, (Col.), 10, 72;
(Ven.), 72;
(Ec.), 137, 145;
(Chile), 258, 265;
(Arg.), 283, 293, 299, 304, 313;
(Par.), 345, 350;
Cape, 289
San Bernadino, 343
San Carlos, (Ven.), 55, 71, 84;
(Urug.), 367
San Carlos de Bariloche, 313
San Cristóbal, 55, 71, 84;
Isl., 133
Sandia, 199
San Eugenio, 356, 367
San Felipe, (Ven.), 55, 66, 81, 83;
(Chile), 247
San Felix, 73, 81, 84
San Fernando, 247
San Fernando de Apure, 55, 71, 84
San Fernando de Atabapo, 55, 75
San Francisco, 310
San Francisco de Yare, 80
San Fructuoso, 356
Sangay Mt., 123
San Ignacio, 335
San Jorge R., 34
San José, 356, 361, 366
San Juan, 283, 295, 303, 322, 323, 325
San Juan R., (Col.), 15, 17, 18, 24, 26, 43, 49
San Juan R., (Ven.), 69, 97
San Julian, 304, 313
San Lorenzo, (Ven.), 82, 95;
(Ec.), 137;
Cape, 121, 131
San Luis, 283, 287, 288, 297, 303, 310, 317, 319, 325
San Luis do Maranhão, 401
San Martín, 48, 152, 173, 188
San Martín, General, 150, 246, 257, 281
San Matias Gulf, 313
San Nicolas, 301
San Pedro, (Chile), 268;
(Par.), 335, 342
San Rafael, (Ven.), 83;
(Arg.), 297
San Ramón, 366
San Roque, Dique, 296
San Salvador, 343, 345, 350
Santa, 167;
R., 158, 165, 166, 167, 184, 186
Santa Ana, 83;
Lake, 170
Sant’ Anna do Livramento, 366, 410, 425
Santa Barbara, 81, 85
Santa Catharina, 375, 385, 388, 392, 418, 420, 422, 426, 431, 432
Santa Cruz, (Bol.), 207, 209, 210, 217, 218, 223, 225, 227, 230,
231, 236, 237, 238, 241, 242, 243, 342, 383;
(Arg.), 283, 300, 304, 317, 318; R., 300;
(Brazil), 411, 430
Santa Elena, 120, 131, 136, 138, 144;
Cape, 121, 122, 131
Santa Fé, 283, 285, 288, 289, 290, 297, 301, 305, 307, 308, 310,
311, 312, 316, 318, 319, 322, 326, 329, 330
Santa Isabel, 406
Santa Lucía, 370
Santa Maria Isl., 133;
Cape, 289
Santa Marta, 10, 12, 19, 21, 30, 31, 32, 36, 41, 45
Santa Marta, Nevada de, 15, 21, 40, 46
Santander, 9, 10, 28, 46, 51
Santander del Norte, 9, 10, 28, 30, 36, 37, 38, 40, 41, 81
Santarem, 406
Santa Rosa, 144
Santa Rosa de Toay, 283
Santa Teresa, 68
Santiago, 246, 247, 248, 249, 251, 254, 257, 264, 265, 272, 276;
R., 124, 126
Santiago de Chuco, 198
Santiago del Estero, 281, 283, 290, 295, 308, 312, 314, 321, 325,
331
Santo Amaro, 412
Santo Antonio, 383, 406
Santos, 4, 374, 387, 388, 394, 408, 414
São Borja, 411
São Felix, 412
São Francisco, 342, 393, 410;
R., 377, 381, 386, 398, 399, 406, 412, 429
São Lourenço R., 386
São Luis de Caceres, 407
São Luis do Maranhão, 401
São Paulo, 218, 254, 366, 375, 377, 385, 388, 394, 395, 408, 409,
410, 411, 414, 415, 416, 418, 422, 424, 425, 426, 427, 429,
430, 431, 432
São Salvador, 375, 398
São Vicente, 374
Sapodilla, 90, 106
Sapotal R., 127
Saramacca R., 109
Sarmiento Mt., 251
Sechura Bay, 163
Segovia Highlands, 60, 65, 66
Senilossa, 309
Senna Madureira, 405
Serena, See La Serena
Sergipe, 375, 398, 412, 432
Serpent’s Mouth, 69
Serrapia, Tree, 90
Sete Quedas Falls, 333, 339, 385
Sevilla de Oro, 119, 145
Sheep, 92, 143, 193, 240, 260, 277, 278, 317, 368, 426
Sibate, 37
