Professional Documents
Culture Documents
Ebook Diagnostic Imaging Chest 3Rd Edition Melissa L Martinez Jimenez Santiago Rosado de Christenson Online PDF All Chapter
Ebook Diagnostic Imaging Chest 3Rd Edition Melissa L Martinez Jimenez Santiago Rosado de Christenson Online PDF All Chapter
https://ebookmeta.com/product/diagnostic-imaging-chest-3rd-
edition-melissa-l-rosado-de-christenson/
https://ebookmeta.com/product/diagnostic-imaging-gynecology-3rd-
edition-akram-m-shaaban/
https://ebookmeta.com/product/diagnostic-imaging-brain-3rd-
edition-miral-d-jhaveri/
https://ebookmeta.com/product/diagnostic-imaging-pediatric-
neuroradiology-3rd-edition-kevin-r-moore/
Diagnostic Imaging: Head and Neck 4th Edition
Bernadette L. Koch Md
https://ebookmeta.com/product/diagnostic-imaging-head-and-
neck-4th-edition-bernadette-l-koch-md/
https://ebookmeta.com/product/diagnostic-imaging-
gastrointestinal-atif-zaheer/
https://ebookmeta.com/product/diagnostic-imaging-musculoskeletal-
non-traumatic-disease-3rd-edition-authors-kirkland-w-davis/
https://ebookmeta.com/product/diagnostic-imaging-brain-miral-d-
jhaveri/
https://ebookmeta.com/product/diagnostic-imaging-oncology-akram-
m-shaaban/
THIRD EDITION
Rosado-de-Christenson
Martínez-Jiménez
Restrepo | Betancourt-Cuellar
Carter | Lichtenberger
Heeger | Ternes
Carrillo-Bayona | Frazier
Silva | Garrana
Alegría | Fuss
ii
THIRD EDITION
Santiago Martínez-Jiménez, MD
Department of Radiology
Saint Luke's Hospital of Kansas City
Professor of Radiology
University of Missouri-Kansas City School of Medicine
Kansas City, Missouri
iii
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as
may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors 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.
iv
Dedications
To my wonderful family – Paul, Jennifer, Heather, David, Mike, and Juniper,
for your unconditional love and support. You are everything to me.
MLR
To Isabela and Lucas. You are simply the best. Just keep smiling and
remember that monsters were never under the bed.
SMJ
v
Contributing Authors
Carlos S. Restrepo, MD Jorge Alberto Carrillo-Bayona, MD
Professor of Radiology Professor of Radiology
Director of Cardiothoracic Imaging Universidad Nacional de Colombia
Department of Radiology Hospital Universitario Mayor Mederi
The University of Texas RIMAB
Health Science Center at San Antonio Bogotá, Colombia
San Antonio, Texas
Aletta Ann Frazier, MD
Sonia L. Betancourt-Cuellar, MD Section Chief, Cardiothoracic Imaging
Professor of Thoracic Imaging ACR Institute for Radiologic Pathology (AIRP)
Department of Thoracic Imaging Silver Spring, Maryland
The University of Texas MD Anderson Cancer Center Professor of Diagnostic Radiology
Houston, Texas University of Maryland School of Medicine
Baltimore, Maryland
Brett W. Carter, MD, CPPS
Director of Clinical Operations Claudio Silva, MD, MSc, MBA
Chief Patient Safety and Associate Professor of Radiology
Quality Officer, Diagnostic Imaging Clínica Alemana - Universidad del Desarrollo
Professor of Thoracic Imaging School of Medicine
The University of Texas MD Anderson Cancer Center Cardiothoracic Imaging Division, Radiology Department
Houston, Texas Clínica Alemana de Santiago
Santiago, Chile
John P. Lichtenberger, III, MD
Chief of Thoracic Imaging Sherief H. Garrana, MD
Associate Professor of Radiology Assistant Professor of Radiology
Department of Radiology Department of Radiology
George Washington University Medical Saint Luke’s Hospital of Kansas City
Faculty Associates University of Missouri-Kansas City School of Medicine
Washington, D.C. Kansas City, Missouri
vi
Additional Contributing Authors
Gerald F. Abbott, MD, FACR
Jonathan Hero Chung, MD
Florian J. Fintelmann, MD, FRCPC
Tomás Franquet, MD, PhD
Terrance Healey, MD
Laura E. Heyneman, MD
Jeffrey P. Kanne, MD
Kyung Soo Lee, MD
Diane C. Strollo, MD, FACR
Christopher M. Walker, MD
Helen T. Winer-Muram, MD
Carol C. Wu, MD
vii
Preface
We proudly present the 3rd edition of Diagnostic Imaging: Chest. It is hard to believe
that 9 years have elapsed since the publication of the 2nd edition. I am immensely
grateful to the Elsevier team for giving me the opportunity to, once again, serve as
lead author of this work, and to my good friend, colleague, and practice partner, Dr.
Santiago Martínez-Jiménez, for serving as co-lead author.
The 3rd edition is similar to the 2nd in both style and appearance, with a succinct,
bulleted text format and image-rich depictions of a large number of cardiothoracic
diseases. The content is organized based on both anatomic location and category of
disease. The work is enhanced by a wealth of new material that includes:
• 13 updated and illustrated section introductions that set the stage for
the specific diagnoses that follow
• Updated sections that define and illustrate thoracic imaging terminology,
including many entities from the Fleischner Society glossary of terms, as well
as classic signs in chest imaging
• An updated section on posttreatment changes in the thorax and the
effects of novel therapies that include surgery, radiotherapy, chemotherapy,
immunotherapy, and ablation procedures
• New chapters on emerging diseases, including coronavirus disease-2019
(COVID-19) and e-cigarette or vaping product use-associated lung injury
(EVALI)
• A total of 344 chapters supplemented with updated material and references
• In all, 2,640 images and 2,536 online-only images that include radiographic,
CT,
MR, and PET/CT images, as well as gross photographs and
photomicrographs where appropriate
• Updated graphics that illustrate the anatomic/pathologic basis of various
imaging abnormalities
viii
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
ix
x
Acknowledgments
LEAD EDITOR
Terry W. Ferrell, MS
LEAD ILLUSTRATOR
Lane R. Bennion, MS
TEXT EDITORS
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Nina Themann, BA
Megg Morin, BA
Kathryn Watkins, BA
ILLUSTRATIONS
Richard Coombs, MS
Laura C. Wissler, MA
IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS
PRODUCTION EDITORS
Emily C. Fassett, BA
John Pecorelli, BS
xi
xii
Sections
SECTION 1:
Overview of Chest Imaging
SECTION 2:
Developmental Abnormalities
SECTION 3:
Airway Diseases
SECTION 4:
Infections
SECTION 5:
Pulmonary Neoplasms
SECTION 6:
Interstitial, Diffuse, and Inhalational Lung Disease
SECTION 7:
Connective Tissue Disorders, Immunological Diseases, and Vasculitis
SECTION 8:
Mediastinal Abnormalities
SECTION 9:
Cardiovascular Disorders
SECTION 10:
Trauma
SECTION 11:
Post-Treatment Chest
SECTION 12:
Pleural Diseases
SECTION 13:
Chest Wall and Diaphragm
xiii
TABLE OF CONTENTS
