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2015v1.0
THE REQUISITES
Thoracic Imaging
The Requisites Series
SERIES EDITOR TITLES IN THE SERIES
James H. Thrall, MD Breast Imaging
Radiologist-in-Chief Emeritus Cardiac Imaging
Massachusetts General Hospital Emergency Imaging
Distinguished Juan M. Taveras Professor of Radiology Gastrointestinal Imaging
Harvard Medical School Genitourinary Imaging
Boston, Massachusetts Musculoskeletal Imaging
Neuroradiology Imaging
Nuclear Medicine
Pediatric Imaging
Radiology Noninterpretive Skills
Thoracic Imaging
Ultrasound
Vascular and Interventional Imaging
THE REQUISITES
Thoracic Imaging
THIRD EDITION
Edited by
Jo-Anne O. Shepard, MD
Professor of Radiology
Harvard Medical School;
Director, Thoracic Imaging and Intervention
Director, Cardiothoracic Imaging Fellowship
Massachusetts General Hospital
Boston, Massachusetts
Associate Editors
Gerald F. Abbott, MD Matthew D. Gilman, MD
Associate Professor of Radiology Assistant Professor of Radiology
Harvard Medical School; Harvard Medical School;
Radiologist, Thoracic Imaging and Associate Director, Thoracic Imaging and Intervention
Intervention Associate Director, Cardiothoracic Imaging Fellowship
Department of Radiology Division of Radiology
Massachusetts General Hospital Massachusetts General Hospital
Boston, Massachusetts Boston, Massachusetts
Jeanne B. Ackman, MD, FACR Amita Sharma, MBBS

Assistant Professor of Radiology Associate Professor of Radiology
Harvard Medical School; Harvard Medical School;
Radiologist, Thoracic Imaging and Radiologist, Thoracic Imaging and Intervention
Intervention Division
Director, Thoracic MRI Department of Radiology
Department of Radiology Massachusetts General Hospital
Massachusetts General Hospital Boston, Massachusetts
Carol C. Wu, MD
Subba R. Digumarthy, MBBS Associate Professor of Diagnostic Radiology
Assistant Professor of Radiology University of Texas MD Anderson Cancer Center
Radiologist, Thoracic Imaging and Houston, Texas
Intervention
Division Quality Director, Thoracic Imaging
Department of Radiology
Harvard Medical School
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
THORACIC IMAGING : THE REQUISITES, 3rd edition ISBN: 978-0-323-44886-4

Copyright © 2019 by Elsevier, Inc. All rights reserved.
Previous editions copyrighted 2010, 1998 by Mosby, Inc., an affiliate of Elsevier, Inc.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such as
the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data

Names: Shepard, Jo-Anne O., editor. | Preceded by (work): McLoud, Theresa C. Thoracic radiology.
Title: Thoracic imaging / edited by Jo-Anne O. Shepard; associate editors, Gerald F. Abbott, Jeanne B.
Ackman, Subba Digumarthy, Matthew D. Gilman, Amita Sharma, Carol C. Wu.
Other titles: Thoracic imaging (Shepard) | Requisites series.
Description: Third edition. | Philadelphia, PA : Elsevier, [2019] | Series: Requisites series | Preceded by
Thoracic radiology / Theresa McLoud, Phillip Boiselle. 2nd ed. c2010. | Includes bibliographical
references and index.
Identifiers: LCCN 2017042687 | ISBN 9780323448864 (hardcover : alk. paper)
Subjects: | MESH: Thoracic Diseases–diagnostic imaging | Lung Diseases–diagnostic imaging |
Radiography, Thoracic–methods
Classification: LCC RC941 | NLM WF 975 | DDC 617.5/407572–dc23 LC record available at
https://lccn.loc.gov/2017042687
Content Strategist: Robin Carter

Content Development Specialist: Ann Anderson
Publishing Services Manager: Patricia Tannian
Project Manager: Ted Rodgers
Design Direction: Amy Buxton
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my husband Bill
and our children Sarah, John, and Bobby
with whose love and support all is possible
To my parents
Anne and John O’Malley
for their inspiration
Jo-Anne O’Malley Shepard
In memory of our friends and colleagues

Henry J. Llewellyn, MD (1937-2009)
Beatrice Trotman-Dickenson, MBBS (1957-2015)
Joan Curran Dow (1949-2016)
Foreword
It is a pleasure to help introduce the Third Edition of was a major milestone in medical practice that has created
Thoracic Radiology: The Requisites. Thoracic imaging is a important opportunities for thoracic radiologists but also
cornerstone of radiology practice that touches more patients challenges related to adopting best practices for screening
than any other area of sub-specialization in radiology. Many and correct application of the lung cancer staging system.
of the same technological innovations and advancements Correspondingly there are two chapters in this book that
that have propelled other areas of radiology forward in address these issues, one on screening and one on staging.
the last several years have also substantially changed the The digital transformation in radiology is now substan-
landscape in thoracic imaging, making the publication of tially complete. This transformation is fully incorporated into
the Third Edition timely and important. the Third Edition of Thoracic Radiology: The Requisites,
Dr. Jo-Anne O. Shepard is the editor of the new edition including a chapter that covers PET/CT and PET/MR. While
and has assembled a terrific team of co-editors and authors. PET/CT is well established in thoracic imaging, especially
In this regard, the Third Edition of Thoracic Radiology: for cancer diagnosis and follow-up, the potential for PET/
The Requisites reflects an important trend in authorship. MR is just becoming more widely available. Many of the
The original books were each written by a small number chapters with familiar titles are now more richly illustrated
of people, many with only one or two authors. Over time, with digital images with corresponding emphasis on high-
the breadth and complexity of each topic have increased resolution cross-sectional methods. The associated improve-
to the point that a multi-author approach is now appropri- ments in both image quality and diagnostic capabilities
ate for the level of expertise required. Doctors Gerald F. are highlighted.
Abbott, Jeanne B. Ackman, Subba R. Digmurthy, Mathew D. The Requisites books are not intended to be exhaustive.
Gilman, Amita Sharma, and Carol C. Wu serve as Associate There are “mega” reference texts that catalog rare and
Editors for this edition. Additional contributing authors unusual cases and that present different sides of controver-
include Manudeep Kalra, Alexi Otraji, Melissa Price, Bojan sies. Rather, The Requisites books are intended to provide
Kovacina, Lan Qian (Lancia) Guo, Brett W. Carter, Mylene information on the conditions that radiologists see every day,
Truong, Christopher M. Walker, Susan Gutschow, Shaun- the ones that are at the core of radiology practice. In fact,
agh McDermott, Efren J. Flores, Laura L. Avery, John W. one of the requests to authors is to not look up anything
Nance, Hristina Natcheva, Thomas Keimig, Jonathan Chung, unusual or obscure but to put in the book what they teach
Rydhwana Hossain, Victorine V. Muse, Milena Petranovic, their own residents every day at the workstation. Since the
Florian J. Fintelmann, Bradley S. Sabloff and Justin Stowell. authors are experienced experts in their respective areas,
It is difficult to imagine a stronger group of contributors. this is predictably the most important material.
Dr. Shepard and her co-authors are to be congratulated on The Requisites series is now well over 25 years old
producing a high-quality book that will be both practical and has served thousands of radiologists. The books are
and manageable for the reader. familiar and trusted friends to many people. It is my hope
The format and layout of Thoracic Radiology: The and expectation that radiology trainees as well as practicing
Requisites remain largely intact with early chapters on radiologists seeking to refresh their knowledge will find
technique and normal anatomy and chapters covering major the Third Edition of Thoracic Radiology: The Requisites
diseases and conditions. However, several new chapters a useful text.
address advances in technology and provide for deeper
coverage of increasingly specialized clinical applications. James H. Thrall, MD
For example, in the interval since publication of the Second Radiologist-in-Chief, Emeritus
Edition of Thoracic Radiology: The Requisites, the National Massachusetts General Hospital
Lung Screening Trial (NLST) demonstrated that screening Distinguished Taveras Professor of Radiology
for lung cancer in a defined population saves lives. This Harvard Medical School
vi
Preface
It is an honor and a privilege to be the Editor of the Third pulmonary nodule management strategies. State-of-the-art
Edition of Thoracic Imaging: The Requisites. The prior interventional content includes diagnostic thoracic biopsy
editions, edited by Theresa McLoud and Philip Boiselle, have techniques, fiducial placement to aid VATS surgical resec-
been embraced by students and practitioners of thoracic tion of small pulmonary nodules, and ablative therapies
imaging throughout the world as a reliable source for the for local control of thoracic tumors. More than 1000 new
essentials of state-of-the-art thoracic imaging. images encompass current digital radiographs, MDCT images
Much has changed since the earlier editions in 1998 and including HRCT, and dual energy CT scanning, FDG-PET/
2010. Thoracic Requisites has been rewritten to encompass CT, and PET/MRI. The content has been enhanced by many
a host of new imaging and interventional techniques, up-to- new diagrams and illustrations in full color. New tables and
date disease classifications and staging, current approaches boxes contain concise differential diagnoses and diagnostic
to diagnosis and management, and radiation dose reduction information.
strategies. The content has been arranged into 25 focused In the tradition of the Requisites series, Thoracic Imaging
chapters. An integrated approach to learning normal chest is designed to provide a requisite curriculum in thoracic
anatomy contains correlative radiographic and CT images. imaging for residents and fellows in radiology and allied
There is new material on acute and critical care imaging, specialties, as well as practicing radiologists and other
including post-operative complications, trauma, ICU diag- healthcare providers. Thoracic imaging is growing as a
nosis, and implantable devices. There is extensive new specialty, and the demand for expertise is increasing within
information on thoracic MRI indications, protocols, and both hospital and community practices. Thoracic Imaging:
case material, as well as expanded content on interstitial The Requisites will be an invaluable educational resource
lung disease, infections, and vascular diseases. Updated for all involved in the diagnosis of thoracic disease.
lung cancer coverage includes new tumor staging and
diagnostic techniques, lung cancer screening, and updated Jo-Anne O. Shepard, MD
vii
Contributors
Gerald F. Abbott, MD, FACR Subba R. Digumarthy, MD

