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 SECOND EDITION

FEDERLE • ROSADO-DE-CHRISTENSON
RAMAN • CARTER • WOODWARD • SHAABAN
ii
 SECOND EDITION
Michael P. Federle, MD, FACR
Professor and Associate Chair for Education
Department of Radiology
Stanford University School of Medicine
Stanford, California

Melissa L. Rosado-de-Christenson, MD, FACR

Section Chief, Thoracic Radiology
Department of Radiology
Saint Luke’s Hospital of Kansas City
Professor of Radiology
University of Missouri–Kansas City School of Medicine
Kansas City, Missouri

Siva P. Raman, MD
Assistant Professor of Radiology
Department of Radiology
Johns Hopkins University School of Medicine
Baltimore, Maryland

Brett W. Carter, MD
Assistant Professor of Radiology
Department of Diagnostic Radiology
The University of Texas MD Anderson Cancer Center
Assistant Professor of Radiology
Department of Diagnostic and Interventional Imaging
The University of Texas Medical School at Houston
Houston, Texas

Paula J. Woodward, MD
David G. Bragg, MD and Marcia R. Bragg Presidential Endowed
Chair in Oncologic Imaging
Professor of Radiology
Department of Radiology and Imaging Sciences
University of Utah School of Medicine
Salt Lake City, Utah

Akram M. Shaaban, MBBCh

Professor of Radiology
Department of Radiology and Imaging Sciences
University of Utah School of Medicine
Salt Lake City, Utah

iii
 1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

IMAGING ANATOMY: CHEST, ABDOMEN, PELVIS, SECOND EDITION ISBN: 978-0-323-47781-9

Copyright © 2017 by Elsevier. All rights reserved.

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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be
noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the
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practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.

Publisher Cataloging-in-Publication Data

Names: Federle, Michael P. | Rosado-de-Christenson, Melissa L. | Raman, Siva P. |

Carter, Brett W. | Woodward, Paula J. | Shaaban, Akram M.
Title: Imaging anatomy. Chest, abdomen, pelvis / [edited by] Michael P. Federle, Melissa L.
Rosado-de-Christenson, Siva P. Raman, Brett W. Carter, Paula J. Woodward, and
Akram M. Shaaban.
Other titles: Chest, abdomen, pelvis.
Description: Second edition. | Salt Lake City, UT : Elsevier, Inc., [2016] | Includes
bibliographical references and index.
Identifiers: ISBN 978-0-323-47781-9
Subjects: LCSH: Diagnostic imaging--Handbooks, manuals, etc. | Chest--Anatomy--Handbooks,
manuals, etc. | Abdomen--Anatomy--Handbooks, manuals, etc. | Pelvis--Anatomy--Handbooks,
manuals, etc. | Imaging systems in medicine--Handbooks, manuals, etc. | MESH: Thorax--
anatomy & histology--Atlases. | Abdomen--anatomy & histology--Atlases. | Pelvis--anatomy
& histology--Atlases. | Magnetic Resonance Spectroscopy--Atlases. | Tomography, X-Ray
Computed--Atlases.
Classification: LCC RC78.7.D53 D534 2016 | NLM WE 17 | DDC 616.07’54--dc23

International Standard Book Number: 978-0-323-47781-9

Cover Designer: Tom M. Olson, BA
Cover Art: Lane R. Bennion, MS
Printed in Canada by Friesens, Altona, Manitoba, Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

iv
 Dedications
To Ric Harnsberger, whose vision, enthusiasm, charisma, and hard work created
and sustained this entire enterprise. Your legacy will endure long after all of our
names are forgotten.
MPF

To my family, especially my husband, Paul, and my daughters, Jennifer and

Heather, whose love, encouragement, and support have seen me through this
project. To my dear friend and coauthor, Dr. Brett Carter, from whom I continue
to learn every day.
MRDC

To my wife, Janani Venkateswaran, whose support throughout my career has

helped sustain me and drive me forward.
SPR

I dedicate this project to my parents, Ralph and Joy Carter, without whom this
effort would not have been possible.
BWC

To Miguel Flores.
The stalwart patriarch of the Flores/z clan, whose staunch work ethic remains
an inspiration to me. You started in this world with so little and have done so
much. Thank you not only for your example but also for your hijo.
PJW

To my parents, I truly owe you everything.

To my wife, Inji, son, Karim, and daughters, May and Jena, the jewels of my life,
thanks for your understanding and tremendous support.
AMS

v
vi
Additional Contributing Authors
Gerald F. Abbott, MD, FACR
Associate Radiologist, Thoracic
Massachusetts General Hospital
Associate Professor
Harvard Medical School
Boston, Massachusetts

Rania Farouk El Sayed, MD, PhD

Assistant Professor
Genitourinary and MR Pelvic Floor Imaging Unit
Department of Radiology, Faculty of Medicine
Cairo University Hospitals
Cairo, Egypt

vii
viii
 Preface

In his elegant foreword to the first edition of this book, Professor Morton Meyers
related the evolution of our understanding of human anatomy, from Vesalius’ Fabrica
through the many contributions of surgeons, such as Harvey Cushing, who wrote that
“...from the publication of the Fabrica almost to the present day the intimate pursuit
of...anatomy has constituted the high road for entry into the practice of surgery.”
Meyers went on to write, “Today it is the radiologist who is most facile with highly
detailed anatomy, and who...demonstrates this in vivo. Dissectional anatomy has been
superseded by cross-sectional anatomy.”

In the decade since the publication of the first edition of this book, our ability to define
normal and abnormal anatomy of the chest, abdomen, and pelvis has continued
to advance. An example is the major improvement in MR evaluation of the pelvis,
depicting in multiple planes with unprecedented detail the pertinent anatomical
alterations that may result in pelvic floor laxity, urinary and fecal incontinence, and
perianal fistulas. Similar advances have been made in the multimodality depiction of
anatomic structures throughout the body, and these have been incorporated into this
second edition of Imaging Anatomy.

As with the first edition, we feature what Meyers deemed “exquisite, museum-quality
illustrations,” paired with the imaging modalities most relevant to the understanding
of human anatomy in health and disease.

We hope that the efforts of our radiologist authors and talented medical illustrators
will make the anatomy of the chest, abdomen, and pelvis “come alive” for our readers.

Michael P. Federle, MD, FACR

Professor and Associate Chair for Education
Department of Radiology
Stanford University School of Medicine
Stanford, California

ix
x
Acknowledgments

Text Editors
Arthur G. Gelsinger, MA
Nina I. Bennett, BA
Terry W. Ferrell, MS
Karen E. Concannon, MA, PhD
Matt W. Hoecherl, BS
Megg Morin, BA

Image Editors
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

Illustrations
Lane R. Bennion, MS
Richard Coombs, MS
Laura C. Sesto, MA

Art Direction and Design

Tom M. Olson, BA
Laura C. Sesto, MA

Lead Editor
Lisa A. Gervais, BS

Production Coordinators
Angela M. G. Terry, BA
Rebecca L. Hutchinson, BA
Emily Fassett, BA

