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Rapid Review of ECG Interpretation in Small Animal Practice 2nd Edition Mark A Oyama (Author)
Silke Hecht asserts her right to be known as the translator of this work.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission of the copyright holder.
Published by 5m Publishing Ltd, Benchmark House, 8 Smithy Wood Drive, Shefeld, S35 1QN, UK
Tel: +44 (0) 1234 81 81 80 www.5mpublishing.com
A catalogue record for this book is available from the British Library.
ISBN 9781789180930
Book layout by Toynbee Editorial Services Ltd, Great Easton, UK
Printed by Replika Press Pvt Ltd, India
Photos and illustrations by Schattauer
Important note:
Medicine is an ever-changing science, so the contents of this publication, especially recommendations concerning diagnostic and therapeutic procedures, can only give an account of the knowledge at the time of publication. While utmost care has been taken to ensure that all specifcations regarding drug selection and dosage and treatment options are accurate, readers are urged to review the product information sheet and any relevant material supplied by the manufacturer, and, in case of doubt, to consult a specialist. From both an editorial and public interest perspective, the publisher welcomes notifcation of possible inconsistencies. The ultimate responsibility for any diagnostic or therapeutic application lies with the reader.
No special reference is made to registered names, proprietary names, trademarks, etc. in this publication. The appearance of a name without designation as proprietary does not imply that it is exempt from the relevant protective laws and regulations and therefore free for general use.
This publication is subject to copyright, all rights are reserved, whether the whole or part of the material is concerned. Any use of this publication outside the limits set by copyright legislation, without the prior written permission of the publisher, is liable to prosecution.
14.2.2 Cystography and urethrography (retrograde) 262
14.2.3 Other contrast studies 267
14.3 Renal and ureteral diseases 269
14.3.1 Abnormalities in renal number and position 269
14.3.2 Abnormalities in renal size and shape 269
14.3.3 Abnormalities in renal opacity 269
14.3.4 Pyelonephritis 269
14.3.5 Chronic renal disease 269
14.3.6 Hydronephrosis and hydroureter 269
14.3.7 Polycystic kidney disease (PKD) 274
14.3.8 Perirenal pseudocysts 274
14.3.9 Renal neoplasia 274
14.3.10 Renal and ureteral calculi 274
14.3.11 Renal or ureteral rupture 277
14.3.12 Ectopic ureter 277
14.4 Diseases of the urinary bladder and urethra 278
14.4.1 Cystitis and urethritis 279
14.4.2 Bladder and urethral calculi 279
14.4.3 Bladder and urethral neoplasia 281
14.4.4 Urachal diverticulum 281
14.4.5 Bladder or urethral rupture 281
14.5 Pregnancy and diseases of the female reproductive tract 282
14.5.1 Pregnancy 282
14.5.2 Ovarian diseases 283
14.5.3 Diseases of the uterus 283
14.6 Diseases of the male reproductive tract 286
14.6.1 Diseases of the prostatic gland 286
14.6.2 Other diseases of the male reproductive tract 288 15 General principles of orthopaedic radiology 290
Silke
Hecht, Federica Morandi and Gregory B. Daniel
15.1
16 Congenital and developmental bone
Federica Morandi, Silke Hecht and Gregory B. Daniel
15.2.2
17 Acquired bone and joint diseases 336
Federica
19.9.4
Silke Hecht, Federica Morandi and Gregory B. Daniel
Marcy Souza and Jürgen Schumacher
Anatomy
Anatomy
Radiographic technique
Preparation, positioning and technique
Contrast studies
Disorders of the head
Disorders of the cardiovascular system
Disorders of the respiratory tract
Disorders of the coelomic cavity, liver and spleen
Coelomic cavity
Liver
Spleen
Disorders of the gastrointestinal tract
Impaction
Dilatation
Other fndings
Disorders of the urogenital tract
Diseases of the kidneys
Diseases of the gonads
Disorders of the musculoskeletal
20 Small mammals
Michaela Gumpenberger, Jasmin Hassan and Alexandra Böhler
21 Reptiles
Michaela Gumpenberger, Jürgen Schumacher and Marcy Souza
21.3.3
21.6
21.7
Preface
It is hard to believe that more than 10 years have passed since the publication of the frst German language edition of this diagnostic radiology textbook. This English version represents a translation of the second, extensively revised edition. Even though advanced imaging modalities (ultrasound, CT and MRI) continue to gain importance in veterinary medicine, the radiographic examination remains a mainstay in the diagnostic workup of small animal patients. Veterinarians in small animal practice, specialty hospitals and academia alike are routinely asked to interpret radiographs, and competence in radiographic diagnosis is expected from non-radiologist specialists in their area of expertise (surgeon, internist, neurologist, etc.). The primary goal of this book is to provide veterinary students, practitioners and specialists with a comprehensive overview of radiographic fndings in diseases of small animal and exotic patients, including both common and more unusual conditions. In addition, information is provided on basic radiology principles and
physics, artefacts, practical radiation safety, radiographic contrast procedures, and basic principles and applications of advanced imaging technologies. Hopefully, readers will fnd this book to be an interesting, educational and helpful resource for clinical practice and teaching.
I would like to thank my co-authors for their contributions, the staf members of Schattauer (now Thieme) for their support with the two prior German editions, and Sarah Hulbert and Alessandro Pasini from 5m Publishing for their help in seeing this project through. Special thanks go to Marcy Souza for her assistance with editing the exotic animal chapters. I would also like to extend my deepest gratitude to Jenny Cattermole for her superb copyediting skills. Last but not least, I would like to thank my husband Bill for his encouragement and patience. And now – enjoy the book! Knoxville, September 2019 Silke Hecht
Contributors
Editor
Silke Hecht, Dr. med. vet., DACVR, DECVDI Department of Small Animal Clinical Sciences
University of Tennessee College of Veterinary Medicine 2407 River Drive Knoxville, TN 37996, USA shecht@utk.edu
Authors
William H. Adams, DVM, DACVR (R, RO) Department of Small Animal Clinical Sciences
University of Tennessee College of Veterinary Medicine 2407 River Drive Knoxville, TN 37996, USA wha@utk.edu
Alexandra Böhler, Dr. med. vet. University of Veterinary Medicine
Diagnostic Imaging Veterinärplatz 1 1210 Vienna, Austria alexandra.boehler@vetmeduni.ac.at
Gregory B. Daniel, DVM, MS, DACVR Virginia–Maryland Regional College of Veterinary Medicine 205 Duck Pond Drive, Phase II (0442) Blacksburg, VA 24061, USA gdaniel@vt.edu
Randi Drees, Dr. med. vet., PhD, DACVR (R, RO), DECVDI add RadOncol, PGCertAP, MRCVS Royal Veterinary College Hawkshead Lane Hatfeld, Hertfordshire AL9 7TA, United Kingdom rdrees@rvcac.uk
Michaela Gumpenberger, Dr. med. vet. University of Veterinary Medicine
Diagnostic Imaging Veterinärplatz 1 1210 Vienna, Austria Michaela.Gumpenberger@vetmeduni.ac.at
Jasmin Hassan, Dr. med. vet. Rustenschacherallee 1020 Vienna, Austria jasmin.hassan@gmx.net
George A. Henry, DVM, DACVR Department of Small Animal Clinical Sciences University of Tennessee College of Veterinary Medicine 2407 River Drive Knoxville, TN 37996, USA gahenry@mac.com
Eberhard Ludewig, Prof. Dr. med. vet., DECVDI University of Veterinary Medicine
Diagnostic Imaging Veterinärplatz 1 1210 Vienna, Austria ludewig@vetmed.uni-leipzig.de
Federica Morandi, DVM, MS, DECVDI, DACVR
Department of Small Animal Clinical Sciences
University of Tennessee College of Veterinary Medicine 2407 River Drive Knoxville, TN 37996, USA fmorandi@utk.edu
Stefanie Ohlerth, Prof. Dr. med. vet., DECVDI Clinic for Diagnostic Imaging Vetsuisse Faculty, University of Zurich Winterthurerstraße 260 8057 Zurich, Switzerland sohlerth@vetclinics.uzh.ch
Jürgen Schumacher, Dr. med. vet., DACZM, DECZM
Department of Small Animal Clinical Sciences
University of Tennessee College of Veterinary Medicine 2407 River Drive Knoxville, TN 37996, USA jschumacher@utk.edu
Tobias Schwarz, Dr. med. vet., MA, DVR, DECVDI, DACVR, MRCVS
Department of Veterinary Clinical Studies
Royal (Dick) School of Veterinary Studies
The University of Edinburgh Roslin, EH25 9RG, UK tobias.schwarz@ed.ac.uk
Marcy Souza, DVM, MPH, DABVP (Avian), DACVPM
Department of Biomedical & Diagnostic Sciences
University of Tennessee College of Veterinary Medicine 2407 River Drive Knoxville, TN 37996, USA msouza@utk.edu
Basic radiology principles and interpretation
Silke Hecht and Eberhard Ludewig
1.1 Introduction
When inspecting and interpreting a radiograph two basic principles have to be considered.