Associate Professor of Radiology Assistant Professor of Radiology
Harvard Medical School; Radiologist, Thoracic Imaging and Intervention
Radiologist, Thoracic Imaging and Intervention Division Quality Director, Thoracic Imaging
Department of Radiology Department of Radiology
Massachusetts General Hospital Massachusetts General Hospital
Boston, Massachusetts Boston, Massachusetts
Chapter 2, Normal Anatomy and Atelectasis Chapter 1, Radiological Techniques and Dose Reduction
Chapter 16, Mycobacterial Infection Strategies in Chest Imaging
Chapter 17, Approach to Diffuse Lung Disease: Anatomic Chapter 4, PET-CT and PET-MRI: Technique, Pitfalls, and
Basis and High-Resolution Computed Tomography Findings
Chapter 12, The Postoperative Chest
Jeanne B. Ackman, MD, FACR Chapter 19, Pneumoconioses
Assistant Professor of Radiology Chapter 22, Incidental Pulmonary Nodule
Harvard Medical School; Chapter 24, Lung Cancer Staging
Radiologist, Thoracic Imaging and Intervention
Director, Thoracic MRI Florian J. Fintelmann, MD
Department of Radiology Assistant Professor of Radiology
Massachusetts General Hospital Harvard Medical School;
Boston, Massachusetts Radiologist, Thoracic Imaging and Intervention
Chapter 3, Thoracic Magnetic Resonance Imaging: Department of Radiology
Technique and Approach to Diagnosis Massachusetts General Hospital
Chapter 5, The Mediastinum Boston, Massachusetts
Chapter 7, The Pleura, Diaphragm, and Chest Wall Chapter 25, Interventional Techniques
Chapter 13, Thoracic Trauma
Efren J. Flores, MD
Laura L. Avery, MD Instructor of Radiology
Assistant Professor of Radiology Harvard Medical School;
Harvard Medical School; Radiologist, Emergency Radiology
Associate Director, Emergency Radiology Director, Radiology Community Health Improvement
Radiology Clerkship Director Department of Radiology
Department of Radiology Massachusetts General Hospital
Boston, Massachusetts Chapter 13, Thoracic Trauma
Chapter 13, Thoracic Trauma
Matthew D. Gilman, MD
Brett W. Carter, MD Assistant Professor of Radiology
Assistant Professor of Diagnostic Radiology Harvard Medical School;
Quality Officer, Diagnostic Imaging Associate Director, Thoracic Imaging and Intervention
Director, CT and MRI Associate Director, Cardiothoracic Imaging Fellowship
Clinical Co-Director, Quantitative Imaging Analysis Core Department of Radiology
The University of Texas MD Anderson Cancer Center Massachusetts General Hospital
Houston, Texas Boston, Massachusetts
Chapter 6, The Airways Chapter 8, Congenital Thoracic Malformations
Chapter 20, Obstructive Lung Diseases Chapter 9, Thoracic Lines and Tubes
Chapter 21, Pulmonary Tumors and Lymphoproliferative Chapter 11, Pulmonary Embolus and Pulmonary Vascular
Disorders Diseases
Jonathan Chung, MD Lan Qian (Lancia) Guo, MD, FRCP(C)

Associate Professor of Radiology Radiologist, Division of Cardiothoracic Imaging
Interim Chief of Quality Department of Medical Imaging
Section Chief, Thoracic Radiology University of Toronto
Department of Radiology Sunnybrook Health Sciences Centre
The University of Chicago Medicine Toronto, Ontario, Canada
Chicago, Illinois Chapter 5, The Mediastinum
Chapter 18, Diffuse Lung Diseases Chapter 7, The Pleura, Diaphragm, and Chest Wall
viii
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Contributors ix
Susan Gutschow, MD Victorine V. Muse, MD

Clinical Assistant Professor of Radiology Assistant Professor of Radiology
University of Missouri-Kansas City Harvard Medical School;
Kansas City, Missouri Radiologist, Thoracic Imaging and Intervention
Chapter 10, Acute Thoracic Conditions in the Intensive Department of Radiology
Care Unit Massachusetts General Hospital
Rydhwana Hossain, MD Chapter 19, Pneumoconioses
Assistant Professor of Diagnostic Radiology and Nuclear
Medicine John W. Nance, MD
University of Maryland School of Medicine Assistant Professor of Radiology
Baltimore, Maryland Director of Cardiovascular CT
Chapter 19, Pneumoconioses Medical University of South Carolina
Charleston, South Carolina
Mannudeep Kalra, MD, DNB Chapter 14, Community-Acquired Pneumonia
Associate Professor of Radiology
Harvard Medical School; Hristina Natcheva, MD
Radiologist, Thoracic and Cardiac Imaging Assistant Professor of Radiology
Director, Webster Center for Advanced Radiation Boston University School of Medicine;
Research and Education Radiologist, Department of Radiology
Department of Radiology Boston Medical Center
Boston, Massachusetts Chapter 15, Pulmonary Disease in the
Chapter 1, Radiological Techniques and Dose Reduction Immunocompromised Patient
Strategies in Chest Imaging
Alexi Otrakji, MD
Thomas Keimig, MD Research Fellow
Radiologist Harvard Medical School;
Henry Ford Hospital Clinical Fellow in Radiology
Detroit, Michigan Department of Radiology
Chapter 16, Mycobacterial Infection Massachusetts General Hospital;
Research Fellow
Bojan Kovacina, MDCM Harvard Medical School
Assistant Professor of Radiology Boston, Massachusetts
McGill University; Chapter 1, Radiological Techniques and Dose Reduction
Radiologist Strategies in Chest Imaging
Jewish General Hospital
Montreal, Quebec, Canada Milena Petranovic, MD
Chapter 4, PET-CT and PET-MRI: Technique, Pitfalls, and Instructor of Radiology
Findings Harvard Medical School
Chapter 12, The Postoperative Chest Radiologist, Thoracic Imaging and Intervention
Chapter 24, Lung Cancer Staging Department of Radiology
Suzanne Loomis, MS, FBCA Boston, Massachusetts
Production Supervisor Chapter 22, Incidental Pulmonary Nodule
Radiology Education Media Services (REMS);
Department of Radiology Melissa Price, MD
Massachusetts General Hospital Instructor of Radiology
Boston, Massachusetts Harvard Medical School
Medical Illustrations Radiologist, Thoracic Imaging and Intervention
Department of Radiology
Shaunagh McDermott, MB, BCh, BAO, FFR, (RCSI) Massachusetts General Hospital
Assistant Professor of Radiology Boston, Massachusetts
Harvard Medical School; Chapter 2, Normal Anatomy and Atelectasis
Radiologist, Thoracic Imaging and Intervention
Chapter 11, Pulmonary Embolus and Pulmonary Vascular
Diseases
Chapter 23, Lung Cancer Screening
x Contributors
Amita Sharma, MD Justin Stowell, MD