xi
xii
 Sections

SECTION 1: CHEST

SECTION 2: ABDOMEN

SECTION 3: PELVIS

xiii
 TABLE OF CONTENTS

636 Small Intestine

SECTION 1: CHEST Siva P. Raman, MD and Michael P. Federle, MD, FACR
4 Chest Overview 666 Colon
Melissa L. Rosado-de-Christenson, MD, FACR Siva P. Raman, MD and Michael P. Federle, MD, FACR
44 Lung Development 708 Spleen
Melissa L. Rosado-de-Christenson, MD, FACR Siva P. Raman, MD and Michael P. Federle, MD, FACR
64 Airway Structure 732 Liver
Brett W. Carter, MD and Gerald F. Abbott, MD, FACR Siva P. Raman, MD and Michael P. Federle, MD, FACR
86 Vascular Structure 778 Biliary System
Melissa L. Rosado-de-Christenson, MD, FACR Siva P. Raman, MD and Michael P. Federle, MD, FACR
106 Interstitial Network 804 Pancreas
Brett W. Carter, MD and Gerald F. Abbott, MD, FACR Siva P. Raman, MD and Michael P. Federle, MD, FACR
118 Lungs 834 Retroperitoneum
Melissa L. Rosado-de-Christenson, MD, FACR Siva P. Raman, MD and Michael P. Federle, MD, FACR
148 Hila 860 Adrenal
Melissa L. Rosado-de-Christenson, MD, FACR Siva P. Raman, MD and Michael P. Federle, MD, FACR
178 Airways 882 Kidney
Brett W. Carter, MD and Gerald F. Abbott, MD, FACR Siva P. Raman, MD and Michael P. Federle, MD, FACR
200 Pulmonary Vessels 920 Ureter and Bladder
Melissa L. Rosado-de-Christenson, MD, FACR Siva P. Raman, MD and Michael P. Federle, MD, FACR
232 Pleura
Brett W. Carter, MD and Gerald F. Abbott, MD, FACR SECTION 3: PELVIS
258 Mediastinum 946 Vessels, Lymphatic System and Nerves, Pelvic
Melissa L. Rosado-de-Christenson, MD, FACR Paula J. Woodward, MD and Akram M. Shaaban, MBBCh
294 Systemic Vessels
Melissa L. Rosado-de-Christenson, MD, FACR MALE
336 Heart
Melissa L. Rosado-de-Christenson, MD, FACR 974 Male Pelvic Wall and Floor
380 Coronary Arteries and Cardiac Veins Paula J. Woodward, MD and Akram M. Shaaban, MBBCh
Akram M. Shaaban, MBBCh 1000 Testes and Scrotum
402 Pericardium Paula J. Woodward, MD and Akram M. Shaaban, MBBCh
Melissa L. Rosado-de-Christenson, MD, FACR 1018 Prostate and Seminal Vesicles
422 Chest Wall Paula J. Woodward, MD and Akram M. Shaaban, MBBCh
Brett W. Carter, MD and Gerald F. Abbott, MD, FACR 1036 Penis and Urethra
Paula J. Woodward, MD and Akram M. Shaaban, MBBCh
SECTION 2: ABDOMEN FEMALE
448 Embryology of Abdomen
1050 Female Pelvic Floor
Michael P. Federle, MD, FACR and Siva P. Raman, MD
Paula J. Woodward, MD, Rania Farouk El Sayed, MD, PhD,
484 Abdominal Wall
and Akram M. Shaaban, MBBCh
Siva P. Raman, MD and Michael P. Federle, MD, FACR
1078 Uterus
508 Diaphragm
Paula J. Woodward, MD and Akram M. Shaaban, MBBCh
Siva P. Raman, MD and Michael P. Federle, MD, FACR
1104 Ovaries
528 Peritoneal Cavity
Paula J. Woodward, MD and Akram M. Shaaban, MBBCh
Siva P. Raman, MD and Michael P. Federle, MD, FACR
550 Vessels, Lymphatic System and Nerves, Abdominal
Siva P. Raman, MD and Michael P. Federle, MD, FACR
592 Esophagus
Michael P. Federle, MD, FACR and Siva P. Raman, MD
608 Gastroduodenal
Siva P. Raman, MD and Michael P. Federle, MD, FACR

xiv
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 SECOND EDITION

FEDERLE • ROSADO-DE-CHRISTENSON
RAMAN • CARTER • WOODWARD • SHAABAN
This page intentionally left blank
 SECTION 1

Chest

Chest Overview 4
Lung Development 44
Airway Structure 64
Vascular Structure 86
Interstitial Network 106
Lungs 118
Hila 148
Airways 178
Pulmonary Vessels 200
Pleura 232
Mediastinum 258
Systemic Vessels 294
Heart 336
Coronary Arteries and Cardiac Veins 380
Pericardium 402
Chest Wall 422
 Chest Overview
Chest

GENERAL ANATOMY AND FUNCTION CHEST RADIOGRAPHY

Chest Wall Standard Chest Radiography
• Anatomy • Imaging study of choice for initial assessment of
○ Spine cardiopulmonary disease
○ Sternum • PA and lateral chest radiographs
○ Ribs ○ Orthogonal views (at right angles to each other)
○ Clavicles ○ Analysis of orthogonal views for precise anatomic
○ Scapulae localization of imaging abnormalities
○ Skeletal muscles Standard Radiographic Positioning
○ Chest wall nerves and vessels
• Upright patient
○ Skin and subcutaneous fat
• Full inspiration and breath hold near total lung capacity
• Function
• No rotation or motion
○ Protects lungs, cardiovascular structures, and
• Attempt to minimize overlying osseous structures
intrathoracic organs
• Area of interest closest to image receptor (IR)
○ Participates in bellows-like process of respiration
• Radiographic technique
Pleura ○ Source-to-image receptor distance (SID): 72 inches to
• Anatomy minimize magnification
○ Thin, continuous membrane ○ Central x-ray beam centered on thorax
○ Parietal pleura: Lines nonpulmonary surfaces ○ Beam collimation to include outer chest wall
○ Visceral pleura: Lines pulmonary surfaces Radiographic Projections
○ Pleural space: Potential space between pleural surfaces
• Posteroanterior (PA) chest radiography
• Function
○ Term PA: Describes PA direction of x-ray beam traversing
○ Production and absorption of normal pleural fluid chest toward IR
– Lubrication of pleural surfaces ○ Anterior chest against IR
– Facilitation of lung motion during respiration ○ Head vertically positioned and chin on top of grid device
○ Clearance of abnormal pleural fluid ○ Dorsal wrists on hips, and elbows rotated anteriorly to
Airways move scapulae laterally
• Anatomy ○ Shoulders moved caudally and squarely against IR to
○ Trachea bring clavicles below apices
○ Mainstem bronchi • Left lateral chest radiography
○ Lobar bronchi ○ Term left lateral: Denotes that left lateral chest wall is
against IR
○ Segmental/subsegmental bronchi
○ X-ray beam traverses chest from right to left toward IR
○ Bronchioles
○ Arms above head to move upper extremities away from
○ Distal airways and alveoli
lungs and mediastinum
• Function
• Anteroposterior (AP) chest radiography
○ Gas exchange during respiration
○ Term AP: Describes anteroposterior direction of x-ray
○ Protective mechanisms against foreign particles
beam traversing chest toward IR
– Mucociliary escalator
○ Supine and bedside (portable) radiography and imaging
– Cough reflex of sitting and semiupright patients
○ Gas exchange to and from alveolar-capillary interface – Neonates, infants, and young children
Heart and Great Vessels – Debilitated and unstable patients
• Anatomy – Critically ill and bed-ridden patients
○ Venae cavae ○ Distinctive features
○ Right atrium – Magnification of anterior structures (heart and
○ Right ventricle mediastinum) farthest from IR; shorter SID
○ Pulmonary arteries – Clavicles course horizontally and partially obscure
apices
○ Capillary network
– Ribs assume horizontal course
○ Pulmonary veins
• Lateral decubitus chest radiography
○ Left atrium
○ Recumbent position with right or left side down
○ Left ventricle
○ Elevation of chest on radiolucent support
○ Thoracic aorta and branches
○ Frontal radiograph (AP or PA) with horizontal x-ray beam
• Function
○ Indications
○ Pump action for systemic and pulmonary circulations
– Evaluation of pleural fluid in dependent pleural space
○ Transport of deoxygenated blood to capillary-alveolar
(x-ray beam tangential to fluid-lung interface)
interface
– Evaluation of air in nondependent pleural space (x-ray
○ Transport of oxygenated blood to tissues
beam tangential to visceral pleura-air interface)
4
 Chest Overview
• Apical lordotic (AP or PA axial) chest radiography
○ Superior angulation of x-ray beam from horizontal plane
of 15-20°
○ Distinctive features
– Clavicles and first anterior ribs project above apices
– Ribs course horizontally
– Magnification (foreshortening) of mediastinum
○ Indications
– Radiographic visualization of apex, superior
mediastinum and thoracic inlet
– Enhanced visualization of minor fissure in suspected
middle lobe atelectasis
• Expiratory radiography
○ Evaluation of air-trapping
○ Evaluation of pneumothorax (limited value)
– No clear difference in sensitivity or specificity for
diagnosis
Radiographic Interpretation
• Assessment of patient's identity and location of right/left
markers
• Assessment of entire thorax
○ Frontal radiography
– Inclusion of all thoracic structures from larynx to lung
bases
– Full inspiration
□ Diaphragm below posterior 9th-10th ribs or at 5th-
7th anterior ribs at mid clavicular line
○ Lateral radiography
– Inclusion of anteroposterior extent of chest wall
– Inclusion of apical lung and posterior
costodiaphragmatic sulci
• Assessment of appropriate radiographic positioning
○ No rotation
– Spinous process of T3 (posterior structure) centered
between medial clavicles (anterior structures) on
frontal radiography
– Superimposition of right and left ribs posterior to
thoracic vertebrae on lateral radiography
○ Medial aspects of scapulae lateral to lungs on frontal
radiography
○ Arms above thorax without superimposition on lung and
mediastinum on lateral radiography
• Appropriately exposed radiograph
○ Assessment of peripheral pulmonary vasculature
○ Visualization of pulmonary vessels through heart and
diaphragm on frontal radiography
○ Visualization of vertebrae through heart on frontal
radiography
• Systematic evaluation
○ Assessment of multiple superimposed structures and
tissues
○ Assessment of all visible structures including portions of
neck, shoulders, and upper abdomen
○ Anatomic localization of abnormalities
○ Assessment of associated findings
○ Comparison to prior studies
• Challenges
○ Evaluation of retrocardiac lung
○ Evaluation of retrodiaphragmatic lung
○ Evaluation of apical lung
Chest
Radiographic Densities
• 5 radiographic densities
○ Air
○ Water (fluid, blood, and soft tissue)
○ Fat
○ Bone
○ Metal (contrast, metallic portions of medical devices,
metallic foreign bodies)
• Silhouette sign
○ Intrathoracic process (mass, consolidation, pleural fluid)
that touches mediastinum or diaphragm obscures
visualization of their borders on radiography
○ Critical for radiographic diagnosis of
– Atelectasis
– Consolidation
– Pleural effusion
COMPUTED TOMOGRAPHY
General Concepts
• Imaging based on x-ray absorption by tissues with differing
atomic numbers
• Display of differences in x-ray absorption in cross-sectional
format
• Excellent spatial resolution
• Enhanced visualization of structures of different tissue
density based on display of wide range of Hounsfield unit
(HU) measurements
○ Window width refers to number of HU displayed
○ Window level refers to median (center) HU
○ Window width and level for assessment of thoracic CT
– Lung window (width of 1,500 HU; level of -650 HU)
□ Evaluation of lungs, airways, and air-containing
portions of gastrointestinal tract
□ Identification of pneumomediastinum,
pneumoperitoneum, and soft tissue gas
– Soft tissue (mediastinal) window (width of 400 HU;
level of 40 HU)
□ Evaluation of vascular structures and soft tissues of
mediastinum and chest wall
– Bone window (width of 2,000 HU; level of 400 HU)
□ Evaluation of skeletal and calcified structures
□ Evaluation of metallic objects and medical devices
– Liver window (width of 150 HU; level of 50 HU
without contrast and 100 HU with contrast)
□ Evaluation of upper abdomen: Liver, kidney
□ Evaluation of pleural effusions for solid pleural
nodules
Conventional CT
• Evaluation, localization, and characterization of
abnormalities detected on radiography
• Localization of lesions in preparation for CT-guided
biopsy/drainage
Contrast-Enhanced CT
• Administration of intravenous contrast
○ Evaluation of vascular structures
○ Evaluation of vascular abnormalities
○ Distinction of vascular structures from adjacent soft
tissues (e.g., lymph nodes)
5
 Chest Overview
Chest