26 Peribronchovascular
SECTION 1: OVERVIEW OF CHEST Santiago Martínez-Jiménez, MD
IMAGING 27 Perilobular Pattern
INTRODUCTION AND OVERVIEW Santiago Martínez-Jiménez, MD
28 Perilymphatic
4 Approach to Chest Imaging Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 29 Pneumatocele
Melissa L. Rosado de Christenson, MD, FACR
ILLUSTRATED TERMINOLOGY 30 Reticular Pattern
6 Approach to Illustrated Terminology Melissa L. Rosado de Christenson, MD, FACR
Melissa L. Rosado de Christenson, MD, FACR 31 Secondary Pulmonary Lobule
8 Acinar Nodules Melissa L. Rosado de Christenson, MD, FACR
Melissa L. Rosado de Christenson, MD, FACR and Tyler H. 32 Traction Bronchiectasis
Ternes, MD Melissa L. Rosado de Christenson, MD, FACR
9 Air Bronchogram 33 Tree-in-Bud Opacities
Tyler H. Ternes, MD Melissa L. Rosado de Christenson, MD, FACR
10 Air-Trapping
Tyler H. Ternes, MD CHEST RADIOGRAPHIC AND CT SIGNS
11 Airspace 34 Approach to Chest Radiographic and CT Signs
Tyler H. Ternes, MD Santiago Martínez-Jiménez, MD
12 Architectural Distortion 40 Air Crescent Sign
Tyler H. Ternes, MD Santiago Martínez-Jiménez, MD
13 Bulla/Bleb 41 Cervicothoracic Sign
Tyler H. Ternes, MD Santiago Martínez-Jiménez, MD
14 Cavity 42 Comet Tail Sign
Melissa L. Rosado de Christenson, MD, FACR Santiago Martínez-Jiménez, MD
15 Centrilobular 43 CT Halo Sign
Santiago Martínez-Jiménez, MD and Melissa L. Rosado de Santiago Martínez-Jiménez, MD
Christenson, MD, FACR 44 Deep Sulcus Sign
16 Consolidation Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 45 Fat Pad Sign
17 Cyst Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 46 Finger-in-Glove Sign
18 Ground-Glass Opacity Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 47 Hilum Convergence Sign
19 Honeycombing Santiago Martínez-Jiménez, MD
Santiago Martínez-Jiménez, MD 48 Hilum Overlay Sign
20 Interlobular Septal Thickening Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 49 Incomplete Border Sign
21 Intralobular Lines Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 50 Luftsichel Sign
22 Mass Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 51 Reversed Halo Sign
23 Miliary Pattern Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 52 Rigler and Cupola Signs
24 Mosaic Attenuation Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 53 S-Sign of Golden
25 Nodule Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR 54 Signet Ring Sign
Santiago Martínez-Jiménez, MD
xiv
TABLE OF CONTENTS
55 Silhouette Sign
Santiago Martínez-Jiménez, MD
SYSTEMIC CIRCULATION
110 Accessory Azygos Fissure
ATELECTASIS AND VOLUME LOSS Sherief H. Garrana, MD
56 Approach to Atelectasis and Volume Loss 112 Azygos and Hemiazygos Continuation of the IVC
Melissa L. Rosado de Christenson, MD, FACR and Gerald F. Sherief H. Garrana, MD
Abbott, MD, FACR 116 Persistent Left Superior Vena Cava
60 Atelectasis Claudio Silva, MD, MSc, MBA
Tomás Franquet, MD, PhD 120 Aberrant Subclavian Artery
64 Cicatricial Atelectasis Sherief H. Garrana, MD
Brett W. Carter, MD, CPPS 122 Right Aortic Arch
65 Rounded Atelectasis Santiago Martínez-Jiménez, MD
Brett W. Carter, MD, CPPS 126 Double Aortic Arch
Carlos S. Restrepo, MD and Diane C. Strollo, MD, FACR
SECTION 2: DEVELOPMENTAL 130 Aortic Coarctation
ABNORMALITIES Tyler H. Ternes, MD and Santiago Martínez-Jiménez, MD
xv
TABLE OF CONTENTS
248 Infectious Bronchiolitis
MALIGNANT NEOPLASMS John P. Lichtenberger, III, MD and Laura E. Heyneman, MD
178 Squamous Cell Carcinoma, Airways 252 Constrictive Bronchiolitis
Sonia L. Betancourt-Cuellar, MD Brett W. Carter, MD, CPPS
182 Adenoid Cystic Carcinoma 256 Swyer-James-MacLeod Syndrome
Sonia L. Betancourt-Cuellar, MD Allen Heeger, DO
186 Mucoepidermoid Carcinoma 260 Asthma
Sonia L. Betancourt-Cuellar, MD Carlos S. Restrepo, MD and Santiago Martínez-Jiménez,
190 Metastasis, Airways MD
Sonia L. Betancourt-Cuellar, MD
SECTION 4: INFECTIONS
AIRWAY NARROWING AND WALL
THICKENING INTRODUCTION AND OVERVIEW
192 Saber-Sheath Trachea 266 Approach to Infections
Brett W. Carter, MD, CPPS Santiago Martínez-Jiménez, MD
194 Tracheal Stenosis
Aletta Ann Frazier, MD GENERAL
196 Tracheobronchomalacia 268 Bronchopneumonia
Aletta Ann Frazier, MD Sherief H. Garrana, MD
200 Middle Lobe Syndrome 270 Community-Acquired Pneumonia
Santiago Martínez-Jiménez, MD Claudio Silva, MD, MSc, MBA and Jeffrey P. Kanne, MD
206 Airway Granulomatosis With Polyangiitis 274 Hospital-Acquired Pneumonia
Jorge Alberto Carrillo-Bayona, MD Jorge Alberto Carrillo-Bayona, MD
208 Tracheobronchial Amyloidosis 276 Lung Abscess
John P. Lichtenberger, III, MD and Jeffrey P. Kanne, MD Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD
210 Tracheobronchopathia Osteochondroplastica 280 Septic Emboli
Sonia L. Betancourt-Cuellar, MD John P. Lichtenberger, III, MD and Carol C. Wu, MD
212 Relapsing Polychondritis
Jorge Alberto Carrillo-Bayona, MD BACTERIA
214 Rhinoscleroma 284 Pneumococcal Pneumonia
Jorge Alberto Carrillo-Bayona, MD Jorge Alberto Carrillo-Bayona, MD
288 Staphylococcal Pneumonia
BRONCHIAL DILATATION AND IMPACTION
Jorge Alberto Carrillo-Bayona, MD
216 Bronchitis 292 Klebsiella Pneumonia
Carlos S. Restrepo, MD and Carol C. Wu, MD Jorge Alberto Carrillo-Bayona, MD
218 Bronchiectasis 294 Pseudomonas Pneumonia
Sherief H. Garrana, MD and Laura E. Heyneman, MD Sherief H. Garrana, MD
222 Cystic Fibrosis 296 Legionella Pneumonia
Aletta Ann Frazier, MD Carlos S. Restrepo, MD and Jeffrey P. Kanne, MD
226 Allergic Bronchopulmonary Aspergillosis 298 Nocardiosis
Allen Heeger, DO Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD
230 Primary Ciliary Dyskinesia 300 Actinomycosis
Melissa L. Rosado de Christenson, MD, FACR and Carlos S. Carlos S. Restrepo, MD and Tomás Franquet, MD, PhD
Restrepo, MD 302 Melioidosis
234 Mounier-Kuhn Syndrome Jorge Alberto Carrillo-Bayona, MD
Sonia L. Betancourt-Cuellar, MD and Carlos S. Restrepo, 304 Tuberculosis
MD Melissa L. Rosado de Christenson, MD, FACR
236 Williams-Campbell Syndrome 308 Nontuberculous Mycobacterial Infection
Sonia L. Betancourt-Cuellar, MD Kyung Soo Lee, MD
238 Broncholithiasis 312 Mycoplasma Pneumonia
Santiago Martínez-Jiménez, MD Jorge Alberto Carrillo-Bayona, MD
xvi
TABLE OF CONTENTS
320 Cytomegalovirus Pneumonia
Carol C. Wu, MD and Carlos S. Restrepo, MD
UNCOMMON NEOPLASMS
324 COVID-19 398 Pulmonary Hamartoma
Santiago Martínez-Jiménez, MD and Sherief H. Garrana, Allen Heeger, DO
MD 402 Bronchial Carcinoid
Sonia L. Betancourt-Cuellar, MD
FUNGI 406 Neuroendocrine Carcinoma
328 Histoplasmosis Cristina Fuss, MD and Sonia L. Betancourt-Cuellar, MD
Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD 410 Kaposi Sarcoma