Assistant Professor of Radiology Resident
Harvard Medical School Department of Radiology
Radiologist, Thoracic Imaging and Intervention University of Missouri–Kansas City
Department of Radiology Kansas City, Missouri
Massachusetts General Hospital Chapter 8, Congenital Thoracic Malformations
Chapter 17, Approach to Diffuse Lung Disease: Anatomic Mylene T. Truong, MD
Basis and High-Resolution Computed Tomography Professor of Diagnostic Imaging
Chapter 18, Diffuse Lung Diseases Section Chief of Thoracic Imaging
Chapter 23, Lung Cancer Screening University of Texas MD Anderson Cancer Center
Houston, Texas
Jo-Anne O. Shepard, MD Chapter 6, The Airways
Professor of Radiology Chapter 21, Pulmonary Tumors and Lymphoproliferative
Harvard Medical School; Disorders
Director, Thoracic Imaging and Intervention
Director, Cardiothoracic Imaging Fellowship Christopher M. Walker, MD
Massachusetts General Hospital Associate Professor of Radiology
Boston, Massachusetts University of Missouri–Kansas City;
Chapter 2, Normal Anatomy and Atelectasis Saint Luke’s Hospital
Chapter 6, The Airways Kansas City, Missouri
Chapter 16, Mycobacterial Infection Chapter 8, Congenital Thoracic Malformations
Chapter 20, Obstructive Lung Diseases Chapter 10, Acute Thoracic Conditions in the Intensive
Chapter 23, Lung Cancer Screening Care Unit
Chapter 25, Interventional Techniques
Carol C. Wu, MD
Bradley S. Sabloff, MD Associate Professor of Diagnostic Radiology
Professor of Diagnostic Radiology University of Texas MD Anderson Cancer Center
University of Texas MD Anderson Cancer Center Houston, Texas
Houston, Texas Chapter 6, The Airways
Chapter 21, Pulmonary Tumors and Lymphoproliferative Chapter 20, Obstructive Lung Diseases
Disorders Chapter 21, Pulmonary Tumors and Lymphoproliferative
Disorders
Contents
Chapter 1 Chapter 13
Radiologic Techniques and Dose Reduction Thoracic Trauma 279
Strategies in Chest Imaging 1 Efren J. Flores, Laura L. Avery, Jeanne B. Ackman
Mannudeep K. Kalra, Alexi Otrakji, Subba R. Digumarthy
Chapter 14
Chapter 2 Community-Acquired Pneumonia 289
Normal Anatomy and Atelectasis 19 John W. Nance
Melissa Price, Jo-Anne O. Shepard, Gerald F. Abbott
Chapter 15
Chapter 3 Pulmonary Disease in the Immunocompromised
Thoracic Magnetic Resonance Imaging: Technique Patient 310
and Approach to Diagnosis 61 Hristina Natcheva
Jeanne B. Ackman
Chapter 16
With MR sniff test video
Mycobacterial Infection 323
Chapter 4 Thomas Keimig, Jo-Anne O. Shepard, Gerald F. Abbott
PET-CT and PET-MRI: Technique, Pitfalls, and
Chapter 17
Findings 88
Approach to Diffuse Lung Disease: Anatomic Basis
Bojan Kovacina, Subba R. Digumarthy
and High-Resolution Computed Tomography 335
Chapter 5 Amita Sharma, Gerald F. Abbott
The Mediastinum 97
Chapter 18
Lan Qian (Lancia) Guo, Jeanne B. Ackman
Diffuse Lung Diseases 355
Chapter 6 Jonathan H. Chung
The Airways 137 Chapter 19
Brett W. Carter, Jo-Anne O. Shepard, Mylene T. Truong, Carol C. Wu
Pneumoconioses 377
Rydhwana Hossain, Subba R. Digumarthy, Victorine V. Muse
Chapter 7
The Pleura, Diaphragm, and Chest Wall 159 Chapter 20
Lan Qian (Lancia) Guo, Jeanne B. Ackman Obstructive Lung Diseases 391
Carol C. Wu, Brett W. Carter, Jo-Anne O. Shepard
Chapter 8
Congenital Thoracic Malformations 193 Chapter 21
Justin Stowell, Matthew D. Gilman, Christopher M. Walker Pulmonary Tumors and Lymphoproliferative
Disorders 405
Chapter 9
Mylene T. Truong, Carol C. Wu, Brett W. Carter, Bradley S. Sabloff
Thoracic Lines and Tubes 210
Matthew D. Gilman Chapter 22
Incidental Pulmonary Nodule 428
Chapter 10
Milena Petranovic, Subba R. Digumarthy
Acute Thoracic Conditions in the Intensive Care
Unit 226 Chapter 23
Susan E. Gutschow, Christopher M. Walker Lung Cancer Screening 441
Shaunagh McDermott, Jo-Anne O. Shepard, Amita Sharma
Chapter 11
Pulmonary Embolus and Pulmonary Vascular Chapter 24
Diseases 238 Lung Cancer Staging 450
Shaunagh McDermott, Matthew D. Gilman Bojan Kovacina, Subba R. Digumarthy
Chapter 12 Chapter 25
The Postoperative Chest 259 Interventional Techniques 460
Bojan Kovacina, Jo-Anne O. Shepard, Subba R. Digumarthy Florian J. Fintelmann, Jo-Anne O. Shepard, Amita Sharma
xi
Acknowledgments
Massachusetts General Hospital has a long and venerable I am most grateful to Dr. Juan Taveras, who as Chair-
history of excellence in thoracic imaging. Many of the man of Radiology at Massachusetts General Hospital
early icons in chest imaging were faculty at MGH, includ- appointed me as faculty in the Thoracic Division at MGH,
ing Drs. Ross Golden, Aubrey Otis Hampton, and Felix understanding the value of subspecialization in radiology.
Fleischner, whose radiographic signs we still acknowledge A special thanks to Dr. James Thrall, who as Chairman of
today and are referenced in this book. I was fortunate the Department of Radiology at MGH provided me the
to have trained at MGH with Drs. Reginald Greene, Paul opportunity to develop and lead the Thoracic Division that
Stark, and Theresa McLoud, and as a fellow with Robert we enjoy today. Through his sage mentorship we have a
Pugatch, to whom I am most grateful for their outstanding robust and diverse division of incredibly talented faculty. I
teaching, mentoring, and leadership. In the MGH tradition am so proud that the Cardiothoracic Fellowship Program,
of educational excellence, we have collectively trained with the leadership of Dr. Matthew Gilman and all our
hundreds of residents and fellows in thoracic imaging, many faculty, produces so many wonderful thoracic radiologists.
of whom are recognized today as leaders in the field both Thank you to our current Chairman, Dr. James Brink, for
nationally and internationally. acknowledging the commitment and contributions of our
This book would not have been possible without the group and for his continued strong support of our clinical,
help of my current and former colleagues in the Thoracic educational, and research missions.
Division at MGH. The Associate Editors, Drs. Gerald Abbott, Finally, this book would not have been possible without
Jeanne Ackman, Subba Digumarthy, Matthew Gilman, the support of so many others. Veronica Noah and Lisa
Amita Sharma, and Carol Wu, have generously provided Howell, Staff Assistants at MGH, have provided invaluable
their expertise, creativity, and direction in producing this administrative support. I would also like to recognize the
new, updated edition. I am thankful to all the contributing dedicated professionals at Elsevier whose advice, guidance,
authors who have hailed from MGH as faculty, fellows, and support have made this publication possible.
or trainees. A special thanks to Suzanne Loomis, a gifted
medical illustrator, who has graced this edition with beauti- Jo-Anne O. Shepard, MD
ful color illustrations, and to Dr. Gerald Abbott, who has
artfully enhanced the images.
xii
Chapter 1
Radiologic Techniques and
Dose Reduction Strategies
in Chest Imaging
Mannudeep K. Kalra, Alexi Otrakji, and Subba R. Digumarthy
INTRODUCTION oxysulfide. The direct type of DR systems is used in mam-