• A radiograph produced either by exposing an X-ray flm or a digital detector is an image of the patient resulting from partial transmission of the X-ray beam through the body with variable attenuation in diferent tissues. Generation of a useful radiograph requires the presence of structures and organs within the body which attenuate X-rays differently. If this was not the case, the outer margins of an object would still be visible as they contrast with the (more radiolucent) surrounding air, but an inner structure would not be recognizable (Fig. 1.1).
• A radiograph is a two-dimensional representation of a three-dimensional object. This results in artefacts and particularities the veterinarian has to be familiar with to be able to produce useful radiographs and interpret them correctly.
1.2 Nomenclature and image orientation
The correct description of a radiograph is based on the path of the X-ray beam through the patient from point of entrance to point of exit. For example, on a ventrodorsal radiograph the cassette or plate is located at the back of the patient, and the X-ray beam traverses the patient from ventral to dorsal. On a dorsoventral radiograph the beam path is reversed. On a laterolateral radiograph the X-ray beam traverses the patient either from left to right or from right to left. When obtaining a mediolateral view the X-ray beam enters the medial aspect of a body part and exits laterally (radiographs of extremities). As the terms ‘laterolateral’ and ‘mediolateral’ are cumbersome they are usually replaced with the simple term lateral. On a right
1
lateral view the right side of the patient, and on a left lateral view the left side of the patient, is positioned adjacent to the X-ray plate.
A few special nomenclature rules apply to radiographs of the extremities and the head. While radiographic views proximal to the carpus and tarsus are termed craniocaudal or caudocranial, respectively, the terminology changes to dorsopalmar or dorsoplantar and palmarodorsal or plantarodorsal, respectively, from the carpus and tarsus distally. For radiographs of the head, cranial is replaced with rostral.
Most radiographs in small animals are acquired with the patient positioned on an X-ray table and using a vertical X-ray beam. If under certain circumstances radiographs with a horizontal beam technique are necessary (e.g. for a diagnosis of pneumoperitoneum), or if special techniques are used for radiographic evaluation of the head (e.g. intraoral radiographs), this should be noted in the radiographic report.
The evaluation of a radiograph is principally a form of pattern recognition, similar to techniques employed
Fig. 1.1 Radiograph of a banana, which in contrast to the human or animal body lacks interior organs and appears homogeneous on a radiograph.
in machine learning. To train the investigator’s eye in the recognition of normal anatomy, radiographs should always be positioned in the same orientation (i.e. following the same pattern). Following international standards, lateral views (including radiographs of extremities) should always be positioned with the cranial/rostral part of the patient towards the left and the caudal part to the right. Dorsoventral/ventrodorsal radiographs are positioned with the cranial part of the patient towards the top, the right side to the left and the left to the right of the observer. Radiographs of the extremities are oriented with the distal part at the bottom of the image.
1.3 Radiographic opacity
The X-ray permeability of a structure depends on the atomic number, the physical density and its thickness. Materials of a higher density (bone or mineral calculi) absorb more X-rays than less dense materials (gas or fat) and will appear brighter on a resultant radiograph. Similarly, thick layers of a given material will absorb more X-rays than thin layers. The most commonly used term
Gas – Fat – Fluid/Soft Tissue – Bone – Metal
• Increasing aborption of X-rays
• Increasingly bright on radiographs
• Increasing opacity
Gas – Fat – Fluid/Soft Tissue – Bone – Metal
• Increasing transmission of X-rays
• Increasingly dark on radiographs
• Increasing radiolucency
Fig. 1.2 Comparison of different radiographic opacities.
Fig. 1.3 Lateral a and ventrodorsal b abdominal radiographs of a well-nourished cat. The excellent abdominal detail is attributed to fat deposits. The margins between the caudal pole of the left kidney and adjacent retroperitoneal fat as well as the ventral liver margin and adjacent peritoneal/falciform fat are marked by large arrows. An incidental well-defned round mineral opaque structure is associated with the left mid abdominal fat (fat necrosis, ‘Bates body’) (small straight arrow). The small bent arrow indicates overlap of the caudal pole of the right kidney with the cranial pole of the left kidney, resulting in additive X-ray absorption and resultant increased opacity compared to individual kidneys (summation).
for diferences in radiographic appearance of tissues based on degree of X-ray attenuation is opacity. Other terms occasionally found in the literature include radiolucency (decreased opacity) and radiopacity
There are fve diferent radiographic opacities (Fig. 1.2):
• air
• fat
• soft tissue and fuid
• bone
• metal.
Several and sometimes all of these opacities may be concurrently noted on a radiograph. In Figure 1.3 the following opacities are represented:
• gas (intestinal loops and caudal lung felds)
• fat (retroperitoneal and peritoneal space)
• soft tissue and fuid (liver, kidneys, urinary bladder, etc.)
• bone (vertebrae, ribs, etc.).
The diferential absorption of X-rays is useful for the interpretation of regular radiographs and is the basic concept of radiographic contrast studies. Although often
forgotten, fat is tremendously important in radiographic interpretation as it has a lower opacity than soft tissue and thus allows delineation of abdominal organs. Similarly, air (e.g. intraluminal gas in intestinal segments or air in body cavities as seen with pneumothorax) may serve as a natural contrast medium and can help delineate neighbouring structures of similar opacity.
1.4 Silhouetting and summation
The presence of diferent opacities within the patient results in two radiographic phenomena: silhouetting and summation. A radiographic report will often comment on structures silhouetting or summating, respectively.
1.4.1 Silhouetting
When two structures of the same or similar opacity are in physical contact with each other, their margins cannot be distinguished radiographically. Conversely, structures that are separated by material of a diferent opacity are easily identifed. This phenomenon explains the poor serosal detail observed on abdominal radiographs in any of the following circumstances:
• very young animals with little to no abdominal fat deposits
• very thin/cachectic patients
• patients with ascites in which abdominal efusion obscures the margins of soft-tissue opaque abdominal organs (Fig. 1.4; see also section 11.3).
Fig. 1.4 Lateral abdominal radiograph in an 11-yearold German Shepherd Dog. There is poor serosal detail indicated by lack of visibility of abdominal organ margins due to a large volume of abdominal effusion (ascites). The kidneys are clearly delineated due to the presence of retroperitoneal fat and the absence of retroperitoneal effusion. The ultimate diagnosis in this patient was haemoabdomen due to a ruptured splenic mass.
On the other hand, there is nothing more appealing to a radiologist than abdominal radiographs of a well-nourished (fat) cat which are characterized by excellent serosal margin detail (Fig. 1.3).
Other examples of silhouetting on radiographs include:
• inability to distinguish the wall of a cardiac chamber from intraluminal blood
• obscured cardiac and diaphragmatic margins in patients with pleural efusion
• inability to diagnose tumours of the bladder wall as they are obscured by adjacent urine.