332 Coccidioidomycosis Carlos S. Restrepo, MD and Brett W. Carter, MD, CPPS
Carlos S. Restrepo, MD and Diane C. Strollo, MD, FACR
334 Blastomycosis
LYMPHOMA AND LYMPHOPROLIFERATIVE
Carlos S. Restrepo, MD and Diane C. Strollo, MD, FACR
DISORDERS
336 Cryptococcosis 414 Follicular Bronchiolitis
Brett W. Carter, MD, CPPS Jorge Alberto Carrillo-Bayona, MD
338 Paracoccidioidomycosis 418 Lymphoid Interstitial Pneumonia
Jorge Alberto Carrillo-Bayona, MD Jorge Alberto Carrillo-Bayona, MD
340 Aspergillosis 422 Nodular Lymphoid Hyperplasia
Allen Heeger, DO Santiago Martínez-Jiménez, MD
346 Zygomycosis 424 Post-Transplant Lymphoproliferative Disease
Sonia L. Betancourt-Cuellar, MD John P. Lichtenberger, III, MD and Christopher M. Walker,
348 Pneumocystis jirovecii Pneumonia MD
Sherief H. Garrana, MD 428 Pulmonary Lymphoma
Sonia L. Betancourt-Cuellar, MD
PARASITES
352 Dirofilariasis
METASTATIC DISEASE
Carlos S. Restrepo, MD and Tomás Franquet, MD, PhD 432 Hematogenous Metastases
354 Hydatidosis Aletta Ann Frazier, MD
Carlos S. Restrepo, MD and Tomás Franquet, MD, PhD 436 Lymphangitic Carcinomatosis
356 Strongyloidiasis Sonia L. Betancourt-Cuellar, MD
Carlos S. Restrepo, MD and Brett W. Carter, MD, CPPS 440 Tumor Emboli
358 Amebiasis Carlos S. Restrepo, MD and Florian J. Fintelmann, MD,
Carlos S. Restrepo, MD FRCPC
362 Schistosomiasis
Carlos S. Restrepo, MD SECTION 6: INTERSTITIAL, DIFFUSE, AND
INHALATIONAL LUNG DISEASE
SECTION 5: PULMONARY NEOPLASMS
INTRODUCTION AND OVERVIEW
INTRODUCTION AND OVERVIEW 446 Approach to Interstitial, Diffuse, and Inhalational
366 Approach to Pulmonary Neoplasms Lung Disease
Melissa L. Rosado de Christenson, MD, FACR Santiago Martínez-Jiménez, MD
xvii
TABLE OF CONTENTS
548 Dendriform Pulmonary Ossification
SMOKING-RELATED DISEASES Jorge Alberto Carrillo-Bayona, MD
474 Respiratory Bronchiolitis and RBILD
Jorge Alberto Carrillo-Bayona, MD SECTION 7: CONNECTIVE TISSUE
476 Desquamative Interstitial Pneumonia DISORDERS, IMMUNOLOGICAL
Jorge Alberto Carrillo-Bayona, MD DISEASES, AND VASCULITIS
480 Pulmonary Langerhans Cell Histiocytosis
Tyler H. Ternes, MD INTRODUCTION AND OVERVIEW
484 Combined Pulmonary Fibrosis and Emphysema 552 Approach to Connective Tissue Disorders,
Aletta Ann Frazier, MD Immunological Diseases, and Vasculitis
Santiago Martínez-Jiménez, MD
PNEUMOCONIOSIS
486 Asbestosis IMMUNOLOGICAL AND CONNECTIVE TISSUE
Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD DISORDERS
490 Silicosis and Coal Worker's Pneumoconiosis 554 Interstitial Pneumonia With Autoimmune Features
Brett W. Carter, MD, CPPS and Julia Alegría, MD (IPAF)
494 Hard Metal Pneumoconiosis Santiago Martínez-Jiménez, MD
Carlos S. Restrepo, MD 558 Rheumatoid Arthritis
496 Berylliosis Sonia L. Betancourt-Cuellar, MD
Sonia L. Betancourt-Cuellar, MD 562 Scleroderma
500 Silo-Filler's Disease Julia Alegría, MD and Jonathan Hero Chung, MD
Tyler H. Ternes, MD 566 Mixed Connective Tissue Disease
Julia Alegría, MD and Laura E. Heyneman, MD
OTHER INHALATIONAL DISORDERS 568 Polymyositis/Dermatomyositis
502 Hypersensitivity Pneumonitis Julia Alegría, MD and Carlos S. Restrepo, MD
Julia Alegría, MD 572 Systemic Lupus Erythematosus
506 Smoke Inhalation Julia Alegría, MD and Laura E. Heyneman, MD
John P. Lichtenberger, III, MD and Terrance Healey, MD 576 Sjögren Syndrome
510 E-Cigarette or Vaping Product Use-Associated Lung Sonia L. Betancourt-Cuellar, MD
Injury (EVALI) 582 Ankylosing Spondylitis
Carlos S. Restrepo, MD Tyler H. Ternes, MD
512 Aspiration 586 Inflammatory Bowel Disease
Carlos S. Restrepo, MD Sonia L. Betancourt-Cuellar, MD
516 Excipient Lung Disease 590 Erdheim-Chester Disease
Santiago Martínez-Jiménez, MD Carlos S. Restrepo, MD
xviii
TABLE OF CONTENTS
620 Behçet Syndrome 688 Coronary Artery Aneurysm
Aletta Ann Frazier, MD Julia Alegría, MD and John P. Lichtenberger, III, MD
622 Necrotizing Sarcoid Granulomatosis 690 Paraesophageal Varices
Aletta Ann Frazier, MD John P. Lichtenberger, III, MD
692 Mediastinal Lymphangioma
SECTION 8: MEDIASTINAL Aletta Ann Frazier, MD
ABNORMALITIES 694 Mediastinal Hemangioma
Aletta Ann Frazier, MD
INTRODUCTION AND OVERVIEW
626 Approach to Mediastinal Abnormalities GLANDULAR ENLARGEMENT
Melissa L. Rosado de Christenson, MD, FACR 696 Thymic Hyperplasia
Santiago Martínez-Jiménez, MD
PRIMARY NEOPLASMS 700 Mediastinal Goiter
630 Thymoma Santiago Martínez-Jiménez, MD
Melissa L. Rosado de Christenson, MD, FACR
634 Thymic Neuroendocrine Neoplasm DISEASES OF THE ESOPHAGUS
Sherief H. Garrana, MD 704 Achalasia
636 Thymic Carcinoma Julia Alegría, MD
Sherief H. Garrana, MD 706 Esophageal Diverticula
638 Thymolipoma Julia Alegría, MD and Tomás Franquet, MD, PhD
Melissa L. Rosado de Christenson, MD, FACR 708 Esophageal Stricture
640 Mediastinal Teratoma Claudio Silva, MD, MSc, MBA and Santiago Martínez-
John P. Lichtenberger, III, MD Jiménez, MD
644 Mediastinal Seminoma 710 Esophageal Carcinoma
Aletta Ann Frazier, MD Sonia L. Betancourt-Cuellar, MD
646 Nonseminomatous Malignant Germ Cell Neoplasm
Aletta Ann Frazier, MD MISCELLANEOUS CONDITIONS
648 Neurogenic Neoplasms of the Nerve Sheath 714 Mediastinal Lipomatosis
Sherief H. Garrana, MD Claudio Silva, MD, MSc, MBA
652 Neurogenic Neoplasms of the Sympathetic Ganglia 716 Mediastinitis
John P. Lichtenberger, III, MD Claudio Silva, MD, MSc, MBA
654 Neurofibromatosis 720 Mediastinal Fat Necrosis
Sonia L. Betancourt-Cuellar, MD Allen Heeger, DO
724 Extramedullary Hematopoiesis
LYMPHADENOPATHY
Claudio Silva, MD, MSc, MBA and Santiago Martínez-
656 Metastatic Disease, Lymphadenopathy Jiménez, MD
Brett W. Carter, MD, CPPS 726 Hiatal Hernia
660 Mediastinal Lymphoma Tyler H. Ternes, MD
Sherief H. Garrana, MD
664 Fibrosing Mediastinitis SECTION 9: CARDIOVASCULAR
Sherief H. Garrana, MD DISORDERS
668 Castleman Disease
Brett W. Carter, MD, CPPS INTRODUCTION AND OVERVIEW
732 Approach to Cardiovascular Disorders
CYSTS Santiago Martínez-Jiménez, MD
672 Bronchogenic Cyst
Aletta Ann Frazier, MD DISEASES OF THE AORTA AND GREAT
676 Esophageal Duplication Cyst VESSELS
Aletta Ann Frazier, MD 736 Atherosclerosis
678 Pericardial Cyst Carlos S. Restrepo, MD and Santiago Martínez-Jiménez,
Aletta Ann Frazier, MD MD
682 Thymic Cyst 740 Aortic Aneurysm
Aletta Ann Frazier, MD Carlos S. Restrepo, MD and Santiago Martínez-Jiménez,
MD
VASCULAR LESIONS
742 Acute Aortic Syndromes
684 Mediastinal Vascular Masses Santiago Martínez-Jiménez, MD and Julia Alegría, MD
Brett W. Carter, MD, CPPS
xix
TABLE OF CONTENTS
748 Marfan Syndrome 820 Cardiac Myxoma
Claudio Silva, MD, MSc, MBA and Santiago Martínez- John P. Lichtenberger, III, MD
Jiménez, MD 824 Cardiac Sarcoma