mography units. Compared with CR, DR systems are faster,
This chapter reviews various x-ray–based techniques used allow more efficient throughput, have better image quality,
in thoracic imaging, including radiography, fluoroscopy, and have higher radiation dose efficiency. For these reasons,
digital tomosynthesis, and computed tomography (CT). mobile and wireless DR systems have immense applications
in critical care settings, emergency departments, and
CONVENTIONAL, COMPUTED, AND intraoperative imaging.
DIGITAL RADIOGRAPHY Digitization of radiographic images with CR and DR has
also enabled benefits in the form of electronic image storage
Merely 1 year after discovery of x-rays by Wilhelm Konrad and display on the picture archiving and communication
Roentgen, calcium tungstate was chosen as the material system (PACS) as well as image manipulations such as
for the first screen cassettes based on Thomas Edison’s adjustment of brightness and contrast, edge enhancement,
assessment of about 5000 chemicals for their light-producing inverted image display, zooming, and subtraction capabilities.
capabilities upon exposure to x-rays. For the next 75 years, Modern radiography units are more radiation dose
conventional radiography remained confined to the radio- efficient and use automatic exposure control techniques
graphic films sandwiched between two calcium tungstate– to terminate the radiographic exposure when the desired
based fluoroscopic screens. It was not until the mid-1970s quality is reached. It is also important that the operators
that the first computer-based processing of radiographic use appropriate guidelines (e.g., centering, breath-hold
images began to emerge with concomitant introduction instruction, and coning) to minimize unnecessary repetition
of rare earth chemicals into intensifying screens, which of radiographs.
had better x-ray absorption and lower radiation dose As opposed to readout workstations for CR, which
requirements. implied some readout time, with DR systems, radiographs
The earlier versions of computed radiography (CR) used could be ready for interpretation in as little as 5 seconds
the cassettes with new fluorescent materials, which retained after their acquisition (Fig. 1.2).
the information of x-ray exposure as a latent image. This
information was retrieved by stimulation with a thin focused CHEST RADIOGRAPHY: PROJECTIONS
laser beam, which resulted in re-emission of light. This AND VIEWS
light was captured with light-sensitive diodes and converted
to electrical signals stored and processed with computers. The plain chest radiograph is the most commonly performed
Although initial versions of CR required much higher imaging procedure in most radiology practices, constituting
radiation exposure, subsequent refinements in the detectors between 30% and 50% of studies. The standard routine
resulted in considerable decreases in radiation doses. The chest radiograph consists of an erect radiograph made in
cassette-based CR systems also required specific readout the posteroanterior (PA) projection and a left lateral
stations, which have also decreased in size and cost. These radiograph, both obtained at full inspiration. In the standard
systems are in common use because of their flexibility and PA projection, the patient faces the cassette, and the x-ray
lower costs. tube is located 6 feet behind the patient. The arms are
Developments in CR technology finally led to direct directed away from the chest with the hands resting on
digital radiography (DR), with electronic detectors. In the the waist. This technique prevents magnification of anterior
direct conversion type of DR system, the incident x-ray structures such as the heart. The full inspiration allows
photons interact with photodiodes and generate electrons, complete expansion of the lungs and separation of pulmo-
which form digital images. In the indirect conversion type, nary blood vessels to improve detection of pathology. In
x-ray photons interact with a scintillator to generate light an ideally performed standard radiograph, the trachea is
photons, which then subsequently interact with photodiodes in midline projection over the spine and is equidistant
to release electrons to form digital images (Fig. 1.1). from the heads of both clavicles. The lung apices, the
The indirect conversion type of DR system is most lateral costophrenic (CP) angles of the lungs, and the
commonly used in chest radiography, and commonly used diaphragm are completely visualized, and the diaphragm
scintillation detectors are cesium iodide and gadolinium lies at or below the anterior sixth and posterior ninth ribs.
1
Exploring the Variety of Random
Documents with Different Content
Littleton W. Tazewell, and supported by Randolph and three or four
other members of the grand jury. One witness thought that the vote
stood 9 to 7.
Narrow though the loophole might be, Wilkinson squeezed
through it. The indictment of Burr was at length obtained. The
conspirators, who had at first vehemently averred that Wilkinson
would never dare to appear, and who if he should appear intended
to break him down before the grand jury, were reduced to hoping
for revenge when he should come on the witness-stand. Meanwhile,
June 26, Burr pleaded not guilty, and the court adjourned until
August 3, when the trial was to begin.
Thus far the President had carried everything before him. He had
produced his witnesses, had sustained Wilkinson, indicted Burr, and
defied Marshall’s subpœnas. This success could not be won without
rousing passion. Richmond was in the hands of the conspirators, and
they denounced Jefferson publicly and without mercy, as they
denounced Wilkinson and every other government officer.
“As I was crossing the court-house green,” said an eye-witness,
[328] “I heard a great noise of haranguing some distance off.
Inquiring what it was, I was told it was a great blackguard from
Tennessee, one Andrew Jackson, making a speech for Burr and
damning Jefferson as a persecutor.”
Hay wrote to the President, June 14:[329]—

“General Jackson, of Tennessee, has been here ever since the 22d,
denouncing Wilkinson in the coarsest terms in every company. The
latter showed me a paper which at once explained the motive of this
incessant hostility. His own character depends on the prostration of
Wilkinson’s.”
This paper was no doubt Jackson’s secret denunciation to

Claiborne. Young Samuel Swartwout, who had some reason to
complain of the ridiculous figure he had been made to cut, jostled
Wilkinson in the street, and ended by posting him for a coward. John
Randolph echoed Luther Martin’s tirades against the President.
Randolph was in despair at Jefferson’s success.
“My friend,” he wrote to Nicholson,[330] “I am standing on the soil
of my native country divested of every right for which our fathers
bled. Politics have usurped the place of law, and the scenes of 1798
are again revived. Men now see and hear, and feel and think,
politically. Maxims are now advanced and advocated which would
almost have staggered the effrontery of Bayard or the cooler
impudence of Chauncey Goodrich when we were first acquainted.”
All this work was but skirmishing. The true struggle had still to
come. So long as the President dealt only with grand jurors and
indictments, he could hardly fail to succeed; but the case was
different when he dealt directly with Chief-Justice Marshall and with
the stubborn words of the Constitution, that “no person shall be
convicted of treason unless on the testimony of two witnesses to the
same overt act, or on confession in open court.” The district-attorney
was ready with a mass of evidence, but the chief-justice alone could
say whether a syllable of this evidence should be admitted; and
hitherto the chief-justice had by no means shown a bias toward the
government. Hay was convinced that Marshall meant to protect Burr,
and he wrote to the President on the subject:[331]—
“The bias of Judge Marshall is as obvious as if it was stamped
upon his forehead. I may do him injustice, but I do not believe that I
am, when I say that he is endeavoring to work himself up to a state
of f[irmness?] which will enable [him] to aid Burr throughout the trial
without appearing to be conscious of doing wrong. He seems to think
that his reputation is irretrievably gone, and that he has now nothing
to lose by doing as he pleases. His concern for Mr. Burr is wonderful.
He told me many years ago, when Burr was rising in the estimation of
the Republican party, that he was as profligate in principle as he was
desperate in fortune. I remember his words; they astonished me. Yet
when the grand jury brought in their bill, the chief-justice gazed at
him for a long time, without appearing conscious that he was doing
so, with an expression of sympathy and sorrow as strong as the
human countenance can exhibit without palpable emotion.”
August 3 the court opened its session and the trial began. Not
until August 17 was the jury impanelled; and meanwhile a new
figure appeared at Burr’s side. Blennerhassett arrived in Richmond
August 4, and was brought before the court August 10. He began at
once a private journal of the trial, which remained the only record of
what passed among the conspirators. As each witness appeared,
Blennerhassett told the gossip regarding him.
“The once redoubted Eaton,”[332] who was put first upon the
stand, “has dwindled down in the eyes of this sarcastic town into a
ridiculous mountebank, strutting about the streets under a
tremendous hat, with a Turkish sash over colored clothes, when he is
not tippling in the taverns, where he offers up with his libations the
bitter effusions of his sorrows.”
“Old sly-boots” Dayton,[333] he said, was lurking about corners.

Wilkinson[334] “exhibited the manner of a sergeant under a court-
martial rather than the demeanor of an accusing officer confronted
with his culprit. His perplexity and derangement, even upon his direct
examination, has placed beyond all doubt ‘his honor as a soldier and
his fidelity as a citizen.’”
These comments were sharp, yet the pages of Blennerhassett’s
diary were not so severe upon any of the witnesses for the
government as they were upon Burr himself. Blennerhassett had
wakened to the discovery that Burr was, after all, but a vulgar
swindler. The collapse of Burr’s courage when confronted by Cowles
Meade and the Mississippi militia at Cole’s Creek January 17; his
desertion of Blennerhassett and his flight toward Spanish territory;
the protest of the bills which he had drawn on pretended funds in
New York, and which Blennerhassett had indorsed under Allston’s
guaranty; the evident wish of Allston to repudiate this guaranty as
he had repudiated Burr; and the ruin which had fallen on
Blennerhassett’s property at the island,—taught the Irishman how
thoroughly he had been duped:[335]—
“The present trial cannot fail to furnish ample testimony, if not to
the guilt, at least to the defect of every talent under the assumption
of which this giddy adventurer has seduced so many followers of riper
experience and better judgment than myself.”
Yet Burr’s mastership in deportment, his superficial dignity, his
cheerfulness and sanguine temperament, and the skill with which he
managed legal tactics, made an impression on Blennerhassett’s
mind:—
“As a jockey might restore his fame in the course after he had
injured it on the tight-rope, so, perhaps, the little ‘Emperor’ at Cole’s
Creek may be forgotten in the attorney at Richmond.”[336]
For a few days the trial went on undisturbed, while the