1.4.2 Summation
When two separate structures are superimposed on a radiograph their individual X-ray absorption and thus opacity are additive. A typical example is the region of increased opacity observed at the overlap of the cranial pole of the left kidney with the caudal pole of the right kidney on a lateral abdominal radiograph (see Fig. 1.3a). When summation of two soft-tissue opaque structures is observed it indicates that these are not in direct physical contact.
1.5 Radiographic perception
Our patients are three-dimensional objects (subjects) which are converted into a two-dimensional format when obtaining a radiograph. This process and the associated loss of depth perception results in an unusual appearance and potentially the inability to identify otherwise familiar structures depending on the direction of the beam in respect to the area of interest (Fig. 1.5). Full evaluation of (disease) processes occurring in a patient’s body therefore requires at least two radiographs obtained with orthogonal beam orientation in most situations.
The following phenomena come into play when a radiograph is evaluated in a single projection.
• Distortion/magnifcation: Variations in distance of parts of the patient from the X-ray tube (‘focus’) on the one hand and the receptor (flm/plate) on the other hand result in changes in apparent size of a structure (Fig. 1.6) and distortion (Fig. 1.7).
• Superimposition of structures: Unless aided by magnifcation, it is usually impossible to separately evaluate symmetric anatomic structures (e.g. vertebral transverse processes, ribs, coxofemoral joints or bones of the skull) or determine laterality of a disease process (e.g. pleural efusion or fracture) on a lateral view only. In addition to the inability to distinguish the left and right sides of the patient on a lateral view, superimposition of surrounding structures may result in complete inability to evaluate a lesion on a single projection (Fig. 1.8).
a b
Fig. 1.5 Radiograph of a bottle.
a The object is easily recognized on this ‘lateral’ view.
b The orthogonal (‘rostrocaudal’) view makes identifcation of the object impossible even for experienced radiologists.
a b
Fig. 1.8 Lateral (oblique) a and ventrodorsal b abdominal radiographs in a 9-year-old domestic shorthair cat. On the lateral view there is a large mass of soft-tissue opacity (arrows) in the plane of the cranial/mid-ventral abdomen. This lesion is of uncertain organ association. On the ventrodorsal view the mass is associated with the subcutaneous tissues of the right abdominal wall lateral to the right kidney, i.e. it is in extra-abdominal location! Histopathological examination yielded a diagnosis of fbrosarcoma.
Fig. 1.6 Two radiographs of the same pen (middle picture) positioned directly on the cassette (left) and on a 13 cm foam block (right), respectively. There is notable magnification of the object on the second radiograph resulting from an increased object–film distance. Considering that certain body parts (thorax, abdomen) are often thicker than 13 cm even in small animals, the investigator has to take into account that anatomic structures distant from the plate will be magnifed, possibly to a signifcant degree.
Fig. 1.7 Schematic drawing illustrating the effect of X-ray beam angle on the resultant radiograph. The primary beam in a is in perpendicular orientation to the object and the X-ray flm, while it is angled in b The resultant ‘radiographic images’ appear markedly different. This illustration of image distortion secondary to an angled primary beam underlines the need for beam collimation to the region of interest. Whole-body survey radiographs are at best of limited diagnostic yield especially in larger patients.
• Special anatomic considerations: When obtaining a lateral thoracic radiograph, the dependent lung (adjacent to the plate) collapses and becomes soft-tissue opaque, which will result in loss of visualization of small soft-tissue lesions such as nodules due to silhouetting. Thus, opposite lateral views in addition to a dorsoventral or ventrodorsal projection are essential when evaluating a patient for pulmonary lesions (e.g. preoperative check for metastases or suspicion of aspiration pneumonia) (Fig. 1.9; see also Chapter 9). Additional radiographic projections (e.g. horizontal beam views or tangential views of the thoracic wall) may be needed in a given patient to answer a specifc clinical question.
• Changes that are only visible in a specifc projection: Some (even extensive) changes may only be visible on one specifc projection but not others, and in other instances the full extent of an abnormality may be underestimated on one view versus another (Fig. 1.10 and 1.11).
Fig. 1.9 Right lateral a and left lateral b thoracic radiographs in a 10-year-old female mixed-breed dog with a diagnosis of mammary tumours. A mass of soft-tissue opacity associated with the left caudal lung lobe (arrowheads) is visible on both views owing to its large size. An additional smaller soft-tissue nodule located between the second and third rib (white arrow) is also visible on both views. However, two additional nodules are only seen on the left lateral view (a; black arrows) and would have been missed a if only a right lateral view had been obtained. Their visibility only on the left lateral view indicates that they are located in the nondependent (right) side of the lung. A ventrodorsal or dorsoventral view should always be obtained to complete a radiographic metastatic series. Radiographically suspected pulmonary metastatic disease was confrmed with histopathological examination.
Fig. 1.10 Lateral a and caudocranial b radiographs of the scapula in a 2-year-old male neutered mixed-breed dog. A comminuted scapular fracture clearly seen in b is not visible in a even with the beneft of hindsight. b
1.6 Radiograph description and interpretation
Choice of the appropriate radiographic examination based on indication, acquisition of high-quality diagnostic radiographs, and complete and accurate evaluation not only test the medical knowledge but also the visual capabilities of the veterinarian, and the examiner has to be familiar with the possibilities and limitations of the technique to maximize its diagnostic utility. In many cases, a diagnosis in a given patient is not solely made on the basis of a radiograph, but radiographs are used to complement patient signalment, history, clinical examination and laboratory fndings.
Radiographic interpretation should always occur in a dark room. For conventional radiographs, evaluation should include assessment using a view box and, if needed, a hot lamp. Evaluating radiographs just using the light from a window or a ceiling light is unacceptable. For digital radiographs, a large high-quality computer monitor is a must.
Radiographic interpretation requires a good basic knowledge of normal radiographic anatomy and physiological variants. An anatomy textbook and a radiographic
surgical
a On the craniocaudal view implant placement appears adequate. Note suboptimal radiographic technique with superimposition of the tail (black arrowheads) over the area of interest.
b On the lateral view intra-articular extension of one of the pins placed in the femoral head and neck is evident (arrow). This fnding necessitates immediate surgical revision to avoid future severe degenerative joint disease!
atlas should be at hand. Additionally, a catalogue or collection of normal radiographs that can serve as a comparison if needed is a good idea.
The radiographic interpretation should always follow a systematic approach but can be customized to meet individual investigator preferences (e.g. evaluation following organ systems versus evaluation according to body regions). Once a personalized approach has been established it should always be followed. The major goal of this approach is to minimize the risk of incomplete assessment, particularly if a pathological fnding is noted early in the course of radiographic interpretation. In particular, inexperienced students and veterinarians tend to summarize radiographic fndings with a single ‘snapshot’ diagnosis (e.g. ‘cranial cruciate rupture’, ‘lung tumour’, or ‘gastric dilatation and volvulus’). Even after identifcation of a major abnormality the remainder of the radiographic study should be thoroughly evaluated for the presence of other possibly signifcant lesions.
The systematic evaluation of a radiograph should begin with a description of available projections and assessment of the technical quality of the study (positioning, technique, artefacts and need for additional views). This should be followed by a complete description of abnormal (and possibly even normal) fndings before a fnal conclusion is reached. If a good radiographic report is relayed over the phone to a veterinarian (or another person with adequate radiographic knowledge), that individual should be able to draw a mental picture without actually having seen the radiographs. Even though a thorough description of radiographs over the phone has lost importance in the age of digital radiography and easy digital transfer of radiographs, the ability to generate a coherent and complete radiographic report remains important.
When interpreting a radiograph the following Roentgen signs are taken into account.
• Size: Size measurements can be given as objective measurements (e.g. 2 × 3 cm) or as semiquantitative values in relation to other structures (e.g. three times the length of the vertebral body L2).
• Shape: There are no limits to descriptors that may be used to describe the shape of a structure (e.g. square, lobulated, egg-shaped). The goal is to allow the reader of a radiographic report to generate a mental image of the abnormality in his/her head.