750 Takayasu Arteritis Brett W. Carter, MD, CPPS
Brett W. Carter, MD, CPPS 826 Pulmonary Artery Sarcoma
752 Superior Vena Cava Obstruction Brett W. Carter, MD, CPPS
Allen Heeger, DO 828 Aortic Sarcoma
John P. Lichtenberger, III, MD
PULMONARY EDEMA
756 Pulmonary Edema SECTION 10: TRAUMA
Melissa L. Rosado de Christenson, MD, FACR INTRODUCTION AND OVERVIEW
PULMONARY HYPERTENSION AND 832 Approach to Chest Trauma
THROMBOEMBOLIC DISEASE Melissa L. Rosado de Christenson, MD, FACR
762 Pulmonary Artery Hypertension AIRWAYS AND LUNG
Brett W. Carter, MD, CPPS
766 Pulmonary Venoocclusive Disease/Pulmonary 834 Tracheobronchial Laceration
Capillary Hemangiomatosis Cristina Fuss, MD and Terrance Healey, MD
Claudio Silva, MD, MSc, MBA 836 Lung Trauma
768 Acute Pulmonary Thromboembolic Disease Allen Heeger, DO
Allen Heeger, DO
772 Chronic Pulmonary Thromboembolic Disease
CARDIOVASCULAR/MEDIASTINUM
Carlos S. Restrepo, MD and Helen T. Winer-Muram, MD 840 Pneumomediastinum
776 Sickle Cell Disease John P. Lichtenberger, III, MD
Aletta Ann Frazier, MD 844 Traumatic Aortic Injury
780 Fat Embolism Allen Heeger, DO
Brett W. Carter, MD, CPPS 848 Esophageal Perforation
782 Hepatopulmonary Syndrome John P. Lichtenberger, III, MD and Diane C. Strollo, MD,
John P. Lichtenberger, III, MD FACR
784 Illicit Drug Use, Pulmonary Manifestations 852 Thoracic Duct Tear
Tyler H. Ternes, MD and Carol C. Wu, MD Allen Heeger, DO
DISEASES OF THE HEART AND PERICARDIUM PLEURA, CHEST WALL, AND DIAPHRAGM
786 Valve and Annular Calcification 854 Traumatic Pneumothorax
Brett W. Carter, MD, CPPS Allen Heeger, DO
790 Aortic Valve Disease 856 Traumatic Hemothorax
Brett W. Carter, MD, CPPS Allen Heeger, DO
794 Mitral Valve Disease 858 Thoracic Splenosis
Claudio Silva, MD, MSc, MBA and John P. Lichtenberger, Allen Heeger, DO
III, MD 860 Rib Fractures and Flail Chest
798 Left Atrial Calcification Cristina Fuss, MD and Jonathan Hero Chung, MD
Claudio Silva, MD, MSc, MBA 864 Spinal Fracture
800 Ventricular Calcification John P. Lichtenberger, III, MD
Claudio Silva, MD, MSc, MBA and Brett W. Carter, MD, 866 Sternal Fracture
CPPS John P. Lichtenberger, III, MD
802 Coronary Artery Calcification 868 Diaphragmatic Rupture
Claudio Silva, MD, MSc, MBA and Brett W. Carter, MD, Cristina Fuss, MD and Jonathan Hero Chung, MD
CPPS
806 Post Cardiac Injury Syndrome SECTION 11: POST-TREATMENT CHEST
Claudio Silva, MD, MSc, MBA
808 Pericardial Effusion
INTRODUCTION AND OVERVIEW
Cristina Fuss, MD 874 Approach to Post-Treatment Chest
814 Constrictive Pericarditis Santiago Martínez-Jiménez, MD
John P. Lichtenberger, III, MD
LIFE SUPPORT DEVICES
CARDIOVASCULAR NEOPLASMS 876 Endotracheal and Enteric Tubes
816 Cardiac and Pericardial Metastases Cristina Fuss, MD
John P. Lichtenberger, III, MD
xx
TABLE OF CONTENTS
880 Chest Tubes and Drains 958 Chylothorax
Cristina Fuss, MD Claudio Silva, MD, MSc, MBA
884 Vascular Catheters 960 Empyema
Cristina Fuss, MD Julia Alegría, MD and Jonathan Hero Chung, MD
890 Cardiac Conduction Devices
Cristina Fuss, MD PNEUMOTHORAX
964 Iatrogenic Pneumothorax
SURGICAL PROCEDURES AND Cristina Fuss, MD
COMPLICATIONS 966 Primary Spontaneous Pneumothorax
894 Pleurodesis Cristina Fuss, MD
John P. Lichtenberger, III, MD and Florian J. Fintelmann, 970 Secondary Spontaneous Pneumothorax
MD, FRCPC Cristina Fuss, MD
896 Sublobar Resection
Allen Heeger, DO PLEURAL THICKENING
898 Lung Volume Reduction Surgery 974 Apical Cap
John P. Lichtenberger, III, MD and Carol C. Wu, MD John P. Lichtenberger, III, MD
900 Lobectomy 976 Pleural Plaques
Brett W. Carter, MD, CPPS Allen Heeger, DO
904 Lobar Torsion 980 Pleural Fibrosis and Fibrothorax
Cristina Fuss, MD and Jeffrey P. Kanne, MD Allen Heeger, DO
906 Pneumonectomy
Allen Heeger, DO NEOPLASIA
912 Thoracoplasty and Apicolysis 982 Malignant Pleural Effusion
Julia Alegría, MD and Jeffrey P. Kanne, MD Allen Heeger, DO
914 Lung Herniation 984 Solid Pleural Metastases
Cristina Fuss, MD and Jeffrey P. Kanne, MD Melissa L. Rosado de Christenson, MD, FACR
916 Sternotomy 986 Malignant Pleural Mesothelioma
John P. Lichtenberger, III, MD and Diane C. Strollo, MD, Brett W. Carter, MD, CPPS
FACR 990 Localized Fibrous Tumor of the Pleura
920 Heart Transplantation Melissa L. Rosado de Christenson, MD, FACR
John P. Lichtenberger, III, MD
924 Lung Transplantation SECTION 13: CHEST WALL AND
Cristina Fuss, MD and Jeffrey P. Kanne, MD DIAPHRAGM
928 Esophageal Resection
Julia Alegría, MD and Tomás Franquet, MD, PhD INTRODUCTION AND OVERVIEW
RADIATION, CHEMOTHERAPY, ABLATION 996 Approach to Chest Wall and Diaphragm
Melissa L. Rosado de Christenson, MD, FACR
930 Radiation-Induced Lung Disease
Sonia L. Betancourt-Cuellar, MD CHEST WALL
936 Drug Reaction, Intrathoracic 998 Chest Wall Infections
Sonia L. Betancourt-Cuellar, MD John P. Lichtenberger, III, MD
940 Ablation Procedures 1000 Discitis
Sonia L. Betancourt-Cuellar, MD Julia Alegría, MD
1002 Chest Wall Lipoma and Liposarcoma
SECTION 12: PLEURAL DISEASES Brett W. Carter, MD, CPPS
INTRODUCTION AND OVERVIEW 1006 Elastofibroma and Fibromatosis
Brett W. Carter, MD, CPPS
946 Approach to Pleural Diseases 1010 Chest Wall Metastases
Melissa L. Rosado de Christenson, MD, FACR Claudio Silva, MD, MSc, MBA
1014 Chondrosarcoma
EFFUSION
Sonia L. Betancourt-Cuellar, MD
948 Transudative Pleural Effusion 1016 Plasmacytoma and Multiple Myeloma
Claudio Silva, MD, MSc, MBA Brett W. Carter, MD, CPPS
952 Exudative Pleural Effusion
Claudio Silva, MD, MSc, MBA DIAPHRAGM
956 Hemothorax 1018 Diaphragmatic Eventration
Claudio Silva, MD, MSc, MBA Santiago Martínez-Jiménez, MD
1020 Diaphragmatic Paralysis
Santiago Martínez-Jiménez, MD
xxi
This page intentionally left blank
THIRD EDITION
Rosado-de-Christenson
Martínez-Jiménez
Restrepo | Betancourt-Cuellar
Carter | Lichtenberger
Heeger | Ternes
Carrillo-Bayona | Frazier
Silva | Garrana
Alegría | Fuss
SECTION 1
Illustrated Terminology
Approach to Illustrated Terminology 6
Acinar Nodules 8
Air Bronchogram 9
Air-Trapping 10
Airspace 11
Architectural Distortion 12
Bulla/Bleb 13
Cavity 14
Centrilobular 15
Consolidation 16
Cyst 17
Ground-Glass Opacity 18
Honeycombing 19
Interlobular Septal Thickening 20
Intralobular Lines 21
Mass 22
Miliary Pattern 23
Mosaic Attenuation 24
Nodule 25
Peribronchovascular 26
Perilobular Pattern 27
Perilymphatic 28
Pneumatocele 29
Reticular Pattern 30
Secondary Pulmonary Lobule 31
Traction Bronchiectasis 32
Tree-in-Bud Opacities 33
6
Approach to Illustrated Terminology
7
Acinar Nodules
KEY FACTS
Overview of Chest Imaging
TERMINOLOGY • CT/HRCT
• Acinar nodule (accumulation of pathologic material in ○ Multifocal ground-glass or part-solid nodular opacities