government put Eaton, Truxton, Peter Taylor, the Morgans, and a
number of other witnesses on the stand to prove an overt act of
treason at Blennerhassett’s island; but nothing short of
Blennerhassett’s own confession could place the matter in a clear
light, and Burr’s chief fear was evidently that Blennerhassett should
turn State’s evidence. To prevent this, Allston was persuaded to pay
the more pressing demands against Blennerhassett, and Burr
exerted himself to conciliate him. On the other hand, Jefferson
seemed to hope that he could be won over.[337] Duane, of the
“Aurora,” visited him in prison August 23, and offered to serve as an
intermediary with the government.[338] Had matters gone as the
President hoped, something might have come of this manœuvre; but
before further pressure could be employed, the chief-justice struck
the prosecution dead.
August 19 Burr’s counsel suddenly moved to arrest the evidence.
The government, they said, had gone through all its testimony
relating to the overt act charged in the indictment; it admitted that
Burr was hundreds of miles distant from the scene; and as the
district-attorney was about to introduce collateral testimony of acts
done beyond the jurisdiction of the court, it became the duty of the
defence to object.
For ten days this vital point was argued. All the counsel on either
side exerted themselves to the utmost. Wickham’s opening speech
on the nature of treason was declared by as good a judge as
Littleton Tazewell to be “the greatest forensic effort of the American
bar.”[339] Luther Martin spoke fourteen hours, beginning with an
almost passionate allusion to his idol Theodosia. William Wirt
exhausted his powers of argument and oratory, and in the course of
his address made the rhetorical display which became familiar to
every American, and which introduced a sort of appeal to
Blennerhassett to turn against the more guilty crew who were trying
to sacrifice him to save themselves:—
“Who is Blennerhassett? A native of Ireland, a man of letters, who
fled from the storms of his own country to find quiet in ours.”
George Hay was neither so efficient nor so dexterous as Wirt,
and either intentionally or by awkwardness succeeded in giving the
impression of threatening the court:[340]—
“Mr. Bott says that we are now advocating opinions which on Fries’
trial we condemned.... I beg leave to assure the gentleman that the
censure which the judge drew on himself was not on account of his
opinions, however incorrect they might be, but for his arbitrary and
irregular conduct at the trial, which was one of the principal causes
for which he was afterward impeached. He attempted to wrest the
decision from the jury, and prejudge the case before hearing all the
evidence in it,—the identical thing which this court is now called on by
these gentlemen to do.”
That Hay, knowing well Jefferson’s thoughts and the magic that
hung about the word “impeachment,” should have used these words
inadvertently seemed hardly credible. If he did so, his clumsiness
was as offensive as the threat could have been, for the idea of
impeachment was in the air of the court-house. Burr’s counsel at
once retaliated.[341] “It was very kind of the gentleman to remind
the court of the danger of a decision of the motion in favor of the
prisoner.” Hay protested that he had spoken innocently, and the
chief-justice said that the allusion had not been taken as personal;
but the unpleasant impression remained. “The gentleman plainly
insinuated the possibility of danger to the court,” persisted the
defence; and Luther Martin added,[342]—
“I do not know whether it were intended by this observation that
your honors should be apprehensive of an impeachment in case you
should decide against the wishes of the government. I will not
presume that it was used with that view, but it is susceptible of being
so misunderstood, however innocently or inadvertently it may have
been made.”
August 31 the chief-justice read his decision. Much the longest of
Marshall’s judicial opinions; elaborately argued, with many citations,
and with less simple adherence to one leading thought than was
usual in his logic,—this paper seemed, in the imagination of
Marshall’s enemies, to betray a painful effort to reconcile his dictum
in Bollman’s case with the exclusion of further evidence in the case
of Burr. To laymen, who knew only the uncertainties of law; who
thought that the assemblage on Blennerhassett’s island was such an
overt act as might, without violent impropriety, be held by a jury to
be an act of levying war; and who conceived that Burr, although
absent from the spot, was as principal present in a legal sense such
as would excuse a jury in finding him guilty,—an uneasy doubt could
not fail to suggest itself that the chief-justice, with an equal effort of
ingenuity, might have produced equal conviction in a directly
opposite result. On the other hand, the intent of the Constitution
was clear. The men who framed that instrument remembered the
crimes that had been perpetrated under the pretence of justice; for
the most part they had been traitors themselves, and having risked
their necks under the law they feared despotism and arbitrary power
more than they feared treason. No one could doubt that their
sympathies, at least in 1788, when the Constitution was framed,
would have been on the side of Marshall’s decision. If Jefferson,
since 1788, had changed his point of view, the chief-justice was not
under obligations to imitate him.
“If it be said that the advising or procurement of treason is a
secret transaction which can scarcely ever be proved in the manner
required by this opinion, the answer which will readily suggest itself is
that the difficulty of proving a fact will not justify conviction without
proof.”
At the close of his decision the chief-justice, with simple dignity
which still compels respectful admiration, took up the gauntlet which
the district-attorney had flung at his feet. As though turning from the
crowd in the court-room to look for a moment directly into the eyes
of the President, the threatened chief-justice uttered a few words
that were at once answer and defiance:—
“Much has been said in the course of the argument on points on
which the Court feels no inclination to comment particularly, but which
may perhaps not improperly receive some notice.
“That this Court dares not usurp power is most true; that this
Court dares not shrink from its duty is not less true. No man is
desirous of placing himself in a disagreeable situation; no man is
desirous of becoming the peculiar subject of calumny; no man, might
he let the bitter cup pass from him without self-reproach, would drain
it to the bottom; but if he has no choice in the case,—if there is no
alternative presented to him but a dereliction of duty or the
opprobrium of those who are denominated the world,—he merits the
contempt as well as the indignation of his country who can hesitate
which to embrace....
“No testimony relative to the conduct or declarations of the
prisoner elsewhere and subsequent to the transactions on
Blennerhassett’s island can be admitted; because such testimony,
being in its nature merely corroborative, and incompetent to prove the
overt act in itself, is irrelevant until there be proof of the overt act by
two witnesses.”
On the following day, September 1, District-Attorney Hay
abandoned the case, and the jury entered a verdict of “Not guilty.”
Hay instantly reported to Monticello the result of his efforts, and
added criticisms upon Marshall:[343]—
“Wirt, who has hitherto advocated the integrity of the chief-justice,
now abandons him. This last opinion has opened his eyes, and he
speaks in the strongest terms of reprobation.”
September 4 Jefferson replied in the tone which always
accompanied his vexation:[344]—
“Yours of the 1st came to hand yesterday. The event has been
what was evidently intended from the beginning of the trial; that is to
say, not only to clear Burr, but to prevent the evidence from ever
going before the world. But this latter case must not take place. It is
now, therefore, more than ever indispensable that not a single
witness be paid or permitted to depart until his testimony has been
committed to writing.... These whole proceedings will be laid before
Congress, that they may decide whether the defect has been in the
evidence of guilt, or in the law, or in the application of the law, and
that they may provide the proper remedy for the past and the future.”
Accordingly, although the trial for treason was at an end, the
district-attorney pressed the indictment for misdemeanor; and until
October 19 the chief-justice was occupied in hearing testimony
intended for use not against Burr, but against himself. Then at last
the conspirators were suffered to go their way, subject to legal
proceedings in Ohio which the government had no idea of
prosecuting; while the President, mortified and angry, prepared to
pursue Marshall instead of Burr. The Federalists, who always
overrated the strength of party passions, trembled again for the
Judiciary; but in truth nothing was to be feared. The days of
Jefferson’s power and glory had passed forever, while those of
Marshall had barely begun. Even on the testimony, the President’s
case was far from being so clear as he had hoped and expected. His
chief witness, Wilkinson, could only with difficulty be sustained; and
the district-attorney, who began by pledging himself before the court
to show the falsity of the charges which had been brought against
the General, ended by admitting their truth.
“The declaration which I made in court in his favor some time
ago,” wrote Hay to the President at the close,[345] “was precipitate;
and though I have not retracted it, everybody sees that I have not
attempted the task which I in fact promised to perform. My
confidence in him is shaken, if not destroyed. I am sorry for it, on his
own account, on the public account, and because you have expressed
opinions in his favor; but you did not know then what you will soon
know, and what I did not learn until after—long after—my declaration
above mentioned.”
The hint was strong. If Wilkinson were discredited, Jefferson

himself was in danger. To attack the Supreme Court on such
evidence was to invite a worse defeat than in the impeachment of
Chase. Meanwhile the country had graver dangers to think about,
and enemies at its doors who were not to be curbed by
proclamations or impeachments.
END OF VOL. III.
FOOTNOTES:
[1] Diary of J. Q. Adams (March 4, 1805), i. 373.