• Opacity: Organs, structures and pathological abnormalities are assigned the aforementioned terms air, fat, soft-tissue, bone or metal opacity.
• Location: The position of a structure on radiographs can be described in diferent ways. Location within a body cavity (e.g. caudoventral abdomen) or position in relation to adjacent structures and organs (e.g. dorsal to the trachea) are commonly included in a
a b
Fig. 1.11 Postoperative radiographs following
repair of a femoral neck fracture in a young cat.
report. To increase objectivity of the description, listing of distances between an abnormality and nearby structures is very helpful, especially if the lesion is subtle or if recheck radiographs are evaluated by somebody unfamiliar with the initial set of flms (e.g. 0.5 cm pulmonary nodule 2 cm dorsal to the sternum at the level of the ffth pair of ribs).
• M argin and contour: Organs and pathological changes are described as sharply marginated or poorly defned, and as having a regular or irregular contour.
• Number: This is used to describe the number of afected organs (e.g. enlargement of one kidney, or pathology in two lung lobes) as well as to list countable pathological abnormalities (e.g. pulmonary nodules or bladder stones).
These Roentgen signs are essential for an accurate description of a radiograph!
Mnemonic: Six Sins Of Lonely MaNiacs.
The following is an example of a detailed radiographic description and diagnostic conclusion. The reader should be able to create a mental image of the abnormalities after reading the report.
Example: Evaluation of abdominal radiographs in a dog
Description: The patient is a small, well-nourished, female spayed middle-aged dog. A right lateral and a ventrodorsal view of the abdomen are available for interpretation. The radiographs are of good diagnostic quality. Within the gastric fundus there are two disc-shaped, round, smoothly marginated and metal opaque structures of 1.8 and 2.6 cm diameter, respectively. The liver, spleen, left kidney, urinary bladder, small intestine, colon and visible musculoskeletal structures are normal. The right kidney is obscured and not clearly visualized. Conclusion: Two metal opacity gastric foreign bodies (coins).
Many veterinarians and radiologists tend to omit a detailed description of normal structures with increasing experience. This is perfectly fne as long as it is ascertained that all structures have defnitely been fully evaluated. After completion of the radiographic assessment the fndings are used in conjunction with other information (patient signalment, history, clinical and laboratory fndings) to establish a diagnosis or a list of reasonable diferential diagnoses.
Suggested reading
Hartung K, Ludewig E, Tellhelm B. Röntgenuntersuchung in der Tierarztpraxis. Stuttgart: Enke 2010.
Hecht S. Für Studium und Praxis: Grundlagen der Röntgenbildentstehung und -interpretation. Tierärztl Prax 2003; 31: 132–5.
Papageorges M. Visual perception and radiographic interpretation. In: Thrall DE (ed.). Textbook of Veterinary Diagnostic Radiology. Philadelphia: WB Saunders 2002; 35–42.
Smallwood JE, Shively MJ, Rendano VT, Habel RE. A standardized nomenclature for radiographic projections used in veterinary medicine. Vet Radiol 1985; 26: 2–9.
Thrall DE. Introduction to radiographic interpretation. In: Thrall DE (ed.). Textbook of Veterinary Diagnostic Radiology, 7th edn. St. Louis: Elsevier 2018; 110–22.
Designing a radiographic 2 technique chart
Eberhard Ludewig and Silke Hecht
2.1 Introduction
Following the purchase of X-ray equipment, the small animal practitioner is confronted with the problem of having to set up a chart with appropriate exposure parameters. Factors influencing the radiographic technique include patient size, composition of tissues in the region of interest, patient motion, the sensitivity of the available flm–screen or digital detector system and use of a grid. It is not possible to produce a technique chart that will work under all circumstances. However, some basic rules exist which will aid the practitioner in obtaining the best possible radiographs using a given system.
2.2 Infuence of tube voltage (kVp) and tube current–time product (mAs) on image quality
Radiographic exposure factors include kVp, which determines the energy and thus penetrative capacity of the X-ray beam, and mAs, which is the product of the tube current (mA) and the exposure time (s) and which determines the quantity of X-rays produced. In flm–screen radiography the goal is to select an exposure resulting in
an appropriate degree of flm blackening (optical density, i.e. fraction of light transmitted through the flm). Mean optical density should range between 1.0 and 1.4, and all structures of interest should be in the useful range of 0.5 to 2.2 (Fig. 2.1).
2.2.1 Under- and overexposure
In flm–screen radiography, the immediate goal of choosing a ‘good’ kVp and mAs combination is achieving adequate mean flm darkening. Underexposure results in a radiograph that is too light overall as a result of a decreased detector dose. On the other hand, overexposure results in excessive flm blackening. In both instances diagnostic image information is lost, and in extreme cases radiographs may be non-diagnostic. Film–screen systems leave very little room for variation in exposure settings, and even minor changes have a signifcant efect on image quality (narrow exposure latitude or dynamic range). Digital radiography systems (storage phosphor systems, fat panel detectors) are much more forgiving and will tolerate fairly large variations in radiographic technique due to their wide dynamic range for exposure. With these systems
Fig. 2.1 Optical density curve of radiographic flm. Exposure should be selected so that the mean optical density (Dx) ranges from 1.0 to 1.4. The useful range, i.e. the range of densities in which struc-
range
Dose (˜Gy) tures can be distinguished by the Underexposure Correct Overexposure reader, falls between 0.5 and 2.2. exposure
there is no direct association between the radiation dose delivered to the detector and the darkness of the resulting radiographs, and it is (nearly) impossible to overexpose or underexpose a radiograph to the point of necessitating repetition of the study. Nevertheless, the detector dose has an impact on image quality. Underexposed digital radiographs are characterized by a grainy appearance (‘noise’), which under extreme circumstances may obscure important structures. Overexposure on the other hand usually goes unnoticed as the change in signal-to-noise ratio with high doses is imperceptible (Fig. 2.2). To ensure adequate image quality, and for radiation safety reasons, exposure parameters should be optimized even when using a digital radiography system. Use of a radiographic technique chart is a practical way to achieve this goal. Furthermore, digital systems are required to indicate a numeric value corresponding to the detector dose (dose indicator).
2.2.2 Motion unsharpness
Unsharpness or blurring caused by involuntary patient motion (e.g. respiration) are common and may limit
diagnostic quality of thoracic, abdominal or spinal radiographs (Fig. 2.3). Exposure time should be kept very short (≤ 0.05, preferably ≤ 0.02 seconds) to avoid this problem. A decrease in mAs (and thus exposure time) can be achieved by the following means.
• Decrease in mAs with concurrent ‘compensatory’ increase in kVp.
• Decrease of the focus-to-detector distance.
• Use of high-speed flm–screen combinations with higher sensitivity.
• Use of X-ray equipment capable of producing higher tube currents.
Halving mAs necessitates increasing kVp by approximately 10 kVp.
Exposure point tables are helpful in adjusting exposure parameters.
Fig. 2.2 Effect of exposure on image quality with a flm–screen system (left) and a digital detector (right). While deviations from optimal technique with a flm–screen system result in very light (underexposed) or dark (overexposed) images, variations in technique do not affect image brightness in a digital system. However, image noise increases with decreasing dose (not noticeable on these printed images). This fgure also illustrates that overexposure on digital radiographs does not affect image quality and thus is not easily noted. These are serial radiographs of the lumbar spine in a German Wirehaired Pointer. The flm–screen system has a sensitivity S=400 (Screen: Kodak Lanex Regular, Film: Kodak T-MAT plus DL; Kodak, Rochester, Great Britain). The digital radiographs were obtained using a photostimulable phosphor plate (Plate: Fuji ST-V, Fujiflm Medical Systems, Tokyo, Japan; Reader: Philips AC 500, Philips Healthcare, Hamburg, Germany). Other factors were left constant (FDD: 110 cm, + grid).