pulmonary acinus) ○ 5-8 mm in size
○ Clustered, rounded, poorly-defined opacities PATHOLOGY
○ Typically multifocal
• Etiology
○ Size: 5-8 mm in diameter
○ Infection
• Acinus
○ Aspiration
○ Largest lung unit in which all airways participate in gas
○ Edema
exchange
○ Hemorrhage
– Structural lung unit distal to terminal bronchiole
○ Pulmonary vasculitis
– Supplied by 1st-order respiratory bronchioles
○ Pulmonary contusion
– Contains alveolar ducts and alveoli
○ Lung cancer: Invasive mucinous adenocarcinoma
○ Size: 6-10 mm in diameter
• Secondary pulmonary lobule DIAGNOSTIC CHECKLIST
○ Contains 3-25 acini • Sputum analysis for diagnosis of infection
IMAGING • Diagnosis of vasculitis or malignancy may require
bronchoscopic or open lung biopsy
• Radiography
• History of blunt trauma in pulmonary contusion
○ Multifocal, ill-defined, small, rounded opacities
8
Air Bronchogram
KEY FACTS
9
Air-Trapping
KEY FACTS
Overview of Chest Imaging
TERMINOLOGY PATHOLOGY
• Air-trapping • Etiologies
○ Air retention in lung distal to airway obstruction shown ○ Constrictive bronchiolitis: Peribronchiolar fibrosis of
on expiratory CT membranous and respiratory bronchioles
– Infection, chronic rejection in transplantation,
IMAGING
connective tissue disease, inhalational lung disease,
• Radiography: Lung hyperlucency on expiration hypersensitivity pneumonitis, diffuse idiopathic
• CT pulmonary neuroendocrine cell hyperplasia
○ Inspiration ○ Cellular bronchiolitis: Tree-in-bud nodules +
– Normal lung is homogeneously lucent mosaic attenuation
– Mosaic attenuation: Patchwork of regions of different – Infection, aspiration, respiratory bronchiolitis, follicular
attenuation bronchiolitis, panbronchiolitis
○ Expiration ○ Asthma
– Increased attenuation of normal lung ○ Endoluminal foreign body or neoplasm
– Air-trapping: Sharply-defined geographic foci of lower
attenuation; follow outlines of secondary pulmonary
DIAGNOSTIC CHECKLIST
lobules; affects > 25% of lung volume; not limited to • Consider expiratory HRCT in patients with mosaic
lower lobe superior segments or lingular tip attenuation or suspected constrictive bronchiolitis
– Lobular air-trapping in < 3 adjacent lobules is normal
10
Airspace
KEY FACTS
11
Architectural Distortion
KEY FACTS
Overview of Chest Imaging
TERMINOLOGY PATHOLOGY
• Architectural distortion • Interstitial fibrosis, honeycombing
○ Abnormal displacement of bronchi, vessels, fissures, or • Etiologies
septa secondary to diffuse or localized retractile fibrosis ○ Fibrosing interstitial lung disease (e.g., idiopathic
○ Characteristically related to interstitial fibrosis pulmonary fibrosis, fibrotic nonspecific interstitial
pneumonia)
IMAGING
○ End-stage sarcoidosis
• Radiography ○ Radiation-induced fibrosis
○ Reticular opacities; nodular and mass-like opacities ○ Pneumoconiosis
○ Volume loss ○ Chronic (fibrotic) hypersensitivity pneumonitis
○ Hilar displacement related to volume loss ○ Sequela of infection (e.g., tuberculosis, COVID-19)
○ Bronchiectasis related to volume loss ○ Sequela of acute respiratory distress syndrome
• CT
○ Abnormal displacement of pulmonary vessels and DIAGNOSTIC CHECKLIST
bronchi associated with pulmonary fibrosis • Architectural distortion is an irreversible process that
○ Reticular opacities with interlobular septal thickening denotes fibrosis
and intralobular lines ○ Usually associated with volume loss, reticulation, traction
○ Traction bronchiectasis, honeycombing bronchiectasis/bronchiolectasis, and honeycombing
○ Cicatricial atelectasis; may be nodular or mass-like
12
Bulla/Bleb
KEY FACTS
13
Cavity
KEY FACTS
Overview of Chest Imaging
14
Centrilobular
KEY FACTS
15
Consolidation
KEY FACTS
Overview of Chest Imaging
TERMINOLOGY • CT
• Replacement of alveolar air by edema fluid, pus, blood, ○ Increased lung attenuation; obscures underlying lung
neoplastic cells, or other material (e.g., lipoprotein) architecture
○ Often implies infection (pneumonia) ○ May exhibit intrinsic air bronchograms &/or adjacent
• Synonyms: Airspace/alveolar consolidation acinar or centrilobular nodules
• Focal, patchy, multifocal, or diffuse PATHOLOGY
• Focal consolidation • Etiology
○ Nonsegmental, segmental, lobar ○ Infection: Bacterial, mycobacterial, viral, fungal
○ Mass-like or tumor-like ○ Pulmonary alveolar edema or hemorrhage
IMAGING ○ Neoplastic: Lung cancer, pulmonary lymphoma
• Radiography ○ Inflammatory: Organizing pneumonia, alveolar
sarcoidosis, eosinophilic pneumonia, alveolar
○ Increased parenchymal density
lipoproteinosis, lipoid pneumonia
○ Obscures underlying normal structures (e.g., bronchi,
○ Post treatment: Radiation or drug-induced pneumonitis
vessels)
○ Obscures adjacent structures DIAGNOSTIC CHECKLIST
– Sign of silhouette • Consolidations in adults should be followed to complete
○ May exhibit intrinsic air bronchograms radiographic resolution to exclude underlying malignancy
○ May be spherical, sublobar, or lobar
16
Cyst
KEY FACTS
17
Ground-Glass Opacity
KEY FACTS
Overview of Chest Imaging
TERMINOLOGY PATHOLOGY
• Ground-glass opacity: Increased lung density or attenuation • Etiology
that does not obscure underlying lung architecture (i.e., ○ Acute
bronchi, vessels) – Pneumonia (including Pneumocystis jirovecii, viral,
• Mechanisms mycoplasma), hemorrhage, edema, acute interstitial
○ Alveolar filling &/or collapse pneumonia (AIP), acute respiratory distress syndrome
○ Interstitial thickening (ARDS), eosinophilic lung disease, radiation
○ Increased blood volume pneumonitis, drug toxicity, E-cigarette or vaping
○ Combination of above mechanisms product use-associated lung injury (EVALI)
○ Chronic
IMAGING – Interstitial pneumonias: Nonspecific interstitial
• Radiography pneumonia, desquamative interstitial pneumonia,
○ Hazy increased lung density that does not obscure respiratory bronchiolitis, respiratory bronchiolitis-
underlying structures associated interstitial lung disease
○ Although term may be used to describe radiographic – Hypersensitivity pneumonitis, drug toxicity, radiation
finding, it is typically reserved to describe CT findings pneumonitis, eosinophilic lung disease, vasculitis (with
• CT associated pulmonary hemorrhage or eosinophilic
○ Increased lung attenuation that does not obscure lung disease), lipoid pneumonia, adenocarcinoma
underlying bronchovascular structures (preinvasive, minimally invasive, invasive)
18
Honeycombing
KEY FACTS
(Left) Low-power
photomicrograph (H&E stain)
of a specimen of usual
interstitial pneumonia shows
dense fibrosis and
honeycomb cysts , which
correlate with the layered
cystic spaces seen on CT.