○ Determination of lesion/tissue enhancement ○ Intrinsic vascular "contrast"

• Administration of enteric contrast ○ Increased soft tissue contrast
○ Evaluation of gastrointestinal perforations/leaks
Technique
CT Angiography • Spin-echo sequences typically used in chest imaging
• Vascular imaging ○ T1-weighted images
○ Timing of contrast bolus ○ T2-weighted images
○ Imaging of specific vascular structures • Bright blood sequences
– CT pulmonary angiography for evaluation of
Indications
pulmonary thromboembolic disease
– CT aortography for evaluation of traumatic aortic • Imaging of heart and great vessels
injury or aneurysm • Distinction of vascular structures from adjacent soft tissues
– CT aortography for evaluation of acute aortic without use of contrast
syndrome • Evaluation of mediastinum and hila
□ Baseline unenhanced images required prior to • Diagnostic imaging of thymus
contrast administration to document intramural • Assessment of chest wall and diaphragm
hematoma
ANGIOGRAPHY
High-Resolution CT
Pulmonary Angiography
• Technique
○ Thin sections to minimize partial volume effects • Venous catheterization
○ High-resolution reconstruction algorithm • Cannulation of pulmonary arterial system
• Indications • Indications
○ Evaluation of diffuse infiltrative lung disease ○ Evaluation of congenital and acquired pulmonary
○ Evaluation of patients with unexplained dyspnea and vascular abnormalities
normal radiographs ○ Management of selected cases of thromboembolic
• Special techniques disease
○ Prone imaging for evaluation of peripheral basilar lung Aortography
disease • Arterial catheterization
○ Expiratory imaging for evaluation of small airways • Cannulation of proximal aorta
disease
• Indications
Postprocessing Techniques ○ Evaluation of traumatic aortic and great vessel injury
• Multiplanar reformations ○ Assessment of congenital arterial vascular anomalies
○ Multiplanar evaluation of axially oriented structures and ○ Evaluation of caliber and integrity of aortic and great
abnormalities vessel lumina
○ Evaluation of anatomic location of lung lesions in relation Bronchial Artery and Intercostal Arteriography
to interlobar fissures
• Arterial catheterization
○ Evaluation of chest wall and mediastinal involvement by
• Selective cannulation of bronchial/intercostal arteries
adjacent pulmonary lesions
• Indications
○ Coronal and sagittal lesion measurements
○ Diagnosis and treatment of hemoptysis
• Maximum-intensity projection (MIP)
○ Evaluation of vascular structures
OTHER CHEST IMAGING MODALITIES
○ Increased conspicuity of pulmonary nodules
• Minimum-intensity projection (minIP) Scintigraphy
○ Evaluation of central airways and air-trapping • Positron-emission tomography
• Surface-rendered displays ○ Determination of metabolic activity of lesions
• Volume-rendered techniques for problem solving and ○ Staging of malignant neoplasms
education ○ Use of integrated PET/CT imaging
○ Virtual bronchoscopy • Ventilation-perfusion imaging
○ Evaluation of thromboembolic disease
MAGNETIC RESONANCE IMAGING – Study of choice in pregnant subjects
General Concepts ○ Evaluation of pre- and postoperative lung function
• Application of radiofrequency to excite protons within Ultrasound
magnetic field • Evaluation of pleural effusion
• Detection of signal emitted by nuclei as they relax to their ○ Free vs. loculated
original alignment with generation of image depicting their ○ Thoracentesis/biopsy planning and thoracostomy tube
spatial distribution placement
• Advantages of MR • Evaluation of diaphragmatic motion in cases of suspected
○ Excellent contrast resolution paralysis
○ Multiplanar imaging
6
 Chest Overview

Chest
CHEST OVERVIEW

Chest wall skeletal

structures

Airways

Thoracic great vessels

Lung

Heart

Chest wall muscle

Chest wall subcutaneous

tissue

Pleura

Graphic shows the complex and diverse structures and organs of the thorax. The chest wall skeletal and soft tissue structures surround
and protect the primary organs of respiration, the thoracic cardiovascular system, and the proximal gastrointestinal tract. The apposed
pleural surfaces create a potential space that normally contains a small amount of fluid, which lubricates the pleural surfaces and
reduces friction during respiratory motion. The airways deliver oxygen to the alveolar-capillary interface and carry carbon dioxide out to
the environment. The heart and vessels deliver deoxygenated blood to the capillary-alveolar interface and oxygenated blood to the
peripheral organs and tissues.

7
 Chest Overview
Chest

PA CHEST RADIOGRAPHY

Chest wall skeletal

structures
Aorta

Chest wall soft tissues

Airways

Interlobar pulmonary
artery

Heart

Lung

Normal posteroanterior (PA) chest radiograph helps illustrate inherent challenges regarding interpretation of radiographs of the
thorax. Chest radiography displays a wide range of structures and tissue types with significant superimposition of structures of different
radiographic densities. Portions of the lung may be obscured by overlying mediastinal soft tissues and skeletal structures. Attention to
radiographic image quality is of paramount importance for accurate diagnosis of subtle abnormalities.

8
 Chest Overview

Chest
LATERAL CHEST RADIOGRAPHY

Thoracic aorta
Trachea

Lung

Sternum

Thoracic vertebra
Heart

Hemidiaphragms

Lateral chest radiography is orthogonal (at 90°) to PA chest radiography. The lateral chest radiograph is a complementary radiographic
projection that allows visualization of the retrocardiac left lower lobe and the retrodiaphragmatic lung bases, and it allows evaluation
of the thoracic vertebrae. As on the PA chest radiograph, multiple structures of various densities are superimposed and must be
evaluated in a systematic manner. Evaluation of both PA and lateral chest radiographs allows anatomic localization and
characterization of thoracic abnormalities and the formulation of an appropriate differential diagnosis.