[2] Jefferson’s Writings (Ford), viii. 341.
[3] Gallatin’s Writings, i. 227.
[4] Jefferson to General Heath, Dec. 13, 1804; Jefferson MSS.
[5] Jefferson to Robert Smith, Jan. 3, 1805; Jefferson MSS.
[6] Crowninshield to Jefferson, Jan. 29, 1805; Jefferson MSS.
State Department Archives.
[7] Dearborn to Robertson, March 20, 1805; State Papers, vol.
v.; Indian Affairs, i. 700.
[8] Message of Jan. 30, 1808; State Papers, vol. v.; Indian
Affairs, i. 752.
[9] Jefferson to Gallatin, May 29, 1805; Gallatin’s Writings,
232.
[10] Monroe and Pinckney to Cevallos, Jan. 28, 1805; State
Papers, ii. 636.
[11] Cevallos to Monroe and Pinckney, Jan. 31, 1805; State
Papers, ii. 636.
[12] Monroe and Pinckney to Madison, May 23, 1805; State
Papers, ii. 667.
[13] Pinckney and Monroe to Cevallos, Feb. 5, 1805; State
Papers, ii. 640.
[14] Cevallos to Monroe and Pinckney, Feb. 10, 1805; State
Papers, ii. 541.
Papers, ii. 643.
Papers, ii. 644.
[17] Monroe and Pinckney to Cevallos, Feb. 26, 1805; State
Papers, ii. 646.
[18] Monroe’s diary at Aranjuez, March 16, 1805; Monroe MSS.
[19] Monroe to Armstrong, March 1, 1805; MSS. State
Department Archives.
[20] Armstrong to Monroe, March 12 and 18, 1805; State
Papers, ii. 636.
[21] Pinckney and Monroe to Cevallos, March 30, 1805; State
Papers, ii. 657.
[22] Monroe and Pinckney to Cevallos, April 9, 1805; State
Papers, ii. 658.
Papers, ii. 660.
[24] Cevallos to Pinckney and Monroe, April 13, 1805; State
Papers, ii. 660.
Papers, ii. 662.
[26] Monroe and Pinckney to Madison, 23 May, 1805; State
Papers, ii. 668.
[27] Pinckney and Monroe to Cevallos, May 12, 1805; State
Papers, ii. 665.
[28] Cevallos to Monroe and Pinckney, May 15, 1805; State
Papers, ii. 666.
[29] Erving to Madison, Dec. 7, 1805; MSS. State Department
Archives.
[30] Armstrong to Monroe, May 4, 1805; MSS. State
[31] Armstrong to Madison, July 3, 1805; MSS. State
[32] Cf. Correspondance de Napoleon, xxxii. 321.
[33] Monroe to Madison, June 30, 1805; MSS. State
[34] Monroe to Madison, Oct. 18, 1805; State Papers, iii. 106.
[35] Monroe to Madison, June 3, 1805; State Papers, iii. 93.
[36] Act of April 10, 1805; Instructions of June 29, 1805;
Orders of Aug. 3, 1805.
[37] See First Administration, ii. 400.
[38] Speech of Sir John Nicholl (Advocate-General), Feb. 11,
1805; Cobbett’s Debates, iii. 407.
[39] Monroe to Madison, Aug. 16, 1805; State Papers, iii. 103.
[40] Monroe to Madison, Aug. 20, 1805; State Papers, iii. 105.
[41] Monroe to Madison, Oct. 18, 1805; State Papers, iii. 106.
Monroe to Colonel Taylor, Sept. 10, 1810; Monroe MSS., State
[42] New Reasons for abolishing the Slave-Trade, 1807.
[43] War in Disguise, pp. 131–133.
[44] Bosanquet, Causes of the Depreciation, etc. p. 42.
[45] Jefferson to Madison, March 23, 1805; Madison MSS.
[46] Madison to Jefferson, March 27, 1805; Jefferson MSS.
[48] See p. 8.
[49] Madison to Jefferson, Aug. 2, 1805; Jefferson MSS.
[51] Jefferson to Madison, Aug. 7, 1805; Works, iv. 583.
[52] Jefferson to Madison, Aug. 17, 1805; Jefferson MSS.
[53] Madison to Jefferson, Aug. 20, 1805; Jefferson MSS.
[54] Jefferson to Madison, Aug. 27, 1805; Works iv. 585.
[55] Madison to Jefferson, Sept. 1, 1805; Jefferson MSS.
[56] Gallatin to Madison, Aug. 6, 1805; Gallatin’s Writings, i.
237.
[58] Gallatin to Jefferson, Sept. 12, 1805; Gallatin’s Writings, i.
241.
[59] Gallatin to Jefferson, May 30, 1805; Gallatin’s Writings, i.
233.
[60] Robert Smith to Jefferson, Sept. 10, 1805; Jefferson MSS.
[61] Jefferson to Madison, Sept. 16, 1805; Works, iv. 587.
[63] Jefferson to Madison, Sept. 18, 1805; Jefferson MSS.
[65] Madison to Jefferson, Oct. 16, 1805; Jefferson MSS.
[70] Cabinet Memoranda; Jefferson’s Writings (Ford), i. 308.
[71] Turreau to Madison, 26 Thermidor, An xiii. (Aug. 14,
1805); MSS. State Department Archives.
[72] Jefferson to Madison, Aug. 25, 1805; Works, iv. 584.
[74] Turreau to Talleyrand, 20 Messidor, An xiii. (July 9, 1805);
Archives des Aff. Étr., MSS.
[75] Turreau to Talleyrand, 30 Germinal, An xiii. (April 20,
1805); Archives des Aff. Étr., MSS.
[76] State Papers, ii. 728.
[77] Napoleon to Talleyrand, 22 Thermidor, An xiii. (Aug. 10,
1805); Correspondance, xi. 73.
[78] Talleyrand to Armstrong, 29 Thermidor, An xiii. (Aug. 16,
1805); State Papers, ii. 726.
[79] Turreau to Madison, Jan. 3, 1806; State Papers, ii. 726.
[80] State Papers, ii. 682–695.
[81] Fragments of Voyages and Travels, by Captain Basil Hall,
R. N., F. R. S., London, 1856.
[82] Gallatin to Jefferson, April 16, 1807; Works, i. 335.
[83] Merry to Mulgrave, Sept. 2, 1805; MSS. British Archives.
[84] Merry to Mulgrave, Sept. 30, 1805; MSS. British Archives.
[85] Ibid.
[86] Merry to Mulgrave, Nov. 3, 1805; MSS. British Archives.
[87] Merry to Mulgrave, Nov. 3, 1805: MSS. British Archives.
[88] Merry to Mulgrave, Nov. 3, 1805; MSS. British Archives.
[89] Jefferson to Madison, Aug. 27, 1805; Writings, iv. 585.
[90] Armstrong to Madison, Sept. 10, 1805; MSS. State
[92] Merry to Mulgrave, Dec. 2, 1805; MSS. British Archives.
[93] Jefferson to Judge Cooper, Feb. 18, 1806; Jefferson MSS.
[94] Gallatin to Jefferson, Nov. 21, 1805; Gallatin’s Writings, i.
261.
[95] Jefferson to Gallatin, Nov. 24, 1805; Gallatin’s Writings, i.
264.
[96] Jefferson to Gallatin: Spanish Resolutions, 1805; Gallatin’s
Writings, i. 277.
[97] Gallatin to Jefferson, Dec. 3, 1805; Gallatin’s Writings, i.
278.
[98] Jefferson to Gallatin, Dec. 4, 1805; Gallatin’s Writings, i.
281.
[99] Jefferson to Bidwell, July 5, 1806; Writings, v. 14.
[100] Adams’s Randolph, p. 161.
[101] Turreau to Talleyrand, Jan. 20, 1806; Archives des Aff.
Étr., MSS.
[103] Columbian Centinel, Dec. 21, 1805.
[105] Diary of J. Q. Adams (Nov. 30, 1805), i. 376.
[106] Jefferson to Monroe, May 4, 1806; Writings (Ford), viii.
447.
[107] State Papers, ii. 613.
[108] First Letter of Decius, in the “Richmond Enquirer,”
August, 1806.
[109] Nicholson to Gallatin, Dec. 8, 1805; Gallatin MSS.
[110] Decius, No. 1; Randolph’s speech of April 5, 1806;
Annals of Congress, 1805–1806, pp. 984–985.
[111] Decius, No. 1.
[112] Madison to Armstrong and Bowdoin, March 13, 1806;
State Papers, iii. 539.
[113] Diary of J. Q. Adams (Feb. 8, 1806), i. 405.
[114] Diary of J. Q. Adams (Jan. 15, 1806), i. 383.
[115] Act of Feb. 28, 1806; Annals of Congress, 1805–1806, p.