(Right) Axial HRCT of a patient
with end-stage sarcoidosis
shows extensive
honeycombing with
peribronchovascular
distribution. This distribution
may occur in both end-stage
sarcoidosis and fibrotic
hypersensitivity pneumonitis.
19
Interlobular Septal Thickening
KEY FACTS
Overview of Chest Imaging
TERMINOLOGY PATHOLOGY
• Thickening of interlobular septa, which outline secondary • Etiology
pulmonary lobule ○ Smooth interlobular septal thickening
• Normal interlobular septa are not visible on imaging – Interstitial edema
IMAGING – Lymphangitic carcinomatosis
– Alveolar lipoproteinosis
• Radiography
– Other interstitial lung diseases
○ Thick interlobular septa manifest as Kerley lines
○ Nodular interlobular septal thickening
○ Kerley B lines: Short horizontal lines perpendicular to
– Lymphangitic carcinomatosis
pleura (1.5-2 cm long)
– Lymphoproliferative disorder
○ Kerley A lines: Lines 2-6 cm long, upper lung zones,
course obliquely from hilum toward lung periphery – Sarcoidosis, silicosis, and coal workers pneumoconiosis
○ Kerley C lines: Net-like branching linear opacities at lung ○ Irregular interlobular septal thickening
bases; Kerley B lines seen en face – Pulmonary fibrosis, end-stage sarcoidosis
• CT/HRCT DIAGNOSTIC CHECKLIST
○ Thick interlobular septa • Interstitial edema is most common cause of interlobular
○ Surround and delineate secondary pulmonary lobule septal thickening
○ Smooth or nodular thickening • Nodular interlobular septal thickening should suggest
○ Irregular septal thickening in pulmonary fibrosis malignancy
20
Intralobular Lines
KEY FACTS
21
Mass
KEY FACTS
Overview of Chest Imaging
TERMINOLOGY • CT
• Thoracic lesion > 3 cm in maximal diameter ○ Lung mass: Morphologic features and clinical staging
○ Typically solid, but may exhibit necrosis &/or cavitation (local invasion, lymphadenopathy, metastases)
• May be located in any thoracic anatomic compartment ○ Pleural mass: Focal vs. multifocal; evaluation of local
invasion, lymphadenopathy, pleural effusion
○ Lung, pleura, mediastinum, chest wall, diaphragm
○ Mediastinal mass: Assessment of lesion morphology and
IMAGING attenuation, identification of lymphadenopathy,
• Radiography evaluation of local invasion
○ Lesion identification and localization to specific thoracic ○ Chest wall mass: Assessment and characterization of
anatomic compartment degree of skeletal &/or soft tissue involvement
○ Lung mass: Surrounded by lung, well- or ill-defined, PATHOLOGY
spiculated or lobular borders
• Etiology
○ Pleural mass: May exhibit obtuse angles with adjacent
○ Lung: Lung cancer, lung abscess, metastasis
pleura and incomplete border sign
○ Pleura: Localized fibrous tumor of pleura, metastasis
○ Mediastinal mass: Alteration of mediastinal contours;
focal vs. diffuse; lateral radiography allows localization to ○ Mediastinum: Thymic neoplasm, neurogenic neoplasm,
specific mediastinal compartment lymphadenopathy, congenital cyst, vascular lesion
○ Chest wall mass: Incomplete border sign; may exhibit ○ Chest wall: Metastasis, chondrosarcoma, myeloma
skeletal erosion/destruction &/or soft tissue involvement
22
Another random document with
no related content on Scribd:
CHAPTER XXX
ENDERBY CASTLE
There were two spacious open barouches and one large wagon.
“My lord ordered me, sir, if the weather should be fine, to bring the
barouches for the ladies, as they would be so much pleasanter,” the
man explained, touching his hat, as he held the door of the first
carriage open for Mrs. Force.
The travelers were soon seated—Mr. and Mrs. Force, Wynnette
and Elva in the first barouche, Le, Odalite and Rosemary in the
second, and the two servants, with the dog and the luggage, in the
wagon.
“Oh, how jolly!” exclaimed Wynnette, looking about her.
By this time it was light enough to see their surroundings—the
hoary cliffs and the picturesque fishing village on their right; the far-
spread rocky beach, with the fishing boats drawn up, on their left;
the expanse of ocean beyond, dotted at long distances with sails; and
right near them the only street of the hamlet that ran from the beach
up through a natural cleft in the rocks, and looked something like a
rude, broad staircase of flagstones, which were paved on edge to
afford a hold to horses’ feet in climbing up the steep ascent.
By this time, too, the denizens of the village were out before their
doors to stare at the unusual sight of three carriages and a large party
of visitors for Enderby Castle.
For, of course, as his lordship’s carriages and liveried servants
were there to meet the party of travelers, they must be visitors to the
castle.
The men took off their hats and the women courtesied as the open
carriages passed slowly up the steep street to the top of the cliff,
where it joined the road leading northward along the sea toward
Enderby Castle.
Now the travelers in the open carriages had a grand view of land
and water.
On the east, moorland rolling into hills in the mid distance and
rising into mountains on the far horizon. The newly risen sun shining
above them and tinting all their tops with the soft and varied hues of
the opal stone. Here and there at long distances could be seen the
ruined tower of some ancient stronghold, or the roof and chimneys
of some old farmstead. Everything looked old or ancient on this wild
coast of Cumberland.
On the west the ocean rolled out until lost to view in the mists of
the horizon.
Before them northward the road stretched for many a mile.
Far ahead they saw a mighty promontory stretching out to sea. At
its base the waves dashed, leaped, roared, tumbled like raging wild
beasts clawing at the rocks. On the extreme edge of its point arose a
mass of gray stone buildings scarcely to be distinguished from the
foundation on which they were built.
“How far is it to Enderby Castle?” inquired Mr. Force of the
coachman who drove his carriage.
“Ten miles from the station, sir,” replied the man, touching his hat.
“That is the castle,” said Mrs. Force, pointing to the pile of
buildings on the edge of the promontory, and handing the field glass
with which she had been taking a view of her birthplace and first
home.
“That! It is a fine, commanding situation, but it scarcely looks to be
more than five miles from here.”
“It is not, if we could take a bee line over land and sea, but the road
has to follow the bend of the estuary,” replied the lady.
All the occupants of both carriages, which had come to a standstill,
were now on their feet gazing at that hoary headland, capped with its
ancient stronghold.
The field glass was passed from one to another, while the carriages
paused long enough for all to take a view.
“So that was the home of my grandparents and of our forefathers
for—how long, dear mamma?” inquired Odalite.
“Eight centuries, my dear. The round tower that you see is the
oldest part of the edifice, and was built by Kedrik of Enderbee in the
year 950.”
“Lord, what a fine time the rats, mice, bats, owls, rooks and ghosts
must have in it!” remarked Wynnette.
“It is like a picture in a Christmas ghost story,” said Elva.
“It seems like Aunt Sukey was reading it all to me out of a novel by
the evening fire at Grove Hill,” mused Rosemary.
“Go on,” said Mr. Force.
And the carriages started again.
The road, still running along the top of the cliff, turned gradually
more and more to the left until its course verged from the north to
the northwest, and then to the west, as it entered upon the long, high
point of land upon which stood the castle. The road now began to
ascend another steep, paved with stones on edge to make a hold for
the horses’ feet in climbing, and at length entered a sort of alley
between huge stone walls that rose higher and higher on either side
as the road ascended, until it reached a heavy gateway flanked with
towers, between which, and over the gateway, hung the spiked and
rusting iron portcullis, looking as if it were ready, at the touch of a
spring, to fall and impale any audacious intruder who might pass
beneath it. But it was fast rusted into its place, where it had been
stationary for ages.