Fig. 2.3 Motion unsharpness/blurring in feline thoracic radiographs collimated to area of interest.
a Peripheral vascular structures are not visible and thus cannot be evaluated for any changes.
b With a decreased exposure time pulmonary vessels are sharply marginated and clearly visible. b
Fig. 2.4 Effect of exposure on greyscale of the image. Both radiographs were obtained using a flm–screen system with a sensitivity of S=400. The mean optical density of both radiographs is identical.
a 42 kVp, 8 mAs.
b 52 kVp, 2 mAs. b
2.2.3 Display of differences in attenuation
An important basic concept allowing radiographs to be used for diagnostic purposes is that diferences in X-ray attenuation between tissues are displayed as diferent shades of grey on the image (greyscale). This display can be steered by exposure. Important parameters when discussing greyscale are ‘dynamic range’ (number of all shades of grey displayed on an image) and ‘contrast’ (relative diferences in brightness of neighbouring structures). With increasing kVp values, attenuation differences between tissues decrease due to the higher penetrative capacity of the X-ray beam. In regions where tissues difer signifcantly in their X-ray attenuation properties (thorax, skeletal system), high kVp values should be used to minimize the efect of diferential attenuation by tissues and allow display of the entire spectrum of attenuation diferences on the radiograph. Conversely, in regions with low object contrast (abdomen), low kVp values should be used a
Fig. 2.5 Greyscale changes dependent on the optical density curve (gradient) of a radiographic flm.
a Optical density curves of a ‘steep’ and a ‘shallow’ flm. With a steep curve, more absorption values are included in the same shade of grey. This results in high contrast and little exposure leeway (low latitude). b
b Radiograph obtained using a ‘shallow’ flm. The thorax is characterized by high inherent contrast (range of X-ray attenuating structures from low to high). By using a flm and technique aimed at a decrease in image contrast, regions with a low density (lung) can be evaluated as well as structures with a high density (mediastinum, spine).
c Radiograph obtained using a ‘steep’ film. Pre-existing large attenuation differences between structures are accentuated, resulting in decreased image information (in this case especially affecting the lung). c
to accentuate minor attenuation diferences between tissues. In both instances mAs has to be adjusted accordingly. In small animal radiography tube voltage typically ranges between 40 and 100 kVp.
Tube voltage (kVp) afects greyscale. High kVp values result in a decrease in image contrast (Fig. 2.4).
The potential to steer the image greyscale by manipulating exposure parameters is somewhat limited as several additional factors have to be taken into account when choosing kVp (patient size, sensitivity of detectors, etc.). Another important way to adjust contrast and dynamic range is to use radiographic flm with diferences in density curve steepness (Fig. 2.5).
2.3 Film–screen systems and digital radiography
In flm–screen systems the light output yielded by intensifying screens depends on the thickness of the screen’s phosphor layer. Thick layers (high-speed screens) result in a higher light yield, but a certain degree of image blur is unavoidable due to light scatter. With thinner screens there is less light scatter and the resultant image is sharper. However, thin screens require an increase in exposure time to result in the same degree of flm blackening (high-detail screens) compared to thicker screens. Manufacturers provide a ‘sensitivity value’ (S) indicating the dose requirements of a given flm–screen system. This value is standardized and allows comparison between systems produced by diferent manufacturers (Table 2.1). For radiographs in small animal patients, high-speed flm–screen systems (sensitivity approximately 400) are used for larger patients and for regions in which respiratory motion is of concern to allow short exposure times. High-detail flm–screen systems (sensitivity approximately 100) are used to image small structural changes in thinner body regions. Under certain circumstances use of especially detailed systems
(mammography flm, non-screen flm) may be indicated and goes along with an increase in exposure factors and radiation dose. Care should be taken to always use matching flm–screen combinations. As properties of radiographic screens change over time, the same exposure may lead to diferent radiographic results. Thus, concurrent use of older and newer screens in the same practice is not advisable.
Film–screens systems with a sensitivity (S) of 100 and 400, respectively, difer by a factor of four in their intensifying properties. A flm–screen system with a sensitivity of 100 requires a fourfold increase in mAs to achieve the same flm blackening compared with a 400 system.
In a similar way to conventional flm–screen systems, digital detectors also difer in their dose efciency (see section 3.1.3; Fig. 3.2). The ‘detective quantum efciency’ (DQE) describes the detector’s ability to convert X-ray quanta to image information. It is defned as the quotient of the square of the signal-to-noise ratio (SNR) at the detector exit to the square of the SNR at the detector entrance:
DQE (f) = (SNR )²(f) : (SNR )²(f) exit entrance
DQE is infuenced by image detail (spatial frequency, f ). As system unsharpness and noise have a greater efect at higher frequencies, imaging of smaller details (i.e. higher frequencies) is more dependent on DQE than imaging of larger structures. Using an identical exposure, detectors with a high DQE produce a higher SNR compared to detectors with a low DQE. Alternatively, to maintain a constant SNR, systems with a high DQE allow dose reduction compared to systems with a lower DQE.
2.4 Grids
The purpose of grids is to avoid scatter radiation produced in the patient reaching the detector, which decreases image contrast. As scatter radiation contributes to the degree of flm blackening (or signal generation using a digital detector), and as some primary X-rays are absorbed by the grid, use of a grid necessitates an increase in exposure. Therefore, it is important to determine which circumstances require the use of a grid. Basically, a grid is necessary when patient thickness exceeds 10 cm in regions with a high soft-tissue component and 15 cm in regions with a high gas component. For smaller structures, use of a grid is to be avoided to ensure short exposure times and decrease radiation dose to patient and personnel. Digital detectors with high DQE exhibit signifcant dose-saving potential. Even with larger patient thicknesses, low exposure settings can be applied. This results in less scattered radiation. Under these circumstances it may not be necessary to use a grid.
Table 2.1 Image detector dose and limit of spatial resolution of flm–screen systems (according to DIN 6868-50).
Use of a grid necessitates an increase in exposure factors. The grid factor determines how much exposure has to be increased (Table 2.2).
Grid factors (Bucky factors) typically range between 3 and 7. The grid factor depends on the grid ratio, in other words the ratio between the height of the lead strips and the distance between two strips. Grids used in veterinary radiography typically have a grid ratio ranging from 5:1 to 12:1.
2.5 Focus-to-detector distance
In contrast to large animal radiography, the focus-todetector distance (FDD) is typically kept constant for small animal radiographs. However, a change in FDD is sometimes necessary even in small animal radiography (e.g. for horizontal beam radiographs). With an increase in distance between the X-ray tube and the detector, fewer X-ray quanta reach the detector. Specifically, the intensity of the X-ray beam is inversely proportional (squared) to the distance from the source (inverse square law; see also Chapter 4) necessitating an adjustment in exposure factors.
When changing the focus-to-detector distance (FDD) the new mAs value can be determined by simply using the following formula:
mAs = (FDD )2/(FDD )2 × mAs
2.6 Practical application
Several factors afect the choice of optimal exposure parameters:
• patient: region, thickness, condition
• focus-to-detector distance
• sensitivity of flm–screen system or DQE of digital detector, respectively
• grid: yes/no; if yes: grid factor
• generator
• collimation
• overlying bandage material.
The efect of several of these image factors on quality has been discussed above.
When designing a chart with optimized exposure parameters, most of these variables should initially be kept constant, and only body region and thickness should be modifed.
For thoracic and abdominal radiographs patient thickness is measured using calipers.
The common method of guessing body size based
Table 2.2 Correction factors to adjust radiographic technique according to the grid ratio.
Grid ratio Increase in mAs (multiplied by original value) Increase in kVp (added to original value)
Notes: It is important to modify either mAs or kVp, not both at the same time! Modifed from Curry et al. 1990.
Important rules:
1. Exposure should be doubled with an increase in body thickness:
− 3 cm for the abdomen
− 5 cm for the thorax
2. Doubling of the detector dose can be achieved by:
− doubling mAs OR
− increasing kVp by 10.
on ‘experience’ is inappropriate and commonly dissatisfactory. Using visual inspection alone it is virtually impossible to determine a 3 cm difference in a dog’s thickness (requiring either doubling or halving of the exposure!).