1228.
[116] Ames to Pickering; Ames’s Works, i. 342. Cf. Lodge’s
Cabot, p. 315.
[117] Boston Memorial; Annals of Congress, 1806–1809,
Appendix, p. 890.
[118] Message of Jan. 17, 1806; State Papers, ii. 727.
[119] Annals of Congress, 1793–1795, p. 155.
[121] Randolph’s Speech of March 5, 1805; Annals of
Congress, 1805–1806, p. 571.
[122] Merry to Mulgrave, Feb. 2, 1806; MSS. British Archives.
[126] Jefferson to Monroe, March 10, 1808; Works, v. 253.
[129] Jefferson to Monroe, March 16, 1806; Jefferson MSS.
[130] Jefferson to Monroe, March 18, 1806; Jefferson MSS.
[131] Adams’s Randolph, p. 199–202.
[133] Samuel Smith to W. C. Nicholas, April 1, 1806; Nicholas
MSS.
[134] Cf. Jefferson to W. C. Nicholas, March 24 and April 13,
1806. Writings (Ford), viii. 434.
[135] W. C. Nicholas to Jefferson, April 2, 1806; Jefferson
MSS.
[137] Annals of Congress, March 26, 1806, p. 851.
[140] Miranda to Madison, Jan. 22, 1806; Madison MSS.
[141] Yrujo to Cevallos, Feb. 12, 1806; MSS. Spanish Archives.
[142] Yrujo to Turreau, Feb. 4, 1806; MSS. Spanish Archives.
[143] Turreau to Yrujo, Feb. 7, 1806; MSS. Spanish Archives.
[144] See p. 111.
[145] Merry to Lord Mulgrave, March 19, 1806; MSS. British
Archives.
[147] Merry to C. J. Fox, May 4, 1806; MSS. British Archives.
Étr., MSS.
[149] Turreau to Talleyrand, May 10, 1806; Archives des Aff.
Étr., MSS.
[150] Jefferson to Bidwell, July 5, 1806; Works, v. 14;
Jefferson MSS.
[151] Pickering to Gouverneur Morris, Oct. 21, 1814; Lodge’s
Cabot, p. 535.
[152] Deposition of Matthew Lyon; Wilkinson’s Memoirs, ii.
Appendix, lxviii.
[153] Adair to Wilkinson, Jan. 27, 1806; Wilkinson’s Memoirs,
ii. Appendix, lxxvii.
[154] Wilkinson’s Memoirs, ii. 283.
[155] Daniel Clark to Wilkinson, Sept. 7, 1805; Wilkinson’s
Memoirs, ii. Appendix, xxxiii.
[156] Wilkinson to Clark, Oct. 12, 1807; Clark’s Proofs, p. 154.
[157] Wilkinson’s Memoirs, ii. Appendix, lxxxvi.
[158] Merry to Mulgrave, Aug. 4, 1805; MSS. British Archives.
[159] Turreau to Talleyrand, Feb. 13, 1806; Archives des Aff.
Étr., MSS.
[160] Wilkinson’s Evidence, Burr’s Trial; Annals of Congress,
1807–1808, p. 611.
[162] Merry to Lord Mulgrave, Nov. 25, 1805; MSS. British
Archives.
[163] Yrujo to Cevallos, Dec. 5, 1805; MSS. Spanish Archives.
[164] Yrujo to Cevallos, Jan. 1, 1806; MSS. Spanish Archives.
[165] Deposition of General Eaton; Life of William Eaton, p.
396.
[166] Burr to Wilkinson, Dec. 12, 1806; Wilkinson’s Memoirs,
ii. Appendix, lxxxiv.
[167] Evidence of Major Bruff, Burr’s Trial; Annals of Congress,
1807–1808, p. 597.
[168] Evidence of William Eaton, Burr’s Trial; Annals of
Congress, 1807–1808, pp. 511, 512.
[169] Deposition of Jan. 26, 1807; Life of Eaton, p. 401.
[170] Wilkinson’s Memoirs, ii. Appendix, lxxxiii.
[171] Yrujo to Cevallos, May 14, 1806; MSS. Spanish Archives.
[172] Yrujo to Cevallos, June 9, 1806; MSS. Spanish Archives.
[173] Cevallos to Casa Yrujo, March 28, 1806; MSS. Spanish
Archives.
[174] Cevallos to Casa Yrujo, July 12, 1806; MSS. Spanish
Archives.
[175] Merry to C. J. Fox, June 1, 1806; MSS. British Archives.
[176] Blennerhassett Papers, p. 351.
[177] Blennerhassett Papers, p. 333; Blennerhassett to Allston,
March 2, 1811.
[178] Blennerhassett Papers, pp. 397, 535.
[179] Yrujo to Cevallos, Nov. 10, 1806; MSS. Spanish Archives.
[180] Yrujo to Cevallos, Dec. 16, 1806; MSS. Spanish Archives.
[181] Merry to C. J. Fox, Nov. 2, 1806; MSS. British Archives.
[182] Gayarré’s Louisiana; Spanish Domination, pp. 192–199.
[183] See History of First Administration, p. 240.
[184] Marshall’s History of Kentucky, ii. 376–384.
[185] Daveiss to Jefferson, Jan. 10, 1806; View of the
President’s Conduct, by J. H. Daveiss, 1807. Clark’s Proofs, pp.
177–179.
[186] Daveiss to Jefferson, Feb. 10, 1806; View, etc. Cf.
Marshall’s History of Kentucky, ii. 401.
[187] See p. 278.
[188] Jefferson to Daveiss, Feb. 15, 1806; View, etc. Clark’s
Proofs, p. 179.
[189] Burr to John Smith, Oct. 26, 1806; Senate Report, p. 33.
[190] Marshall’s History of Kentucky, ii. 396.
[191] Cabinet Memoranda; Writings (Ford), i. 318.
[192] National Intelligencer, Jan. 12, 1807.
[193] Dearborn to Wilkinson, Nov. 27, 1806; Report of
Committee, Feb. 26, 1811; 3 Sess. 11 Cong. p. 408.
[194] See Cabinet Memoranda of October 22, p. 278.
[195] Proclamation of Nov. 27, 1806; Wilkinson’s Memoirs, ii.
Appendix, xcvii.
[196] Jackson to Claiborne, Nov. 12, 1806; Burr’s Trial. Annals
of Congress, 1807–1808, p. 571.
[197] Letters of General Adair and General Jackson, 1817.
[198] Parton’s Burr, ii. 87.
[199] Parton’s Jackson, i. 322.
[200] Bissell to Andrew Jackson, Jan. 5, 1807; Annals of
Congress, 1806–1807, p. 1017.
[201] Jefferson to Wilkinson, Jan. 3, 1807; Burr’s Trial. Annals
of Congress, 1807–1808, p. 580.
[202] Report of the Select Committee to the Kentucky
Legislature, Dec. 2, 1806; National Intelligencer, Jan. 7, 1807.
1807–1808, p. 515.
[204] Wilkinson to Daniel Clark, Oct. 5, 1807; Clark’s Proofs, p.
154.
[205] Laussat to Decrès, 18 Germinal, An xii. (April 8, 1804);
Archives de la Marine, MSS. Gayarré’s Louisiana, iii. 10.
[206] Gayarré, Spanish Domination, p. 627.
[207] Laussat to Decrès, 18 Germinal, An xii. (April 8, 1804);
Archives de la Marine, MSS.
[208] Gayarré’s Louisiana, iii. 35.
[210] Report of the Committee to inquire into the Conduct of
General Wilkinson, Feb. 26, 1811; 3 Sess. 11 Cong. p. 320.
[214] Clark’s Proofs, p. 145.
[215] Clark to Wilkinson, Oct. 2, 1806; Clark’s Proofs, p. 157.
1807–1808, p. 518. Evidence of Lieutenant Spence, Report of
House Committee, Feb. 26, 1811; 3 Sess. 11 Cong., p. 312.
[217] Wilkinson to Smith, Sept. 28, 1806; Senate Report, Dec.
31, 1807, p. 41.
[218] See p. 253.
[219] Wilkinson to Jefferson, Oct. 20 and 21, 1806;
Wilkinson’s Memoirs, ii. Appendix, xcv.
[220] Wilkinson to Freeman, Oct. 23, 1806; Wilkinson’s
Memoirs, ii. Appendix, ci.
1807–1808, p. 541.
[222] Wilkinson to Cushing, Nov. 7, 1806; Memoirs, ii.
Appendix, xcix.
[223] Ibid.
[224] Ibid.
[225] Wilkinson to Jefferson, Nov. 12, 1806; Memoirs, ii.
Appendix, c.
[226] Wilkinson to Claiborne, Nov. 12, 1806; Memoirs, ii. 328.
[227] Jackson to Claiborne, Nov. 12, 1806; Burr’s Trial. Annals
of Congress, 1807–1808, p. 571.
[229] President’s Message of Jan· 22, 1807. Annals of
Congress, 1806–1807, p. 43.