9
 Chest Overview
Chest

PA CHEST RADIOGRAPHY, POSITIONING AND COLLIMATION

Chin over grid device

Vertical image receptor

X-ray beam travels in

posteroanterior direction
Scapula rotated off lung

Hand pronated with dorsal

wrist on hip

Collimation of x-ray beam

Lung apex included

X-ray beam centered on chest

Least magnification of heart
and mediastinum

Costophrenic angle included

(Top) Graphic shows proper positioning for PA chest radiography. The patient is upright with the anterior chest against the vertical
image receptor, the chin over the top of the device, the arms flexed with the backs of the hands on the hips, and the shoulders internally
rotated to move the scapulae off the lungs. The x-ray beam travels through the patient in a posteroanterior direction. (Bottom) Graphic
shows proper PA chest radiographic collimation for imaging the lungs and mediastinum. The white target sign shows the centering of
the x-ray beam. The blue overlay represents the collimated x-ray beam that extends from the cervical airway superiorly to below the
costophrenic angles inferiorly and includes the left and right skin surfaces. The anterior structures of the chest (shown in color) are
closest to the image receptor and experience the least magnification.

10
 Chest Overview

Chest
PA CHEST RADIOGRAPHY

Spinous process of T3

Medial clavicles

Medial left scapula

Retrocardiac thoracic vertebra

Retrocardiac pulmonary
vessels

Retrodiaphragmatic
pulmonary vessels

Spinous process of T3

Medial right clavicle Medial left clavicle

Medial right scapula

Increased opacity of left
hemithorax

(Top) Well-positioned normal PA chest radiograph shows that the scapulae are rotated off the lungs and the spinous process of T3 is
located equidistant from the medial clavicles. Proper collimation spans from the cervical trachea superiorly to below the costophrenic
angles inferiorly and includes the lateral aspects of the chest wall. Optimal exposure allows visualization of the peripheral pulmonary
vessels, the vertebral bodies (visible through the mediastinum), and the retrocardiac and retrodiaphragmatic pulmonary vessels.
(Bottom) Poorly positioned PA chest radiograph shows marked rotation to the right. The left medial clavicle overlies the spinous
process of T3, and the right medial clavicle is displaced to the right of midline. Increased density of the left hemithorax results from x-
ray penetration of a greater thickness of left-sided chest wall soft tissues, when compared to the right, due to rotation.

11
 Chest Overview
Chest

LEFT LATERAL CHEST RADIOGRAPHY, POSITIONING AND COLLIMATION

Arms extended upward

Vertical image receptor

X-ray beam travels from right

to left

Left lateral chest against grid

device

Upper lung included Upper extremities rotated off

upper lung

x-ray beam centered on chest

Least magnification of left-

sided structures

Costophrenic angle included

Collimation of x-ray beam

(Top) Graphic shows proper positioning for left lateral chest radiography. The patient is upright with the left lateral chest against the
vertical image receptor and the arms extended upward for unobstructed visualization of the upper lungs. The x-ray beam travels
through the patient from right to left for a left lateral chest radiograph. (Bottom) Graphic shows proper left lateral chest radiographic
collimation for imaging the lungs and mediastinum. The white target sign shows the centering of the x-ray beam. The blue overlay
represents the collimated x-ray beam that extends from the cervical airway superiorly to below the costophrenic angles inferiorly and
includes the anterior and posterior skin surfaces. The structures of the left chest (shown in color) are closest to the image receptor and
experience the least magnification.

12
 Chest Overview

Chest
LEFT LATERAL CHEST RADIOGRAPHY

Anterior scapular borders

Hila

Intervertebral disk

Left posterior rib

Left costophrenic angle

Right posterior rib

Right costophrenic angle

Humeri

Upper extremity soft tissues

Left posterior rib

Right posterior rib

Left costophrenic angle

Right costophrenic angle

(Top) Well-positioned normal left lateral chest radiograph shows that the upper extremities are not visible. The hila are centrally
located. The thoracic intervertebral disks are visible. The posterior ribs are superimposed and project behind the vertebrae. There is
minimal magnification of the left posterior ribs, which appear sharper and smaller than the right posterior ribs. Proper collimation
allows inclusion of the lung apices, the posterior costophrenic angles, and the anterior and posterior skin surfaces. (Bottom) Poorly
positioned left lateral chest radiograph shows that the skeletal and soft tissue structures of the upper extremities obscure the anterior
lungs and mediastinum. Rotation precludes superimposition of the posterior ribs. The right posterior ribs appear larger and project
behind the left posterior ribs. The right costophrenic angle projects posterior to the left.

13
 Chest Overview
Chest

AP CHEST RADIOGRAPHY, POSITIONING AND COLLIMATION

Centering of x-ray beam

Supine patient

Radiographic cassette

Bed or x-ray table

Right medial clavicle Left medial clavicle

Aortic arch

Right scapula Left scapula

Heart

Retrodiaphragmatic
pulmonary vessel

(Top) Graphic shows proper positioning for supine AP chest radiography. The patient's back is against the radiographic cassette, and the
upper extremities are by the patient's sides. Internal rotation of the shoulders will minimize the degree of superimposition of the
scapulae on the lateral upper lungs. The x-ray beam travels through the patient in an anteroposterior direction. The heart and anterior
chest structures are farthest from the cassette and experience some magnification. (Bottom) Normal AP chest radiograph shows that
the heart and great vessels appear mildly magnified. The clavicles show a horizontal course and their medial portions obscure the lung
apices. The medial scapulae project over the lateral aspects of the lungs. Note that exposure factors and collimation are optimal with
visualization of retrocardiac and retrodiaphragmatic skeletal and vascular structures.

14
 Chest Overview

Chest
PORTABLE AP CHEST RADIOGRAPHY, TRAUMA AND INTENSIVE CARE

Remote right clavicle fracture

Overlying external monitoring

devices
Appropriately positioned
endotracheal tube

Trauma board artifact

External monitoring device

Umbilical vein catheter tip in

right atrium

External monitoring device

Orogastric tube tip in stomach

(Top) Supine bedside (portable) AP chest radiograph shows a patient involved in a motor vehicle collision. Portable radiographs are used
for imaging debilitated, seriously ill, and traumatized patients. AP chest radiographs in the setting of trauma are often compromised by
technical factors related to overlying radioopaque monitoring and stabilizing devices. However, they provide a quick assessment of the
integrity of the thoracic structures and the position of life support devices. (Bottom) Supine AP chest radiograph shows a 1-day-old
infant born at 31 weeks of gestation with mild respiratory distress syndrome. Portable radiography is optimal for imaging neonates and
infants, particularly those who are seriously ill due to congenital abnormalities &/or prematurity. Portable chest radiography allows
rapid assessment of life support devices, cardiothymic silhouette, pleural spaces, skeletal structures, and upper abdomen.

15
 Chest Overview
Chest

PA AND AP CHEST RADIOGRAPHY

Medial right clavicle

Medial left scapula

Heart

Medial right clavicle

Medial left scapula

Heart

(Top) First of 4 normal chest radiographs of the same patient is shown. PA chest radiograph shows that the heart and mediastinum,
which are closest to the image receptor, undergo the least magnification. The medial clavicles curve inferiorly and do not obscure the
lung apices. The scapulae are rotated laterally and do not obscure the lateral aspects of the lungs. (Bottom) AP chest radiograph of the
same patient shows that the heart and mediastinum appear slightly larger as they are farthest from the image receptor and undergo
some magnification. The clavicles exhibit a horizontal course and their medial aspects obscure the lung apices. The medial portions of
the scapulae overlie the lateral aspects of the lungs.

16
 Chest Overview

Chest
INSPIRATORY AND EXPIRATORY CHEST RADIOGRAPHY

Left posterior 10th rib

Right anterior 8th rib

Apparent mediastinal
widening

Vascular crowding Apparent cardiac enlargement

Left posterior 9th rib

Right anterior 6th rib

(Top) PA chest radiograph obtained at full inspiration shows optimal visualization of the lung bases and the retrocardiac and
retrodiaphragmatic lung. A portion of the 8th anterior right rib is visible through the lung and projects above the hemidiaphragm. A
portion of the 10th posterior left rib is visible through the lung and projects above the hemidiaphragm. (Bottom) PA chest radiograph
obtained at end expiration shows low lung volumes. The lung bases are partially obscured with increased basilar density and vascular
crowding and resultant poor visualization of the retrodiaphragmatic lung. A portion of the right 6th anterior rib is visible through the
lung and projects above the hemidiaphragm. A portion of the left 9th posterior rib is visible through the lung and projects above the
hemidiaphragm.