Even though relatively straightforward exposure point tables are available (Tables 2.3 and 2.4), recalculation of exposure parameters for every single patient is not practical. The solution is to develop a radiographic technique chart listing all relevant exposure factors for a given region and thickness. This can easily be accomplished in small animal practice. A table is generated using well exposed radiographs (of past patients or cadavers if available) in which region thickness and exposure factors were documented as a starting point. Missing exposure parameters for other body regions or patient sizes can be calculated using exposure point tables and flled in over time. To obtain initial test radiographs the following rule can be used.
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The Canon’s voice was steady and gentle.
“Thank you, my child. Bid me good-night, and go, now. You must have some rest, before your journey tomorrow.”
She came to him and he blessed and kissed her as usual, only letting his hand linger for a moment on her head as he repeated as though speaking to himself:
“And with the morn those Angel faces smile “Which I have loved long since and lost awhile.”
“Good-night, Owen. Goodbye,” said Flora.
She left the room, and the Canon raised himself with difficulty from his low chair and said:
“I have some preparations to make for tomorrow. I will leave you for a little while.”
When he had gone, Owen felt the relaxation of his own mental tension.
For the first time, and with a sincerity that left him amazed, he found himself making use of the phrase that from others had so often aroused rebellion in himself:
“He is wonderful!”
Lucilla raised her eyes now, and looked full and gravely at Quentillian.
“Yes. I’m glad you see it at last, Owen.”
“At last?” he stammered, replying to her voice rather than to her words.
“He is very fond of you. He has always been very fond of you, ever since you were a little boy. And it has—vexed me—very often, to see that you gave him nothing in return, that, because he belongs to another school, and another generation, you have almost despised him, I think.”
Owen was conscious of colouring deeply in his sudden surprise and humiliation.
“Although you are so clever, Owen,” she said in the same grave, unironical tone, “it has seemed as though you are not able, at all, to see beyond the surface. I know that my father’s religious sentiment, sentimentality even, his constant outward expression of emotional piety, his guileless optimism, have all jarred upon you. But you have had no eyes for his pathetic courage, his constant striving for what he sees as the highest.”
“Lucilla—in justice to myself—although what you say may be true, if I have judged your father it has been far more on account of his children—of what I have seen of their lives.”
“You were not called upon to constitute yourself the champion of his children. Valeria, even, had no claim on your championship. It was not you whom she loved, and you, too, tried to make Val what she was never meant to be. When Val threw you over, if my father tried to force upon you what you could only see as the conventional beau geste of renunciation, it was because he was incapable of believing that you could have asked a woman to marry you without loving her, body and soul. His forgiveness of Val, whether you thought him entitled to forgive or not, lay between him and her And when you speak of our lives, Owen, can’t you see that Val and Adrian and I, and perhaps in a way even Flora, too, have come to what we were meant for? No one can stand between another soul, and life, really.”
He was oddly struck by the echo of words that he had himself once used to Flora.
“You admit that he tried, to stand between you and life?”
“I do,” she said instantly. “But if he had succeeded, the fault would have been ours.”
She suddenly smiled.
“Isn’t it true that to face facts means freedom? That’s why I’m not an optimist, Owen. I am willing to face all the facts you like. But you, I think, in judging my father, have only faced half of them.”
“You find me intolerant!” he exclaimed, half-ironically. Never before had such an adjective been presented to his strong sense of his own impartiality, his detached rationalism.
“Not exactly. Only, I’m afraid—a little bit of a prig.”
She uttered the strange, unimposing accusation, not rudely, not unkindly, but almost mournfully
“Christianity has been accused of intolerance very often, and with only too much reason, but those outside the Churches, who frankly claim to be agnostic, often seem to me to be the most intolerant of all, of what they look upon as superstition. Why should you despise my father for beliefs that have led him to lead an honourable life, and that have given him courage to bear his many sorrows?”
“You have said, yourself, that the facing of facts means freedom. I can see no freedom, and therefore no beauty, in living in illusion.”
“Not for yourself, perhaps. Illusions could never be anything but conscious, for you.”
“Nor for yourself, Lucilla,” he retorted swiftly.
“But how does that entitle us to despise another for holding them?” she demanded, quite as swiftly. Nevertheless Owen detected a lessening of severity, in so far as she had coupled them together in her speech.
“Tonight,” he said gravely, “I admired your father with all my heart.”
“I’m glad.”
On the words, the same as those with which Lucilla had begun their brief and rather amazing conversation, the Canon returned into the room.
IV
THE DEATH OF AN OPTIMIST (i)
Q ’ next and final summons to St. Gwenllian came some months after Canon Morchard had taken Flora to her Sisterhood, and returned alone.
Owen was unprepared for the change in the Canon’s appearance, although he knew him to be ill.
“Aye, dear lad! It’s the last stage of the journey. I have thought that it was so for some time, and they tell me now that there is no doubt of it. This poor clay is worn out, and the spirit within is to be set free. Verily, I can still repeat those favourite words of mine: ‘All things work together for good, to those that love God.’ If you but knew the number of times during these last few years that I have cried out within myself ‘O for the wings of a dove, that I might fly away and be at rest!’ And now it has come! and I hope to keep my Christmas feast among the blest. They tell me that it cannot be long.”
Quentillian looked the enquiry that he felt it difficult to put into words.
“I can take very little. Soon, they tell me that even that little will have become impossible. See how even the crowning mercy of preparedness is vouchsafed to me! I have put my house in order as well as may be, and have no care save for my poor Lucilla. She will be alone indeed, and it is for her sake, Owen, that I want you to do a great kindness to a dying man.”
“Anything, sir. Do you want me to stay?”
“You have it, Owen.” The Canon laid his hand, thin now to emaciation, upon Quentillian’s.
“Stay with us now until the end comes. It cannot be far off. I have outlived my brothers, and Lucilla’s remaining aunt is old and infirm. It is not fit, even were it possible, that she should come here. She will receive Lucilla most tenderly after I am gone—of that I am assured. But there is no one to uphold her, to spare her needless distress, when the time comes.”
“I will do everything that I can to help her.”
“I know it, dear fellow—I know it. Thank you from the bottom of my heart. It seems natural to treat you as a son.”
The Canon paused and looked wistfully at Quentillian upon the word.
“Perhaps Adrian will come home. I have written to him—a long letter. He need not be afraid of me.
“I have written to my three absent children: To Valeria—my blessing for her little sons—I would have given much to see them before going—aye, and their mother, too, my merry Valeria, as I once called her! I have missed Valeria’s laughter in this quiet house, that was once full of merriment and children’s voices.
“And I have written to Flora, my Flora, who chose the better part. May she indeed be blessed in her choice—little Flora!”
He sank back, looking exhausted.
“I will stay as long as you wish me to stay, and I will do all that I can for Lucilla,” repeated Quentillian.
“I know it. The last anxiety has been allayed. Aye, Owen, I have ceased to concern myself with these things now, I hope. If Adrian comes to me, and if Lucilla can count upon you as upon a brother, then I am well satisfied indeed. My affairs are in good order, I believe. My will is with my solicitors—Lucilla knows the address. What there is, goes in equal shares to Lucilla, Valeria, and Adrian. Flora has received her portion already My books, dear Owen, are yours. All else—personal effects, manuscripts, and the rest—are Lucilla’s. She has been my right hand. There are mementos to Clover, to one or two old friends and servants—nothing else. I have
thought it well to make Lucilla sole executrix—she has helped in all my business for so long!
“So you see that my temporal concerns are over and done with. In regard to the spiritual, I have had the unutterable honour and pleasure of a visit from the Bishop himself. He was all fatherly goodness and kindness. The dear Clover is always at hand for reading, and I can depend on him utterly for those last commendations that are to smooth my way down the Valley of the Shadow. There is nothing wanting. And now you have come!”
The Canon’s wasted face was both radiant and serene.