[230] Wilkinson to Daniel Clark, Dec. 10, 1806; Clark’s Proofs,
p. 150.
[231] Clark’s Proofs, p. 151.
[232] Wilkinson to Daniel Clark, March 20, 1807; Clark’s
Proofs, p. 151.
[233] Wilkinson to Daniel Clark, Oct. 5, 1807; Clark’s Proofs, p.
154.
[234] Deposition of John Shaw, Burr’s Trial; Annals of
Congress, 1807–1808, p. 573.
[235] Evidence of Lieutenant Jacob Jackson, Burr’s Trial;
Annals of Congress, 1807–1808, p. 683.
[238] Robert Smith to Jefferson, Dec. 22, 1806; Jefferson
MSS.
[240] Randolph to Monroe, Jan. 2, 1807; Monroe MSS.
[241] Samuel Smith to W. C. Nicholas, Jan. 9, 1807; Nicholas
MSS.
[242] Wilkinson to Jefferson, Dec. 14, 1806; Annals of
Congress, 1806–1807, p. 1009.
[243] Diary of J. Q. Adams (Jan. 23, 1807), i. 445.
[245] Yrujo to Cevallos, Jan. 28, 1807: MSS. Spanish Archives.
[246] Clark’s Proofs against Wilkinson, 1809.
[263] Diary of J. Q. Adams, i. 464.
[264] Thiers, Consulat et Empire, vi. 30.
[265] Armstrong to Madison, Feb. 17, 1806; MSS. State
[266] Armstrong to Madison, March 9, 1806; MSS. State
[267] Madison to Armstrong and Bowdoin, March 13, 1806;
MSS. State Department Archives.
[268] Armstrong to Madison (private), May 4, 1806; MSS.
[269] Bowdoin to Jefferson, May 20, 1806; Jefferson MSS.
[270] Bowdoin to Jefferson, Oct. 20, 1806; Jefferson MSS.
[271] Armstrong to Madison, Oct. 10, 1806; MSS. State
[272] Talleyrand to Vandeul, May 21, 1806; Archives, des Aff.
Étr., MSS.
[273] Vandeul to Talleyrand, June 19, 1806; Archives des Aff.
Étr., MSS.
[274] Vandeul to Talleyrand, June 23, 1806; Archives des Aff.
Étr., MSS.
[275] Armstrong to Madison, Oct. 10, 1806; MSS. State
[276] Talleyrand to Vandeul, July 3, 1806; Archives des Aff.
Étr., MSS.
[277] Talleyrand to Vandeul, July 12, 1806; Archives des Aff.
Étr., MSS.
[278] Talleyrand to Turreau, July 31, 1806; Archives des Aff.
Étr., MSS.
[279] Armstrong to Madison, Dec. 24, 1806; State Papers ii.
805.
[280] Monroe to Madison, Feb. 12, 1806; MSS. State
[281] Monroe to Madison, April 3, 1806; State Papers, iii. 115.
[282] Monroe to Madison, April 18, 1806; State Papers, iii.
116.
[283] Monroe to Madison, May 17, 1806; State Papers, iii. 124.
[284] Madison to Monroe and Pinkney, May 17, 1806; State
Papers, iii. 119.
[285] Jefferson to Monroe, May 4, 1806; Works, v. 12.
[286] Memoirs of Lord Holland, ii. 98–103.
[287] Oil without Vinegar, Medford, London, 1807.
[288] Monroe and Pinkney to Madison, Jan. 3, 1807; State
Papers, iii. 145.
[289] American State Papers, iii. 151.
[290] Monroe to Colonel Taylor, 10 Sept., 1810; Monroe MSS.,
[291] Order in Council, of Jan. 7, 1807; American State
Papers, iii. 267.
[292] Cobbett’s Debates, viii. 632.
[293] Cobbett’s Debates, viii. 635.
[294] Howick to Erskine, Jan. 8, 1807; Cobbett’s Debates, x.
558. Erskine to Madison, March 12, 1807; American State Papers,
iii. 158.
[295] Edinburgh Review, xxii. 485.
[296] T. P. Courtney’s Additional Observations on the American
Treaty, London, 1808, p. 89.
[297] Madison to Monroe and Pinkney, Feb. 3, 1807; State
Papers, iii. 153.
[298] Turreau to Talleyrand, Dec. 12, 1806; Archives des Aff.
Étr., MSS.
Étr., MSS.
[300] Turreau to Talleyrand, Feb. 23, 1807; Archives des Aff.
Étr., MSS.
[301] Turreau to Talleyrand, April 1, 1807; Archives des Aff.
Étr., MSS.
[302] Turreau to Talleyrand, May 15, 1807; Archives des Aff.
Étr., MSS.
[303] Erskine to Howick, March 6, 1807; MSS. British Archives.
[304] Diary of J. Q. Adams, i. 495.
[305] S. Smith to W. C. Nicholas, March 4, 1807; Nicholas
MSS.
[306] S. Smith to W. C. Nicholas, March 4, 1807; Nicholas
MSS.
[307] Madison to Erskine, March 20, 1807; State Papers, iii.
158.
[308] Same to same, March 29, 1807; Ibid., 159.
[309] Jefferson to Monroe, March 21, 1807; Works, v. 52.
[310] Jefferson to Bowdoin, April 2, 1807; Works, v. 63.
[311] Madison to Jefferson, April 20, 1807; Jefferson MSS.
[312] Madison to Jefferson, April 24, 1807; Jefferson MSS.
[313] Jefferson to Madison, April 21, 1807; Works, v. 69.
[314] Jefferson to Madison, April 21, 1807; Works, v. 74.
[315] Jefferson to W. B. Giles, April 20, 1807; Works, v. 65.
[316] Jefferson to Hay, June 20, 1807; Works, v. 102.
[317] U. S. vs. Kendall, Cranch’s Circuit Court Reports, v. 385.
[318] Jefferson to William Short, June 12, 1807; Works, v. 93.
Cf. Jefferson MSS.
[319] Jefferson to Hay, June 19, 1807; Works, v. 98.
[320] Jefferson to Rodney, June 19, 1807; Jefferson MSS.
[321] Major Bruff’s Testimony, Burr’s Trial; Annals of Congress,
1807–1808, pp. 598–600.
[322] Jefferson to Wilkinson, June 21, 1807; Works, v. 109.
[324] Randolph to Nicholson, June 28, 1807; Nicholson MSS.
[325] Randolph to Nicholson, June 25, 1807; Nicholson MSS.
[326] Annals of Congress, Jan. 11, 1808; Session of 1807–
1808, p. 1397.
[327] Report of the Committee appointed to inquire into the
Conduct of General Wilkinson, Feb. 26, 1811, pp. 281, 298. Cf.
National Intelligencer, Aug. 3, 1807.
[328] Parton’s Life of Burr, ii. 107.
[329] Hay to Jefferson, June 14, 1807; Jefferson MSS.
[330] Randolph to Nicholson, June 25, 1807; Adams’s
Randolph, p. 221.
[331] Hay to Jefferson, Aug. 11, 1807; Jefferson MSS.
[337] Jefferson to Hay, Aug. 20. 1807; Works, v. 174.
[339] Grigsby’s Tazewell, p. 73.
[340] Burr’s Trial, ii. 193.
[343] Hay to Jefferson, Sept. 1, 1807; Jefferson MSS.
[344] Jefferson to Hay, Sept. 4, 1807; Works, v. 187. Cf.
Jefferson MSS.
[345] Hay to Jefferson, Oct. 15, 1807; Jefferson MSS.
Transcriber’s Notes:
1. Obvious printers’, punctuation and spelling errors have been corrected

silently.
2. Some hyphenated and non-hyphenated versions of the same words have

been retained as in the original.
3. Where hyphenation is in doubt, it has been retained as in the original.

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INTRODUCTION oxysulfide. The direct type of DR systems is used in mam-

Hay wrote to the President, June 14:[329]—

This paper was no doubt Jackson’s secret denunciation to

“Old sly-boots” Dayton,[333] he said, was lurking about corners.

For a few days the trial went on undisturbed, while the

The hint was strong. If Wilkinson were discredited, Jefferson

[1] Diary of J. Q. Adams (March 4, 1805), i. 373.

1. Obvious printers’, punctuation and spelling errors have been corrected

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