17
 Chest Overview
Chest

LATERAL DECUBITUS CHEST RADIOGRAPHY, POSITIONING AND COLLIMATION

Collimation of x-ray beam

Lung apex included

Centering of x-ray beam

Arms extended up
Costophrenic angle included

Left side of chest raised on

radiolucent pad

Increased right lung volume

Decreased left lung volume

Normal left pleural space

(Top) Graphic shows proper lateral decubitus PA radiographic collimation for imaging the lungs and mediastinum. The white target sign
shows the centering of the x-ray beam. The blue overlay represents the collimated x-ray beam that extends from the cervical airway
superiorly to below the costophrenic angles inferiorly and includes the left and right skin surfaces. The thorax is elevated on a
radiolucent pad to ensure inclusion of the dependent pleural surface and chest wall. The anterior structures of the chest (shown in
color) are closest to the image receptor and experience the least magnification. (Bottom) Normal left lateral decubitus radiograph
shows a larger lung volume in the nondependent right lung and volume loss manifesting as increased density in the dependent left lung.
There is no pleural thickening or fluid.

18
 Chest Overview

Chest
APICAL LORDOTIC CHEST RADIOGRAPHY, POSITIONING

X-rays travel from anterior to Posterior shoulders against

posterior at 20° angle image receptor

Vertical image receptor

Medial clavicles

Anterior 1st ribs

Right scapula Left scapula

Foreshortened mediastinum

(Top) Graphic shows proper positioning for AP apical lordotic chest radiography. The patient is upright with the posterior shoulders
against the vertical image receptor, and the arms are internally rotated to move the scapulae away from the lungs. The x-ray beam
travels through the patient from anterior to posterior and is centered at the sternal manubrium and oriented superiorly at a 20° angle
from the horizontal plane. (Bottom) Normal apical lordotic chest radiograph projects the medial aspects of the clavicles above the lung
apices. Note that the apex is partly obscured by the anterior aspects of the 1st ribs and their costochondral articulations in this case.
The mediastinum is foreshortened and mildly magnified. The scapulae overlie a significant portion of the bilateral lateral lungs.

19
 Chest Overview
Chest

RADIOGRAPHIC DENSITIES

Fat density

Calcium density in bone

Air density in lung

Air density in gastric gas

Water density in subcutaneous

tissues and liver

Fat density

Calcium in skeleton

Air density in lung

Water density in upper

extremity soft tissues
Water density in mediastinum

Air density in bowel gas

Metal density in clothing

Water density in abdomen (snap)

(Top) PA chest radiograph shows the 4 radiographic densities. Air is present in the lungs bilaterally and within the gastric air bubble.
Water (or soft tissue) density is seen in the mediastinum, abdomen, and subcutaneous tissues. Fat density is visible in the supraclavicular
regions. Calcium density is noted in the skeletal structures. (Bottom) PA chest radiograph shows the 4 radiographic densities. Air density
is present in the lungs and in the bowel gas. Water (soft tissue) density is seen in the mediastinum, abdomen, and subcutaneous soft
tissues. Fat is more difficult to demonstrate in this thin patient but is present in the normal supraclavicular regions. Calcium is
represented by the skeletal structures. Metal is represented by a metallic snap on the patient's gown.

20
 Chest Overview

Chest
RADIOGRAPHIC DENSITIES, MEDICAL DEVICES

Sternal wires

Pulse generator

Coronary sinus lead

Right ventricular leads

Calcified atherosclerotic aorta

Pulse generator

Sternal wires

Coronary sinus lead

Ventricular leads

(Top) First of 2 chest radiographs of a patient with a biventricular pacemaker and implantable cardioverter defibrillator is shown.
Orthogonal radiographs allow accurate assessment of the integrity and position of medical devices. PA chest radiograph shows 2 pacer
leads in the right ventricle and 1 in a tributary of the coronary sinus. The metallic portions of the pulse generator obscure visualization
of the left mid lung. Note cardiomegaly and atherosclerotic calcification of the thoracic aorta. The lungs are clear. Metallic sternal
wires are present. (Bottom) Lateral chest radiograph shows 2 right ventricular leads and a 3rd lead in a tributary of the coronary sinus.
The left lung behind the pulse generator is now visible, although superimposed, on the contralateral right lung. Cardiomegaly, calcified
aortic atherosclerosis, and sternal wires are again noted.

21
 Chest Overview
Chest

SILHOUETTE SIGN

Left lower lobe airspace

disease

Left paraaortic interface

Left hemidiaphragm

Left paravertebral stripe

(Top) First of 2 chest radiographs of a 43-year-old woman who presented with cough and fever is shown. PA chest radiograph shows
low lung volume and left retrocardiac airspace disease with obscuration of the left hemidiaphragm, the left paraaortic interface, and
the left paravertebral stripe consistent with left lower lobe pneumonia. (Bottom) PA chest radiograph obtained 2 years earlier shows a
normal appearance of the left lower lobe with visualization of the medial left hemidiaphragm, the left paraaortic interface, and the left
paravertebral stripe. This case illustrates the value of the silhouette sign and the importance of comparison with prior studies in the
diagnosis of subtle radiographic abnormalities.

22
 Chest Overview

Chest
ANATOMIC LOCALIZATION WITH ORTHOGONAL RADIOGRAPHY

Calcified granuloma

BB pellet

BB pellet

(Top) First of 2 chest radiographs of an asymptomatic 57-year-old man is shown. PA chest radiograph shows a BB pellet projecting over
the left lower lung zone adjacent to the left cardiac border. Note the difference in radiographic density between the metallic BB pellet
and the calcified right mid lung zone granuloma. (Bottom) Lateral chest radiograph (orthogonal to the PA chest radiograph) shows the
BB pellet projecting over the lower sternal body and anterior to the lung. The radiographs allow accurate anatomic localization of the
BB pellet in the soft tissues of the left anterior chest wall. In the same manner, PA and lateral chest radiography allows initial
characterization and anatomic localization of imaging abnormalities.

23
 Chest Overview
Chest

DECUBITUS RADIOGRAPHY FOR EVALUATION OF COMPLEX PLEURAL DISEASE

Air-fluid level in left

hemithorax

Thick visceral pleura

Air-fluid level

(Top) First of 2 chest radiographs of a patient with a left empyema and a bronchopleural fistula is shown. PA chest radiograph shows a
large air-fluid level that spans the width of the left hemithorax. (Bottom) Left lateral decubitus chest radiograph shows a discrepant
length of the air-fluid level, which appears longer than on the PA chest radiograph, indicating that the air and fluid collection has an
elongated shape. Note the thick medial wall of the air and fluid collection. The findings are characteristic of a loculated pleural
effusion. The presence of air indicates a communication with the tracheobronchial tree (bronchopleural fistula), and the findings are
diagnostic of a complicated empyema. In this case, the lateral decubitus radiograph allows localization of the abnormality to the
pleural space and distinction from parenchymal disease.

24
 Chest Overview

Chest
LORDOTIC CHEST RADIOGRAPHY FOR EVALUATION OF APICAL LESION

Right apical mass

Medial right clavicle

Medial right anterior 1st rib

Spiculated right apical mass

(Top) First of 2 chest radiographs of a patient with a right apical mass is shown. PA chest radiograph coned down to the right apex
demonstrates an abnormal irregular apical mass and thickening of the medial aspect of the right apical pleura. (Bottom) AP apical
lordotic radiograph coned down to the right upper lobe allows visualization of the medial aspect of the right apical lung by projecting
the right medial clavicle and right 1st anterior rib above the lung apex. The spiculated lateral border of this right apical lung cancer is
now visible.

25
 Chest Overview
Chest

SILHOUETTE SIGN, LEFT LOWER LOBE AIRSPACE DISEASE

Left lower lobe consolidation

Obscuration of left
hemidiaphragm

Left lower lobe consolidation

producing spine sign

Right posterior rib

Right hemidiaphragm

(Top) First of 2 chest radiographs of a 45-year-old woman with left lower lobe pneumonia is shown. PA chest radiograph shows a subtle
retrocardiac left basilar air space opacity that obscures the lateral aspect of the left hemidiaphragm. The alveolar air in the left lower
lobe has been replaced by an inflammatory process producing the silhouette sign. (Bottom) Lateral chest radiograph shows that the
consolidation is located in the posterior basilar segment of the left lower lobe, produces the spine sign (increasing opacity over the
lower thoracic spine), and obscures the posterior left hemidiaphragm. The right hemidiaphragm is visualized in its entirety as there is no
right lower lobe airspace disease. The left lateral chest radiograph facilitates identification of the right ribs (and the normal ipsilateral
right hemidiaphragm) by virtue of their magnification, as they are farthest from the image receptor.