The grief that had so often shown there seemed to have passed away, and Quentillian found it almost incredible that he had ever seen the Canon angry, or weighed down by a leaden depression of spirits.
“Is he really happy, all the time?” Quentillian asked Lucilla.
“Yes, all the time. Even when he has pain. But they say there won’t be any more pain, most likely, now. He will just sink, gradually. If you knew how very little he is living on, even now, you would be surprised.”
“Are you doing the nursing?”
“He wants a trained nurse. One has been sent for. He thinks that it will spare me,” said Lucilla, smiling a little.
In the days that followed, Owen saw how difficult Lucilla found it to be so spared.
The nurse was an efficient and conscientious woman, and the Canon quickly became dependent upon her. He begged Owen to spend as much time as possible with Lucilla, who remained downstairs, replying to the innumerable letters and the enquirers who came to the house.
She was now only with her father for a brief morning visit, and the hour in the afternoon when the nurse took her exercise out of doors. Very often Quentillian, at the Canon’s request, was also with them then.
“Lucilla and I have long ago said our last words, such as they are,” the Canon told him with a smile. “We understand one another too well to need to be left alone together.”
Time slipped by with monotonous regularity, the changes in the Canon almost imperceptible to the onlookers.
Then, preceded only by a telegram, Adrian came home.
“My father isn’t really dying, is he?” he asked piteously
“He can’t take anything at all, now. It’s a question almost of hours.”
Lucilla took him upstairs to where his father lay, propped upon pillows, and they were left alone together.
“You know, it is very bad for Canon Morchard to have any agitation,” the nurse anxiously pointed out to Lucilla, when the interview had lasted a long while.
“Can it make any real difference?”
“It may reduce his strength more quickly.”
“He would say that it was worth it. He has not seen this son for a long while.”
Lucilla kept the woman out of the room as long as it was possible to do so.
At last Adrian came downstairs.
That evening the Canon said to Quentillian, with tears in his eyes:
“Adrian has promised me to give up his work for that man. Is it not wonderful, dear Owen? All, all added unto me. If this pain of mine is to be the price of my boy’s awaking to his own better nature, how gladly shall I not pay it!”
It was the only time that Quentillian had ever heard him allude to having suffered physical pain.
“I have not been so much at rest about Adrian since he was a little boy,” said the Canon. “He was always the most affectionate of them
all. And he cried like a little child, poor fellow, this afternoon, and voluntarily passed me his promise to leave that man.”
Quentillian’s own involuntary distrust of the promise given by a weak nature, under strong emotional stress, was profound, but he gave no sign of it. It no longer caused him any satisfaction to be aware of a deeper insight in himself than in the Canon. He could not share that guileless singleness of vision, and felt no envy of it, and yet he paradoxically desired that it should remain unimpaired.
He asked Lucilla if she knew of Adrian’s promise.
“He told me. He was crying when he came down. He can’t believe even yet that father is dying, poor Adrian! And yet he must believe it, really, to have made that promise.”
“The Canon is so thankful for it.”
“I know. He wanted it more than anything in the world. Everything has come to make it easy for him to go, Owen.”
Something in her tone made him say gently:
“Poor Lucilla!”
“Even if the impression is only temporary with Adrian, it will be a comfort to him afterwards. He is very unhappy now, that there should have been any estrangement between them.”
It was evident enough that Lucilla, also, had no great reliance upon Adrian’s stability of purpose, although his present reaction had brought such joy and comfort to the dying man.
That night for the first time the Canon’s mind wandered. He spoke of his children as though all were once more of nursery age, and at home together.
“Little Adrian can take my hand, and then he can keep up with the others. Less noise, my love—a little less noise.... Valeria’s voice is too often raised, too often raised—although I like its merry note, in fit and proper season. My merry Valeria! Now are we ready? The sketch-book, Flora, the sketch-book.... I want to see that pretty attempt at the Church finished.”
Then he said with an apologetic note in his voice:
“Flora lacks perseverance, and is too easily discouraged, but we hope that she may show great feeling for art, by and bye. Lucilla’s forte lies in more practical directions. She is my housekeeper—my right hand, I often call her. Look, children, at that effect of sunlight through the beech-leaves. Is it not wonderful? Come, Adrian, my man—no lagging behind....”
Presently a puzzled, distressed look came over his face and he asked: “Is not one missing? Is David here?”
Lucilla bent over him to say, “Yes, father,” but the distressed look still lingered.
“Where is David?” said the Canon. “Was there not some sadness— some trouble between us? No—no—all a dream.”
His face lightened again. “David is safe home. I shall see David tonight.”
By and by he asked to be told the time. It was nine o’clock.
The Canon’s voice had become a weak whisper.
“I thought it was morning, and that I had them all again—little children. Such trustful little hands lying in mine ... and the children have grown up and gone away.... No ... Lucilla, you are there, are you not, my dear love? And Owen—Owen, that was like a third son to me. My own sons are there, too—David is safe home ... only a very little way on ... and Adrian, little Adrian—he promised ... ah, all things work together for good....”
His voice trailed thinly away into silence, his wan face was smiling.
“He will sleep,” whispered the nurse, and her words were verified almost instantly.
Owen took Lucilla away.
There was a strong sense upon him that the summons would not be long delayed now.
Lucilla went downstairs and quietly opened the outer door into the garden. They walked up and down there, Owen watching the red spark waxing and waning from his own cigar. The night was extraordinarily still, the dark arch of the sky powdered with stars.
Neither spoke directly of that which occupied their minds most, but Quentillian said by and bye:
“Where shall you go, eventually?”
“Torquay, perhaps. There is an old aunt there—father’s sister. I shall have just enough not to be dependent upon her, even if I make my home with her.”
“Will that be congenial?”
Lucilla gave a little low, sad laugh.
“I don’t think there’s much alternative, is there? This house, of course, goes to the next incumbent. If Mr. Clover is appointed—and we very much hope that he will be—he would probably buy a good deal of the furniture (which is just as well, as it would certainly drop to pieces if we tried to move it). I couldn’t possibly afford to set up house for myself, in any case. And I must have something to do. Aunt Mary would find plenty for me to do.”
“I daresay,” said Quentillian without enthusiasm.
“Perhaps you are thinking of my taking up an occupation or a profession seriously, but you know, Owen, it isn’t really a practical proposition, though one feels as though it ought to be. Just think for a minute, and tell me what I’m fit for—except perhaps being someone’s housekeeper.”
“My dear Lucilla, with your education and the literary training your father has given you, surely anyone would be glad of your services.”
“Not at all. I can’t write shorthand. My typing, which I taught myself, isn’t nearly as good or as quick as that of any little girl of sixteen who has learnt it properly, and can probably use half a dozen different makes of machine. I’ve never learnt office routine—filing, indexing, bookkeeping, the use of a dictaphone. I believe all those things are
necessary nowadays. I don’t suppose, if I did learn them all now, I should ever be very good or very quick.”
“I’m not suggesting that you should become a City clerk at forty shillings a week.”
“A private secretary, then? I can’t honestly see why anyone should employ a woman with no experience, when there are so many experts wanting work. Languages might be an asset, but most people know French. German isn’t likely to be wanted now, and I don’t fancy there is any great demand for Latin or Greek. Even for teaching, schools want diplomas and certificates, besides proficiency in games.”
“But the higher professions are all open to women of education nowadays,” he protested. “You’re not restricted to the kitchen or the nursery.”
“Do you really think that I could work up, now, for a stiff legal or medical examination, and pass it?” she demanded with a sort of gentle irony. “You don’t realize, Owen, that I’m nearly forty.”
He had not realized it, and it silenced him momentarily.
“I think my chances went by a long time ago,” said Lucilla. “I’ve never told anyone about it, but I think I’d like to tell you now, because I don’t want you to think of me as a victim.”
Quentillian registered a silent mental appreciation of a reason diametrically opposite to the reason for which the majority of confidences are bestowed.