Silla de Caracas, 60
Silver, 195, 231
Sincerín, 31
Sinú R., 16, 22, 36;
V., 44
Siquisique, 81
Sogamoso, 27, 38;
R., 35, 44
Solis, Juan de, 364
Sorata, 215, 225, 236, 455;
Mt., 212, 214
Soriano, 356, 361
Sorocabana, 409
Soroche, 129, 161, 178, 180, 191
Stock, See Live Stock
Sucre, (Ven.), 54, 55, 68, 78, 79, 82, 93, 94;
(Bol.), 206, 207, 209, 217, 224, 225
Sucre, Gen. Antonio José de, 68, 150, 206
Sugar, 41, 87, 105, 110, 142, 185, 241, 321, 349, 416
Sulphur, 94, 275
Sumbay, 200
Supe, 167, 187
Suriname, 109;
R., 109, 110, 111
Tabatinga, 406
Tacna, 148, 151, 152, 247, 255, 266, 274
Tacora, 236, 275
Tacuará R., 359
Tacuarembó, 356, 363, 370
Táchira, 55, 71, 81, 84, 93
Tagua, 21, 43, 142, 143, 191, 418
Taitao, 260
Takutu R., 108
Talara, 202
Talca, 247, 258, 264
Talcahuano, 261, 263, 264, 269, 274
Taltal, 256, 266
Tamalameque, 36, 37
Tamaya, 273
Tambo R., 170, 178, 183
Tannin, 89, 90, 277, 323, 345
Tapajós R., 339, 383, 386, 402, 406
Taquia, 200, 237
Tarapacá, 151, 247, 255, 270
Taratá, 266
Tarija, 207, 209, 217, 223, 237
Tarma, 178
Tebicuary R., 339
Temuco, 247, 269, 277
Therezina, 375, 401
Ticlio, 177, 196
Tierra del Fuego, 251, 274, 283, 290, 300, 318, 325
Tiété R., 385
Tigre, 299;
R., 124, 125
Tin, 232
Tipuani R., 230, 231
Tirapata, 183, 199
Titicaca Lake, 159, 172, 179, 180, 181, 201, 208, 215, 221, 233,
235, 238, 239, 243
Tobacco, 42, 87, 142, 191, 241, 322, 348, 416
Tocantins R., 381, 382, 402, 406, 412
Toco, 266
Tocopilla, 256, 266, 267, 272
Tocujo R., 62, 65, 81
Todos os Santos Lake, 252
Tofo, 273, 274
Tola, 237
Toledo, 366
Tolima, 9, 10, 29, 33, 35, 37, 40, 50
Tongoy, 273
Tonka Bean, 90, 107
Toquilla, 146
Tortoise, 134
Totora, 225
Treinta y Tres, 355, 356, 363, 366
Trelew, 304, 311
Tres Barros, 420
Trinidad, (Bol.), 207, 210, 218;
(Urug.), 367
Trinidad Isl., 69, 87, 93, 97, 106;
Lake, 94, 95
Trombetes R., 384
Trujillo, (Ven.), 55, 72, 81, 84, 85, 93;
(Peru), 149, 152, 154, 164
Tucacas, 65, 79, 81, 98
Tucumán, 281, 283, 285, 294, 308, 310, 312, 321, 322, 331
Tucupita, 55, 76
Tucurutu Mts., 108
Tulcán, 117, 133, 145
Tumaco, 26, 30, 31, 36, 38, 43
Tumbes, 132, 139, 149, 152, 163, 191, 198, 201
Tumbes R., 122, 163
Tumeremo, 74, 84
Tumuc Humac Mts., 109, 112
Tungsten, 200, 325
Tungurahua, 116, 117, 133, 139
Tunja, 10, 27, 35
Tupiza, 217, 223, 230
Tupungato, 251
Turiamo, 79, 92
Tutoya, 401
Tuy R., 63, 68, 80
Ucayali R., 124, 125, 159, 160, 169, 170, 173, 178, 182, 183, 192
Unare R., 60
Uncia, 224, 233, 234
Unduavi, 224
União da Victoria, 342, 393
United Fruit Co., 21, 22
Upata, 73
Urabá Gulf, 16, 23, 35, 41, 46
Uribe, Señor, 11;
President, 355
Uracá, 72, 84
Urcos, 183
Urquiza, General, 304
Urubamba R., 170, 172, 183, 192
Urubupungá Falls, 385
Urucum, 428
Uruguay, 114, 289, 331, 334, 348, 349, 354-371, 416, 427, 431,
452
Uruguay R., 288, 289, 294, 306, 307, 313, 331, 354, 359, 362,
365, 371, 385, 391, 411
Uruguayana, 392, 411
Ushuaiá, 283, 300, 304
Uspallata Pass, 267, 296
Uyuni, 217, 223, 224, 268