26
 Chest Overview

Chest
SILHOUETTE SIGN, MIDDLE LOBE AIRSPACE DISEASE

Middle lobe airspace disease

obscures right cardiac border

Minor fissure

Inferior aspect of right major

fissure

Middle lobe atelectasis

(Top) First of 2 chest radiographs of a 10-year-old asthmatic boy with middle lobe atelectasis is shown. PA chest radiograph shows
airspace opacity in the medial aspect of the right lower lung zone, which obscures the right cardiac border. The location of the process
can be inferred by obscuration of the right cardiac border while the right hemidiaphragm is well visualized. Atelectasis has resulted in
evacuation of alveolar air from the middle lobe producing the silhouette sign. (Bottom) Lateral chest radiograph shows a band-like
opacity that projects over the heart and represents the atelectatic middle lobe. Posteroinferior displacement of the minor fissure and
anterosuperior displacement of the inferior aspect of the right major fissure are typical of middle lobe volume loss and help distinguish
atelectasis from consolidation.

27
 Chest Overview
Chest

CROSS-SECTIONAL ANATOMY

Skeletal structures

Great vessels

Pulmonary vasculature
Airways

Esophagus
Mediastinal lymph node

Lung Pleura

Muscle Subcutaneous fat

Graphic shows the cross-sectional appearance of the mid thorax and illustrates the manner of visualization and assessment of various
organs and tissues in cross section. Cross-sectional imaging allows assessment of the organs, structures, and tissues of the chest. The
soft tissues of the chest wall consist of skin, subcutaneous fat, and chest wall muscles. Together with the skeletal structures, the soft
tissues of the chest wall surround and protect the thoracic cavity and its internal organs and tissues. The apposed pleural surfaces form
the potential pleural space. The pulmonary arteries and veins course through the lungs. The mediastinal fat, mediastinal vascular
structures, esophagus, central tracheobronchial tree, and lymph nodes are also depicted.

28
Another random document with
no related content on Scribd:
 By Alfred Tennyson

My good blade carves the casques of men,

My tough lance thrusteth sure,
My strength is as the strength of ten,
Because my heart is pure.
The shattering trumpet shrilleth high,
The hard brands shiver on the steel,
The splinter’d spear-shafts crack and fly,
The horse and rider reel:
They reel, they roll in clanging lists,
And when the tide of combat stands,
Perfume and flowers fall in showers,
That lightly rain from ladies’ hands.

—From “Sir Galahad.”

OPPORTUNITY
By Edward Rowland Sill

This I beheld, or dreamed it in a dream:—

There spread a cloud of dust along a plain;
And underneath the cloud, or in it, raged
A furious battle, and men yelled, and swords
Shocked upon swords and shields. A prince’s banner
Wavered, then staggered backward, hemmed by foes.

A craven hung along the battle’s edge,

And thought, “Had I a sword of keener steel—
That blue blade that the king’s son bears—but this
Blunt thing—!” he snapped and flung it from his hand,
And lowering crept away and left the field.

Then came the king’s son, wounded, sore bestead,

And weaponless, and saw the broken sword,
Hilt buried in the dry and trodden sand,
And ran and snatched it, and with battle-shout
Lifted afresh, he hewed his enemy down,
And saved a great cause that heroic day.

THE FIRING LINE

By Joaquin Miller

For glory? For good? For fortune or fame?

Why, he for the front when the battle is on!
Leave the rear to the dolt, the lazy, the lame,
Go forward as ever the valiant have gone;
Whether city or field, whether mountain or mine,
Go forward, right on to the Firing Line.

Whether newsboy or plowboy, cowboy or clerk,

Fight forward, be ready, be steady, be first;
Be fairest, be bravest, be best at your work;
Exalt and be glad; dare to hunger, to thirst,
As David, as Alfred—let dogs skulk and whine—
There is room but for men on the Firing Line.
Aye, the place to fight and the place to fall—
As fall we must, all in God’s good time—
It is where the manliest man is the wall,
Where boys are as men in their pride and prime,
Where glory gleams brightest, where brightest eyes shine,
Far out on the roaring red Firing Line.

HOW OSWALD DINED WITH GOD

By Edwin Markham

Over Northumbria’s lone, gray lands,

Over the frozen marl,
Went flying the fogs from the fens and sands,
And the wind with a wolfish snarl.

Frosty and stiff by the York wall

 Stood the rusty grass and the yarrow:
Gone wings and songs to the southland, all—
Robin and starling and sparrow.

Weary with weaving the battle-woof,

Came the king and his thanes to the Hall:
Feast-fires reddened the beams of the roof,
Torch flames waved from the wall.

Bright was the gold that the table bore,

Where platters and beakers shone:
Whining hounds on the sanded floor
Looked hungrily up for a bone.

Laughing, the king took his seat at the board,

With his gold-haired queen at his right:
War-men sitting around them roared
Like a crash of the shields in fight.

Loud rose laughter and lusty cheer,

And gleemen sang loud in their throats,
Telling of swords and the whistling spear,
Till their red beards shook with the notes.

Varlets were bringing the smoking boar,

Ladies were pouring the ale,
When the watchman called from the great hall door:
“O King, on the wind is a wail.

“Feebly the host of the hungry poor

Lift hands at the gate with a cry:
Grizzled and gaunt they come over the moor,
Blasted by earth and sky.”

“Ho!” cried the king to the thanes, “make speed—

Carry this food to the gates—
Off with the boar and the cask of mead—
Leave but a loaf on the plates.”
Still came a cry from the hollow night:
“King, this is one day’s feast;
But days are coming with famine-blight;
Wolf winds howl from the east!”

Hot from the king’s heart leaped a deed,

High as his iron crown:
(Noble souls have a deathless need
To stoop to the lowest down.)

“Thanes, I swear by Godde’s Bride

This is a cursèd thing—
Hunger for the folk outside,
Gold inside for the king!”

Whirling his war-ax over his head,

He cleft each plate into four.
“Gather them up, O thanes,” he said,
“For the workfolk at the door.

“Give them this for the morrow’s meat,

Then shall we feast in accord:
Our half of a loaf will then be sweet—
Sweet as the bread of the Lord!”

—From “The Shoes of Happiness and Other Poems.” Copyright by

Doubleday, Page & Co., and used by kind permission of author and
publisher.

HOW THE GREAT GUEST CAME

By Edwin Markham

Before the Cathedral in grandeur rose,

At Ingelburg where the Danube goes;
Before its forest of silver spires
Went airily up to the clouds and fires;
Before the oak had ready a beam,
While yet the arch was stone and dream—
There where the altar was later laid,
Conrad the cobbler plied his trade.

II

Doubled all day on his busy bench,

Hard at his cobbling for master and hench,
He pounded away at a brisk rat-tat,
Shearing and shaping with pull and pat,
Hide well hammered and pegs sent home,
Till the shoe was fit for the Prince of Rome.
And he sang as the threads went to and fro:
“Whether ’tis hidden or whether it show,
Let the work be sound, for the Lord will know.”

III

Tall was the cobbler, and gray and thin,

And a full moon shone where the hair had been.
His eyes peered out, intent and afar,
As looking beyond the things that are.
He walked as one who is done with fear,
Knowing at last that God is near.
Only the half of him cobbled the shoes;
The rest was away for the heavenly news.
Indeed, so thin was the mystic screen
That parted the Unseen from the Seen,
You could not tell, from the cobbler’s theme
If his dream were truth or his truth were dream.

IV

It happened one day at the year’s white end,

Two neighbors called on their old-time friend;
And they found the shop, so meager and mean,
Made gay with a hundred boughs of green.
Conrad was stitching with face ashine,
But suddenly stooped as he twitched a twine:
“Old friends, good news! At dawn to-day,
As the cocks were scaring the night away,
The Lord appeared in a dream to me,
And said, ‘I am coming your Guest to be!’
So I’ve been busy with feet astir,
Strewing the floor with branches of fir.
The wall is washed and the shelf is shined,
And over the rafter the holly twined.
He comes to-day, and the table is spread,
With milk and honey and wheaten bread.”

His friends went home; and his face grew still

As he watched for the shadow across the sill.
He lived all the moments o’er and o’er,
When the Lord should enter the lowly door—
The knock, the call, the latch pulled up,
The lighted face, the offered cup.
He would wash the feet where the spikes had been;
He would kiss the hands where the nails went in;
And then at the last would sit with Him
And break the bread as the day grew dim.