“I wonder who was the last warder that raised this portcullis?”
mused Wynnette.
“I cannot tell you, my dear. It has not been moved in the memory
of man,” replied Mrs. Force.
“I see ghosts again!” exclaimed Wynnette—“men-at-arms on
yonder battlements! Knights, squires and pursuivants in the
courtyard here! Oh, what a haunted hole is this!”
They entered a quadrangular courtyard paved with flagstones,
inclosed by stone buildings, and having at each of the four corners a
strong tower.
The front building, through which they had passed by the
ascending road, was the most ancient part of the castle and faced the
sea. But in the rear of that was the more recent structure, used as the
dwelling of the earl and his household. This modern building also
faced the sea, on the other side, but it could not be approached from
the cliff road except through the front. These buildings were not used
at all. They were given over to the denizens objected to by Wynnette
—to rats, mice, bats, owls and rooks, and—perhaps ghosts.
On either side the buildings were used as quarters for the servants
and offices for the household.
They drove through the courtyard, under an archway in the wall of
the modern building, and out to the front entrance, facing the open
sea.
Many steps led from the pavement up to the massive oaken doors,
flanked by huge pillars of stone, that gave admittance to the building.
The coachman left his box, went up these stairs and knocked.
The double doors swung open.
Mr. Force alighted and handed out his wife and two elder
daughters, while Le performed the same service for Elva and
Rosemary, and the party walked up the stairs to the open door.
A footman in the gray livery of Enderby bowed them in.
CHAPTER XXXI
MRS. FORCE’S BROTHER
Early the next morning Mr. Force, Leonidas and Wynnette, who
begged to make one of the party, left Enderby Castle for Lancashire.
The gray-haired coachman drove them in an open carriage to the
Nethermost Railway Station.
On this drive they retraced the road on the top of the cliffs which
they had traversed on the previous day.
They reached Nethermost just in time to jump on board the
“parliamentary,” a slow train—none but slow trains ever did stop at
this obscure and unfrequented station.
Mr. Force secured a first-class compartment for himself and party,
and they were soon comfortably seated and being whirled onward
toward Lancaster.
For some miles the road followed the line of the coast in a
southerly direction, and then diverged a little to the eastward until it
reached the ancient and picturesque town of Lancaster, perched
upon its own hill and crowned with its old castle, which dates back to
the time of John of Gaunt.
Here they left their train, and on consulting the local time-table in
the ticket office found that the next train on the branch line going to
the station nearest Angleton did not start until 3 P.M.
This, as it was now but 11 A.M., gave the party an opportunity of
seeing the town, as well as of getting a luncheon.
A chorus of voices offered cabs; but Mr. Force, waving them all
away, walked up the street of antiquated houses and brought his
party to the ancient inn of “The Royal Oak.”
Here he ordered luncheon, to be ready at two, and then set out
with his young people to walk through the town.
They climbed the hill and viewed the castle, now fallen from its
ancient glory of a royal fortress—not into ruin, but into deeper
degradation as the county jail. But the donjon keep, King John’s
Tower, and John of Gaunt’s Gate remain as of old.
They next visited the old parish church of St. Mary’s, where they
saw some wonderful stained glass windows, brass statuary, and oak
carvings of a date to which the memory of man reached not back.
They could only gaze upon the outside of the cotton and silk
factories and the iron foundries before the clock in the church tower
struck two, and they returned to the hotel for lunch.
At three o’clock they took the train for Angleton.
Their course now lay eastward through many a mile of the
manufacturing districts, and then entered a moorland, waste and
sparsely inhabited, stretching eastward to the range of mountains
known in local phraseology as “England’s Backbone.”
It was six o’clock on a warm June afternoon when the slow train
stopped at a little, lonely station, in the midst of a moor, where there
was not another house anywhere in sight.
Here our travelers left their compartment and came out upon the
platform, carpetbags in hand; and the train went on its way.
Our party paused on the platform, looking about them.
On their right hand stood the station, a small, strong building of
stone with two rooms and a ticket office. Behind that the moor
stretched out in unbroken solitude to the horizon.
On their left hand was the track of the railroad, and beyond that
the moor rolling into low hills, toward the distant range of
mountains.
There was not a vehicle of any sort in sight; and there were but two
human beings besides themselves on the spot—one was the ticket
agent and the other the railway porter.
Mr. Force spoke to the latter.
“Where can I get a carriage to take my party on to Angleton?”
The man, a red, shock-haired rustic, stared at the questioner a
minute before answering.
“Noa whurr, maister, leaf it be at t’ Whoit Coo.”
“And where is the White Cow?” inquired the gentleman.
The rustic stretched his arm out and pointed due east.
Mr. Force strained his eyes in that direction, but at first could see
nothing but the moor stretching out in the distance and rolling into
hills as it reached the range of mountains.
“Papa,” said Wynnette, who was straining her eyes also, “I think I
see the place. I know I see a curl of smoke and the top of a chimney,
and the peak of a gable-end roof. I think the rise of the ground
prevents our seeing more.”
“Oie, oie, yon’s t’ Whoit Coo,” assented the porter.
“How far is it from here?” inquired Mr. Force.
“Taw mulls, maister.”
“Can you go there and bring us a carriage of some sort? I will pay
you well for your trouble,” said Mr. Force.
“Naw, maister. Oi’ mawn’t leave t’ stution.”
“Uncle!” exclaimed Le, “I can go and bring you a carriage in no
time. You take Wynnette into the house and wait for me.”
And without more ado Le ran across the track and strode off across
the moor.
Mr. Force took Wynnette into the waiting room of the little
wayside station, where they sat down.
There was no carpet on the floor, no paper on the walls, no shades
at the windows, but against the walls were rows of wooden benches,
and on them large posters of railway and steamboat routes, hotels,
watering places, and so forth, and one picture of the winner of the
last Derby.
They had scarcely time to get tired of waiting before Le came back
with the most wretched-looking turnout that ever tried to be a useful
conveyance.
It was a long cart covered with faded and torn black leather, and
furnished with wooden seats without cushions. Its harness was worn
and patched. But there was one comfort in the whole equipage—the
horse was in very good condition. It was a strong draught horse.
“I shall not have to cry for cruelty to animals, at any rate,” said
Wynnette, as her father helped her up into a seat.
“How far is it to Angleton?” inquired Mr. Force of the driver.
“Sux mulls, surr,” answered the man. “Sux mulls, if yur tek it cross
t’ moor, but tun, ’round b’ t’ rood.”
“Is it very rough across the moor?” inquired Mr. Force.
“Muddlin’, maister,” replied the man.
“Go across the moor,” said the gentleman, as he stepped up into
the carriage.
Le followed him. The horse started and trudged on, jolting them
over the irons on the railway track and striking into the very worst
country road they had ever known.
Yes. It was rough riding across that moor, sitting on hard benches,
in a cart without springs, and drawn by a strong, hard-trotting horse.
Our travelers were jolted until their bones were sore before they
reached the first stopping place.
This was “‘The White Cow,” an old-fashioned inn, in a dip of the
moor, where the ground began to roll in hills and hollows toward the
distant mountains.
The house fronted east, and, as it lay basking in the late afternoon
summer sun, was very picturesque. Its steep, gable roof was of red
tiles, with tall, twisted chimneys, and projecting dormer windows; its
walls were of some dark, gray stone, with broad windows and doors,
and a great archway leading into the stable yard. A staff, with a
swinging sign, stood before the door.
The declining sun threw the shadow of the house in front of it; and
in this shade a pair of country laborers sat on a bench, with a table
before them. They were smoking short pipes and drinking beer,
which stood in pewter pots on the board.
This was the only sign of life and business about the still place.
As the cart drew up Mr. Force got out of it and helped his daughter
to alight.
Le followed them.
“I think we will go in the house and rest a while, and see if we can
get a decent cup of tea, my dear. We have had nothing since we left
Lancaster, at three o’clock, and it is now half-past seven. You must be
both tired and hungry,” said the squire, leading her in.
“‘I’m killed, sire,’”
responded Wynnette, misapplying a line from Browning, as she
limped along on her father’s arm.
The man who had driven them from the railway station, and whom
after developments proved to be waiter, hostler, groom and
bootblack rolled into one for the guests of the White Cow, left his
horse and cart standing and ran before Mr. Force to show the
travelers into the house.
It was needless; but he did it.