Valdivia, (Col.), 34;

(Chile), 246, 247, 248, 259, 264, 277
Valdivia, Pedro de, 246
Valencia, 55, 67, 80, 83, 84, 90;
Lake, 62, 67, 87
Valera, 72
Valle de Upar, 36
Vallenar, 265
Vanadium, 200
Vanilla, 88
Vaupés, 10, 26, 43;
R., 17
Vegetables, 190
Venezuela, 15, 30, 37, 53-99, 101, 423
Venezuela, Gulf of, 64, 65, 78
Ventuari R., 61, 76
Verrugas V., 177
Vespucci, Amerigo, 373
Viacha, 210, 223
Victoria, 375, 397, 411, 430
Vicuñas, 193, 239
Vichada, 10, 27;
R., 17, 27, 75, 91
Viedma, 283, 304
Vilcamayu R., 159
Vilcanota, 159, 211
Villa Bella, 210, 219, 227, 243, 413
Villa Church, 225, 227, 413
Villa Concepción, 342
Villa de Cura, 67, 83
Villa Encarnación, 342
Villa Hayes, 342, 349
Villamizar, 30, 31, 85
Villa Montes, 207, 220
Villa Murtinho, 219, 227, 413
Villavicencio, 10
Villeta, 335
Vinces R., 127
Viña del Mar, 263
Viscacha, 193, 239
Visser, 304
Viticulture, 189, 241, 276, 322, 370
Vitor, 180
Vreeden Hook, 104

Waini R., 108

Water power, 52, 83, 98, 101, 124, 202, 225, 279, 331, 371, 385,
394, 405, 426, 433
West Coast, 114-279
Wheat, 43, 88, 276, 320, 418
Wheelwright, William, 264, 307
Wismar, 104
Wool, 193, 239, 278, 317, 369

Xarquedas, 431
Xingú R., 383, 402
Yacuiba, 210, 220, 223, 243, 312
Yaguachi R., 127
Yaguarón R., 359
Yapurá R., 17, 406
Yaracuy, 54, 55, 66, 77, 81, 93
Yareta, 237
Yaritagua, 66
Yauli, 197, 200
Yauricocha, 197, 198
Yerba Mate, 324, 347, 393, 422
Yhú, 335
Ypoa Lake, 338, 340
Yucca, 142
Yungas, 213, 215, 224, 226, 234, 242, 243
Yungay, 166
Yurimaguas, 173
Yuruán, 108
Yuruary R., 89, 92, 93

Zamora, (Ven.), 55, 71, 88;

(Ec.), 145
Zaragosa, 49
Zarate, 289, 301, 312, 318
Zaruma, 132, 145
Zarzal, 37
Zavala, General, 354
Zinc, 45, 200, 236, 274
Zipiquirá, 37, 45
Zorritos, 144, 201
Zulia, 54, 55, 64;
Lake, 62;
R., 16, 28, 30, 31, 36, 64, 86
Zumba, 139
 Transcriber’s Notes
Page 22: “Madgalena River” changed to “Magdalena River”
Page 92: “Cuidad Bolívar” changed to “Ciudad Bolívar”
Page 199, Page 308 and Page 395: “on acount” changed to “on account”
Page 361: “west of Montevido” changed to “west of Montevideo”
Page 471: “Buenventura and Tumaco” changed to “Buenaventura and Tumaco”
Page 483: “Direccion Gencral” changed to “Direccion General”
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