VI

While the cobbler mused, there passed his pane

A beggar drenched by the driving rain.
He called him in from the stony street
And gave him shoes for his bruisèd feet.
The beggar went and there came a crone,
Her face with wrinkles of sorrow sown.
A bundle of fagots bowed her back,
And she was spent with the wrench and rack.
He gave her his loaf and steadied her load
As she took her way on the weary road.
Then to his door came a little child,
Lost and afraid in the world so wild,
In the big, dark world. Catching it up,
He gave it the milk in the waiting cup,
And led it home to its mother’s arms,
Out of the reach of the world’s alarms.

VII

The day went down in the crimson west

And with it the hope of the blessed Guest,
And Conrad sighed as the world turned gray:
“Why is it, Lord, that your feet delay?
Did You forget that this was the day?”
Then soft in the silence a Voice he heard:
“Lift up your heart, for I kept my word.
Three times I came to your friendly door;
Three times my shadow was on your floor.
I was the beggar with bruisèd feet;
I was the woman you gave to eat;
I was the child on the homeless street!”

—From “The Shoes of Happiness and Other Poems.” Copyright by

Doubleday, Page & Co., and used by kind permission of author and
publisher.

PICKETT’S CHARGE
By Fred Emerson Brooks

When Pickett charged at Gettysburg,

For three long days, with carnage fraught,
Two hundred thousand men had fought;
And courage could not gain the field,
Where stubborn valor would not yield.
With Meade on Cemetery Hill,
And mighty Lee thundering still
Upon the ridge a mile away;
Four hundred guns in counterplay
Their deadly thunderbolts had hurled—
The cannon duel of the world!
When Pickett charged at Gettysburg.

When Pickett charged at Gettysburg,

Dread war had never known such need
Of some o’ermastering, valiant deed;
And never yet had cause so large
Hung on the fate of one brief charge.
To break the center, but a chance;
With Pickett waiting to advance;
It seemed a crime to bid him go,
And Longstreet said not “Yes” nor “No,”
But silently he bowed his head.
“I shall go forward!” Pickett said.
Then Pickett charged at Gettysburg.

Then Pickett charged at Gettysburg;

Down from the little wooded slope,
A-step with doubt, a-step with hope,
And nothing but the tapping drum
To time their tread, still on they come.
Four hundred cannon hush their thunder,
While cannoneers gaze on in wonder!
Two armies watch, with stifled breath,
Full eighteen thousand march to death,
At elbow-touch, with banners furled,
And courage to defy the world,
In Pickett’s charge at Gettysburg.

’Tis Pickett’s charge at Gettysburg:

None but tried veterans can know
How fearful ’tis to charge the foe;
But these are soldiers will not quail,
Though Death and Hell stand in their trail!
Flower of the South and Longstreet’s pride,
There’s valor in their very stride!
Virginian blood runs in their veins,
And each his ardor scarce restrains;
Proud of the part they’re chosen for:
The mighty cyclone of the war,
In Pickett’s charge at Gettysburg.

’Tis Pickett’s charge at Gettysburg:

How mortals their opinions prize
When armies march to sacrifice,
And souls by thousands in the fight
On Battle’s smoky wing take flight.
Firm-paced they come, in solid form
The dreadful calm before the storm.
Those silent batteries seem to say:
“We’re waiting for you, men in gray!”
Each anxious gunner knows full well
Why every shot of his must tell
On Pickett’s charge at Gettysburg.

’Tis Pickett’s charge at Gettysburg:

What grander tableau can there be
Than rhythmic swing of infantry
At shouldered arms, with flashing steel?
As Pickett swings to left, half-wheel,
Those monsters instantly outpour
Their flame and smoke of death! and roar
Their fury on the silent air—
Starting a scene of wild despair:
Lee’s batteries roaring: “Room! Make room!!”
With Meade’s replying: “Doom! ’Tis doom
To Pickett’s charge at Gettysburg!”

’Tis Pickett’s charge at Gettysburg:

Now Hancock’s riflemen begin
To pour their deadly missiles in.
Can standing grain defy the hail?
Will Pickett stop? Will Pickett fail?
His left is all uncovered through
That fateful halt of Pettigrew!
And Wilcox from the right is cleft
By Pickett’s half-wheel to the left!
Brave Stannard rushes ’tween the walls,
No more disastrous thing befalls
Brave Pickett’s charge at Gettysburg.

’Tis Pickett’s charge at Gettysburg:

How terrible it is to see
Great armies making history:
Long lines of muskets belching flame!
No need of gunners taking aim
When from that thunder-cloud of smoke
The lightning kills at every stroke!
If there’s a place resembling hell,
’Tis where, ’mid shot and bursting shell,
Stalks Carnage, arm in arm with Death,
A furnace blast in every breath,
On Pickett’s charge at Gettysburg.

’Tis Pickett’s charge at Gettysburg:

Brave leaders fall on every hand!
Unheard, unheeded all command!
Battered in front and torn in flank;
A frenzied mob in broken rank!
They come like demons with a yell,
And fight like demons all pell-mell!
The wounded stop not till they fall;
The living never stop at all—
Their blood-bespattered faces say:
“’Tis death alone stops men in gray,
With Pickett’s charge at Gettysburg!”
 Stopped Pickett’s charge at Gettysburg
Where his last officer fell dead,
The dauntless, peerless, Armistead!
Where ebbed the tide and left the slain
Like wreckage from the hurricane—
That awful spot which soldiers call
“The bloody angle of the wall,”
There Pickett stopped, turned back again
Alone, with just a thousand men!
And not another shot was fired—
So much is bravery admired!
Pickett had charged at Gettysburg.

Brave Pickett’s charge at Gettysburg!

The charge of England’s Light Brigade
Was nothing to what Pickett made
To capture Cemetery Hill—
To-day a cemetery still,
With flowers in the rifle-pit,
But no one cares to capture it.
The field belongs to those who fell;
They hold it without shot or shell!
While cattle yonder in the vale
Are grazing on the very trail
Where Pickett charged at Gettysburg.

Where Pickett charged at Gettysburg,

In after-years survivors came
To tramp once more that field of fame;
And Mrs. Pickett led the Gray,
Just where her husband did that day.
The Blue were waiting at the wall,
The Gray leaped over, heart and all!
Where man had failed with sword and gun,
A woman’s tender smile had won:
The Gray had captured now the Blue,
What mortal valor could not do
 When Pickett charged at Gettysburg.

—Copyright by Forbes & Co., Chicago, and used by kind

permission of author and publisher.

“INASMUCH....”
By Edwin Markham

Wild tempest swirled on Moscow’s castled height;

Wild sleet shot slanting down the wind of night;
Quick snarling mouths from out of the darkness sprang
To strike you in the face with tooth and fang.
Javelins of ice hung on the roofs of all;
The very stones were aching in the wall,
Where Ivan stood a watchman on his hour,
Guarding the Kremlin by the northern tower,
When, lo! a half-bare beggar tottered past,
Shrunk up and stiffened in the bitter blast.
A heap of misery he drifted by,
And from the heap came out a broken cry.

At this the watchman straightened with a start;

A tender grief was tugging at his heart,
The thought of his dead father, bent and old
And lying lonesome in the ground so cold.
Then cried the watchman starting from his post:
“Little father, this is yours; you need it most!”
And tearing off his hairy coat, he ran
And wrapt it warm around the beggar man.

That night the piling snows began to fall,

And the good watchman died beside the wall.
But waking in the Better Land that lies
Beyond the reaches of these cooping skies,
Behold, the Lord came out to greet him home,
Wearing the hairy heavy coat he gave
By Moscow’s tower before he felt the grave!

And Ivan, by the old Earth-memory stirred,

Cried softly with a wonder in his word:
“And where, dear Lord, found you this coat of mine,
A thing unfit for glory such as Thine?”
Then the Lord answered with a look of light:
“This coat, My son, you gave to Me last night.”

—Copyright by Doubleday, Page & Co., New York, and used by

kind permission of author and publisher.

THE MAN UNDER THE STONE

By Edwin Markham

When I see a workingman with mouths to feed,

Up, day after day, in the dark before the dawn,
And coming home, night after night, through the dusk,
Swinging forward like some fierce silent animal,
I see a man doomed to roll a huge stone up an endless steep.
He strains it onward inch by stubborn inch,
Crouched always in the shadow of the rock....
See where he crouches, twisted, cramped, misshapen:
He lifts for their life;
The veins knot and darken—
Blood surges into his face....
Now he loses—now he wins—
Now he loses—loses—(God of my soul!)
He digs his feet into some earth—
There’s a moment of terrified effort....
Will the huge stone break his hold,
And crush him as it plunges to the gulf?
The silent struggle goes on and on,
Like two contending in a dream.
 —Copyright by Doubleday, Page & Co., New York, and used by
kind permission of author and publisher.