They entered a broad hall paved with flagstones.
On the left of this an open door revealed the taproom, half full of
rustic workingmen, who were smoking, drinking, laughing and
talking, and whose forms loomed indistinctly through the thick
smoke, tinted in one corner like a golden mist by the horizontal rays
of the setting sun that streamed obliquely through the end window.
On the right another open door revealed a large low-ceiled parlor,
with whitewashed walls and sanded floor, a broad window in front
filled with flowering plants in pots, and a broad fireplace at the back
filled with evergreen boughs and cut paper flowers. On the walls
were cheap colored pictures, purporting to be portraits of the queen
and members of the royal family. Against the walls were ranged
Windsor chairs. On the mantelpiece stood an eight-day clock,
flanked by a pair of sperm candles, in brass candlesticks.
In the middle of the floor stood a square table, covered with a
damask cloth as white as new fallen snow, and so smooth and glossy,
with such sharp lines where it had been folded, that proved it to have
been just taken from the linen press and spread upon the table.
The house might be old-fashioned and somewhat dilapidated, not
to say tumble-down, as to its outward appearance; but this large,
low-ceiled room was clean, neat, fresh and fragrant as it was possible
for a room to be.
“This is pleasant, isn’t it, papa?” said Wynnette, as she stood by the
flowery window, threw off her brown straw hat, pulled off her gloves,
drew off her duster, put them all upon one chair and dropped herself
into another.
“Yes. If the tea proves as good as the room, we shall be content,”
replied Mr. Force.
The man-of-all-work, who had slipped out and put on a clean
apron, and taken up a clean towel, with magical expedition, now
reappeared to take orders.
“What would you please to have, sir?”
“Tea for the party, and anything else you have in the house that is
good to eat with it.”
“Yes, sir.”
And the waiter pulled the white tablecloth this way and that and
smoothed it with the palms of his hands, apparently for no other
reason than to prove his zeal, for he did not improve the cloth.
Mr. Force and Le walked out “to look around,” they said.
CHAPTER XXXIII
A CLEW
The one maid-of-all-work came in and asked the young lady if she
would not like to go to a room and wash her face and hands.
Wynnette decidedly would like it, and said so.
The girl was a fresh, wholesome-looking English lass, with rosy
cheeks and rippling red hair. She wore a dark blue dress of some
cheap woolen material, with a white apron and white collar.
She led the young lady out into the hall again, and up a flight of
broad stone steps to an upper hall, and thence into a front bed
chamber, immediately over the parlor.
Here again were the whitewashed walls, clean bare floor, the
broad, white-shaded window, the open fireplace filled with
evergreens, the polished wooden chairs, ranged along the walls, and
all the dainty neatness of the room below. There were, besides, a
white-curtained bed, with a strip of carpet on each side of it; a white-
draped dressing table with an oval glass, and a white-covered
washstand, with white china basin and ewer. In a word, it was a pure,
fresh, dainty, and fragrant white room.
“Oh, what a nice place! Oh, how I should like to stay here to-night,
instead of going further!” exclaimed Wynnette, appreciatively.
The girl made no reply, but began to lay out towels on the
washstand, and to pour water from the ewer into the basin.
“This is a very lonesome country, though, isn’t it?” inquired
Wynnette, who was bound to talk.
“There’s not a many gentry, ma’am. There be mill hands and
pitmen mostly about here,” said the girl.
“Mill hands and pitmen! I saw no mills nor mines, either, as we
drove along.”
“No, ma’am; but they beant far off. The hills do hide them just
about here; but you might seen the high chimneys—I mean the tops
of ’em and the smoke.”
“Are they pitmen down there in the barroom?”
“In the taproom? Yes, ma’am. Mill hands, and farm hands, too.
They do come in at this hour for their beer and ’bacco.”
“Do you have many more customers besides these men?”
“Not ivery day, ma’am; but we hev the farmers on their way to
Middlemoor market stop here; and—and the gentry coming and
going betwixt the station and Fell Hall, or Middlemoor Court, or
Anglewood Manor, ma’am.”
“How far is Anglewood Manor from this?”
“About five miles, ma’am.”
“‘Five!’ Why, I thought it wasn’t more than four. The coachman
told us it was only six from the station and we have come two.”
“That was Anglewood village, I reckon, ma’am. That is only four
miles from here; but Anglewood Manor is a short mile beyant that.”
“Ah! Who keeps this inn? There is no name on the sign.”
“No, ma’am. It’s ‘T’ Whoit Coo.’ It allers hev been ‘T’ Whoit Coo,’
ma’am.”
“But who keeps it?” persisted inquisitive Wynnette.
“Oo! Me mawther keeps it, iver sin’ feyther deed, ma’am. Mawther
tends bar hersen, and Jonah waits and waters horses, and cleans
boots, and does odd jobs, and I be chambermaid.”
“Ah! and who is Jonah?”
“Me brawther.”
“Ah! And so your mother, your brother, and yourself do all the
work and run the hotel?”
“Yes, ma’am. It would no pay us else,” replied the “Maid of the
Inn,” who seemed to be as much inclined to be communicative as
Wynnette was to be inquisitive.
“Oh, well, it is lucky that you are all able to do so. But you have not
told me your name yet.”
“Mine be Hetty Kirby, ma’am. Brawther Jonah’s be Jonah, and
mawther’s be the Widow Kirby,” definitely replied the girl.
“‘Kirby!’ Oh—why——Tell me, did you have a relation named John
Kirby go to America once upon a time?”
“Yes, ma’am, a long time ago, before I can remember, me Oncle
John Kirby, me feyther’s yo’ngest brawther, went there and never
come back.”
“Oh! And—is your grandfather living?”
The “Maid of the Inn” stared. What was all this to the young lady?
Wynnette interpreted her look and explained:
“Because, if he is living, I have got a letter and a bundle for him
from his son in New York.”
“Oh, Law! hev you, though, ma’am? Look at thet, noo! What
wonders in this world. The grandfeyther is living, ma’am, but not in
Moorton. He be lately coom to dwell wi’ ‘is son Job, me Oncle Job,
who be sexton at Anglewood church.”
“Sexton at Anglewood church! Is your uncle sexton at Anglewood
church? And does your grandfather, old Mr. Kirby, live with him?”
The maid of the inn stared again. Why should this strange young
lady take so much interest in the Kirbys?
Again Wynnette interpreted her look, and explained:
“Because if your grandfather does live there, it will save us a
journey to Moorton, as we are going to Anglewood, and can give him
the letter and parcel without turning out of our way,” she said; but
she was also thinking that if this old Kirby, to whom she was bringing
letters and presents from his son in America, was the father of the
sexton at Anglewood church, an inmate of his cottage, and probably
assistant in his work, these circumstances might greatly facilitate
their admission into vaults and mausoleums which the party had
come to see, but which might otherwise have been closed to them.
“Oh, ma’am,” said Hetty, “would you mind letting mawther see the
letter and parcel?”
“No, certainly not; but I have no right to let her open either of
them, you know.”
“She shawnt, ma’am; but it wull do the mawther good to see the
outside ’n ’em. And o’ Sunday, when she goes to church, she can see
the grandfeyther, and get to read t’ letter. And there be t’ bell, ma’am.
And we mun goo doon to tea.”
Wynnette was ready, and went downstairs, attended by the girl.
A dainty and delicious repast was spread upon the table. Tea,
whose rich aroma filled the room and proved its excellence, muffins,
sally-lunns, biscuits, buttered toast, rich milk, cream and butter,
fried chicken, poached eggs, sliced tongue and ham, radishes, pepper
grass, cheese, marmalade, jelly, pound cake and plum cake.
Wynnette’s eyes danced as she saw the feast.
“It is as good as a St. Mary’s county spread! And I couldn’t say
more for it if I were to talk all day!” she exclaimed, as she took her
place at the head of the table to pour out the tea.
Mr. Force asked a blessing, just as he would have done if he had
been at home, and then the three hungry travelers “fell to.”
“Father,” said Wynnette, when she had poured out the tea, which
Hetty began to hand around, “do you know the Widow Kirby who
keeps this hotel——”
“Inn, my dear—inn,” amended the squire. “I am so happy to find
myself in an old-fashioned inn that I protest against its being
insulted with the name of hotel.”
“All right, squire,” said Wynnette.
“‘A sweet by any other smell would name as rose,’