TO GERMANY
By George Sterling

Beat back thy forfeit plow-shares into swords:

It is not yet, the far, seraphic dream
Of peace made beautiful and love supreme.
Now let the strong, unweariable chords
Of battle shake to thunder, and the hordes
Advance, where now the famished vultures scream.
The standards gather and the trumpets gleam;
Down the long hill-side stare the mounted lords.

Now far beyond the tumult and the hate,

The white-clad nurses and the surgeons wait
The backward currents of tormented life,
When on the waiting silences shall come
The screams of men, and, ere those lips are dumb,
The searching probe, the ligature and knife.

II

Was it for such, the brutehood and the pain,

Civilization gave her holy fire
Unto thy wardship, and the snowy spire
Of her august and most exalted fane?
Are these the harvests of her ancient rain
Men reap at evening in the scarlet mire,
Or where the mountain smokes, a dreadful pyre,
Or where the warship drags a bloody stain?

Are these thy votive lilies and their dews,

That now the outraged stars look down to see?
 Behold them, where the cold prophetic damps
Congeal on youthful brows so soon to lose
Their dream of sacrifice to thee—to thee,
Harlot to Murder in a thousand camps!

III

Was it for this that loving men and true

Have labored in the darkness and the light
To rear the solemn temple of the Right,
On Reason’s deep foundations, bared anew
Long after the Cæsarian eagles flew
And Rome’s last thunder died upon the Night?
Cuirassed, the cannon menace from the height;
Armored, the new-born eagles take the blue.

Wait not thy lords the avenging, certain knell—

One with the captains and abhorrent fames
The echoes of whose conquests died in Hell?—
They that have loosened the ensanguined flood,
And whose malign and execrable names
The Seraph of the Record writes in blood.

IV

From gravid trench and sullen parapet,

Profane the wounded lands with mine or shell!
Turn thou upon the world thy cannons’ Hell,
Till many million women’s eyes are wet!
Ravage and slay! Pile up the eternal debt!
But when the fanes of France and Belgium fell
Another ruin was on earth as well,
And ashes that the race shall not forget.

Not by the devastation of the guns,

Nor tempest-shock, nor steel’s subverting edge,
Nor yet the slow erasure of the suns
Thy downfall came, betrayer of thy trust!
 But at the dissolution of a pledge
The temple of thine honor sank to dust.

Make not thy prayer to Heaven, lest perchance,

O troubler of the world, the heavens hear!
But trust in Uhlan and in cannoneer,
And, ere the Russian hough thee, set thy lance
Against the dear and blameless breast of France!
Put on thy mail tremendous and austere,
And let the squadrons of thy wrath appear,
And bid the standards and the guns advance!

Those as an evil mist shall pass away,

As once the Assyrian before the Lord:
Thou standest between mortals and the day,
Ere God, grown weary of thine armored reign,
Lift from the world the shadow of thy sword
And bid the stars of morning sing again.

—Copyright by A. M. Robertson, publisher, San Francisco, and

used by kind permission of author and publisher.

TO THE WAR-LORDS
By George Sterling

Be yours the doom Isaiah’s voice foretold,

Lifted on Babylon, O ye whose hands
Cast the sword’s shadow upon weaker lands,
And for whose pride a million hearths grow cold!
Ye reap but with the cannon, and do hold
Your plowing to the murder-god’s commands;
And at your altars Desolation stands,
And in your hearts is conquest, as of old.
The legions perish and the warships drown;
The fish and vulture batten on the slain;
And it is ye whose word hath shaken down
The dykes that hold the chartless sea of pain.
Your prayers deceive not men, nor shall a crown
Hide on the brow the murder-mark of Cain.

II

Now glut yourselves with conflict, nor refrain,

But let your famished provinces be fed
From bursting granaries of steel and lead!
Decree the sowing of that deadly grain
Where the great war-horse, maddened with his pain,
Stamps on the mangled living and the dead,
And from the entreated heavens overhead
Falls from a brother’s hand a fiery rain.

Lift not your voices to the gentle Christ:

Your god is of the shambles! Let the moan
Of nations be your psalter, and their youth
To Moloch and to Bel be sacrificed!
A world to which ye proffered lies alone
Learns now from Death the horror of your truth.

III

How have you fed your people upon lies,

And cried “Peace! peace!” and knew it would not be!
For now the iron dragons take the sea,
And in the new-found fortress of the skies,
Alert and fierce a deadly eagle flies.
Ten thousand cannon echo your decree,
To whose profound refrain ye bend the knee.
And lift into the Lord of Love your eyes.

This is Hell’s work: why raise your hands to Him,

And those hands mailed, and holding up the sword?
 There stands another altar, stained with red,
At whose basalt the infernal seraphim
Uplift to Satan, your conspirant lord,
The blood of nations, at your mandate shed.

—Copyright by A. M. Robertson, publisher, San Francisco, and

used by kind permission of author and publisher.

PAULINE PAVLOVNA
By T. B. Aldrich
(Scene: Petrograd. Period: The present time. A ballroom in the
winter palace of the prince. The ladies in character costumes and
masks. The gentlemen in official dress and unmasked, with the
exception of six tall figures in scarlet kaftans, who are treated with
marked distinction as they move here and there among the
promenaders.
Quadrille music throughout the dialogue. Count Sergius Pavlovich
Panshine, who has just arrived, is standing anxiously in the doorway
of an antechamber with his eyes fixed upon a lady in the costume of
a maid of honor in the time of Catherine II. The lady presently
disengages herself from the crowd, and passes near Count
Panshine, who impulsively takes her by the hand and leads her
across the threshold of the inner apartment, which is unoccupied.)
He. Pauline!
She. You knew me?
He. How could I have failed? A mask may hide your features, not
your soul. There’s an air about you like the air that folds a star. A
blind man knows the night, and feels the constellations. No coarse
sense of eye or ear had made you plain to me. Through these I had
not found you; for your eyes, as blue as violets of our Novgorod, look
black behind your mask there, and your voice—I had not known that
either. My heart said, “Pauline Pavlovna.”
 She. Ah, your heart said that? You trust your heart then! ’Tis a
serious risk! How is it you and others wear no mask?
He. The Emperor’s orders.
She. Is the Emperor here? I have not seen him.

He. He is one of the six in scarlet kaftans and all masked alike.
Watch—you will note how every one bows down
Before those figures; thinking each by chance
May be the Tsar; yet none know which is he.
Even his counterparts are left in doubt.
Unhappy Russia! No serf ever wore such chains
As gall our Emperor these sad days.
He dare trust no man.

She. All men are so false.

He. Spare one, Pauline Pavlovna.

She. No! all, all!

I think there is no truth left in the world,
In man or woman.
Once were noble souls.—
Count Sergius, is Nastasia here to-night?

He. Ah! then you know! I thought to tell you first.

Not here, beneath these hundred curious eyes,
In all this glare of light; but in some place
Where I could throw me at your feet and weep.
In what shape came the story to your ears?
Decked in the teller’s colors, I’ll be sworn;
The truth, but in the livery of a lie,
And so must wrong me. Only this is true:—
The Tsar, because I risked my wretched life
To shield a life as wretched as my own,
Bestows upon me, as supreme reward—
O irony!—the hand of this poor girl.
Says, “Here I have the pearl of pearls for you,
Such as was never plucked from out the deep
By Indian diver, for a Sultan’s crown.
Your joy’s decreed,” and stabs me with a smile.

She. And she—she loves you.

He. I know not, indeed. Likes me perhaps.

What matters it?—her love?
Sidor Yurievich, the guardian, consents, and she consents.
No love in it at all, a mere caprice,
A young girl’s spring-tide dream.
Sick of her ear-rings, weary of her mare,
She’ll have a lover—something ready made,
Or improvised between two cups of tea—
A lover by imperial ukase!
Fate said the word—I chanced to be the man!
If that grenade the crazy student threw
Had not spared me, as well as spared the Tsar,
All this would not have happened. I’d have been a hero,
But quite safe from her romance.
She takes me for a hero—think of that!
Now by our holy Lady of Kazan,
When I have finished pitying myself, I’ll pity her.

She. Oh, no;—begin with her; she needs it most.

He. At her door lies the blame, whatever falls.

She, with a single word, with half a tear,
Had stopt it at the first,
This cruel juggling with poor human hearts.

She. The Tsar commanded it—you said the Tsar.

He. The Tsar does what she wills—God fathoms why.

Were she his mistress, now! but there’s no snow
Whiter within the bosom of a cloud,
No colder either. She is very haughty,
For all her fragile air of gentleness;