“Before Val and Flossie grew up, it was obvious that I should stay at home and look after the house. Besides, I liked doing it. My father was—and is—the whole world to me. But there was a time, just once, when Val grew up, and David had gone away, when I wanted to go away, too. Of course I’m talking of a good many years ago, and there weren’t so many openings to choose from. But I wanted very much to go to college. Father could just have managed it, without being unfair to any of the others.”
“You told him, then?”
“Oh, yes; I told him.”
“Would he not consent?” inquired Owen, as she paused.
“He promised to consent if I still wished it, after thinking it over.”
“But he persuaded you not to wish it any more?”
“No, it wasn’t that. It’s a little bit difficult to explain. He did ask me what I should gain by it, and whether it wasn’t just restlessness and seeking a vocation to which I was not called. You remember hearing him say that about Val, too?”
“I remember.”
“Well, that was all. He didn’t say anything more. Of course I knew he wouldn’t like my going away from him, without being told. But it was I who decided that it was an occasion for making what I’m afraid I thought of as a sacrifice.”
She surprised him by a little laugh.
“You see, Owen, I think now that I was quite wrong.”
“Quite wrong,” he echoed gravely.
“It was an odd, muddled sort of time for some years after that. I suppose I was resenting my own decision, and yet trying to buoy myself up all the time by thinking of my own self-abnegation and generosity. It had seemed rather a beautiful thing to do at the time— to sacrifice my own life to my widowed father and my motherless brothers and sisters. At first, I remember thinking that there would be something almost sacred about my everyday life at home.”
“When people begin to think that things are sacred to them, it generally means that they’re afraid of facing the truth about them.”
“Exactly It was a long time before I told myself the truth. But in the end I did, when I saw that no one was likely to want to marry me, and that my life was going to be exactly what I had decided to let it be. And of course from the minute I faced it fair and square—after the first—it all became a great deal easier. Besides, there were compensations, really.”
He made a sound of interrogation.
“Well, it’s really a great thing to have a home. I’ve always felt sorry for women who lived in their boxes, and had nowhere of their own. And being mistress of the house all these years—I’ve liked that, and been fairly interested in it. And I’ve got imagination enough to see that books, and music, and a garden, to anyone brought up as we were especially, are quite important items. You know, women who have a career don’t generally get those other things thrown in as well, unless they’re exceptionally fortunate.”
“You set them against independence and your own freedom?”
“I don’t say that, but they do count,” she said steadily. “If it comes to a question of relative values, of course they take second place. But once I’d admitted to myself, quite honestly, that I’d relinquished my chance of the best things of all, then I could quite see those other things as being intrinsically worth something—a very good second best. They’re really only unsatisfactory when one tries to think of them as substitutes. Taken at their own value—well, I’ve found them helpful, you know.”
There was a silence before she spoke again.
“Most of all, there was Father.”
“That relationship has been the biggest factor in your life, of course.”
“Yes.” She paused, and then in a tone resolutely matter-of-fact, said: “I think perhaps I won’t talk about that now. But I know just as well as you do that in the course of nature, those particular links can only be expected to endure for a certain number of years. They’re breaking now, for me, and it means that part of my life goes too.”
He could not contradict her.
“Is Adrian any use?”
“Poor Adrian! He says now that he and I must keep together, and make a home for one another. He wants to comfort me, and he knows Father would be glad; but you can see for yourself that it wouldn’t be fair to take him at his word. Perhaps we may be together
for a little while—till things have worn off a little bit, for him Adrian is emotional, isn’t he? I don’t know what he’ll do, eventually.”
The recollection of Adrian’s promise to the Canon, that he would relinquish his work, was evidently not a factor that Lucilla took into serious consideration. By tacit agreement neither of them alluded to it.
“Valeria will hardly be able to come home, I suppose?”
“Oh, no. It’s out of the question. She couldn’t leave the two babies, nor very well bring them with her.”
“Flora?”
Already, Owen realized with faint surprise, he had come to remember Flora’s corporeal existence only by an effort. He could scarcely feel her to be less separated from the realities of life than one who had died in youth, and been long forgotten. Lucilla only shook her head.
“They are all gone. Whatever anyone may say, Owen, they didn’t shirk their chances. They said Yes to Life as they saw it.”
“Can you be glad of that?”
“Very glad. Even selfishly, I can be glad. Think of three—unfulfilled— lives to be spent side by side, held together by affection if you like, but fundamentally built on an artificial basis! No, no”—her smile held humour, rather than conscious valour, though Owen saw it as valiant too—“I’m glad to have faced my facts at last, though it ought to have been done long ago, when I made my choice. I’m not optimistic now, but I—I’m free.”
As they turned, at the end of the garden path, a dark figure sped across the grass towards them. Adrian’s voice reached them, low and urgent:
“Come!”
(ii)
T Canon lay back against his pillows and it did not need the nurse’s gesture to Lucilla to tell them that he was dying. His breath came loud and fast and his eyes were closed.
Adrian had flung himself on his knees at the bedside and was sobbing, his face hidden in his arms. Quentillian stood beside Lucilla, who held her father’s hand in hers.
“Is he conscious?” Lucilla asked.
The nurse shook her head.
“Can anything be done to make it easier?” Lucilla said then.
“No, my dear. I’ve sent messages for the doctor and Mr. Clover, but ——”
Her face completed the sentence.
They remained motionless, Adrian’s irregular sobs and the Canon’s heavy breathing alone cutting intermittently across the silence.
Quentillian never knew how long it was before Canon Morchard opened his eyes and spoke, articulating with great difficulty.
“All safe—all happy ... verily, all things work together for good!”
He smiled, looking straight across at Owen Quentillian, and suddenly said with great distinctness:
“Mors janua vitæ!”
Owen could hear the cry still, ringing through the room, in the time of dumb struggle that followed.
It seemed a fitting epitome of the spirit that had been Fenwick Morchard’s.
Just before the first hint of day dawned into the room, Lucilla and the nurse laid back on to the pillows the form that they had been supporting.
Adrian was crying and shivering like a child.
“Take him downstairs and give him something hot to drink,” the nurse commanded Owen. “There’s a fire in the kitchen.”
Quentillian looked at Lucilla.
“Please go,” she said. He went downstairs with Adrian.
“If only I’d been better to him! He was awfully good to me, really,” sobbed Adrian. “He used to make an awful fuss of me when I was a little chap, and I wasn’t half grateful enough—beast that I was!”
“Drink this.”
“I can’t.”
“Of course you can. Try and be a man, Adrian, for your sister’s sake.”
“It’s worse for me than for any of them,” said Adrian ingenuously, “because I’ve got things to be remorseful about, and they haven’t. And now it’s too late!”
“You were here in time,” said Quentillian, abominably conscious, and resentful, of his own triteness.
“And I promised him I’d chuck my job. I think it comforted him.”
“I’m sure it did.”
“It was a sacrifice, in a way, to throw the whole thing up, when I was doing well and keen on it, and all that sort of thing; but I’m thankful now that I did it. Perhaps it made up to—him—for my having been such a hound, often and often.”
It was oddly evident that Adrian was torn between genuine grief and shock and a latent desire to make the most of his own former depravity.
“I daresay you’re thinking that having been through the war and everything, I ought to be used to the sight of death,” he said presently; “but it’s quite different when it’s like this. One got sort of hardened there, and everybody was running the same risk—oneself included. But my father—why, it seems like the end of everything, Owen. I must say, I think I’m a bit young to have my home broken up like this, don’t you?”
“Very young,” repeated Quentillian automatically, and yet not altogether without significance.
“I don’t know what will happen, but of course Lucilla and I have to leave St. Gwenllian. It’s hard on her, too. I thought we ought to keep together, you know, for a bit. It seems more natural. I shall have to look for a fresh job, and I don’t know what Hale will say to my chucking him.”
Adrian was silent, obviously uneasy, and it was evident enough that it was the strong revulsion from that anxiety which prompted his next sudden outburst.
“I’m so awfully thankful that I had the strength to make that promise about leaving Hale. It’ll always be a comfort to me to feel that I made a sacrifice for the dear old man, and that he—went—the happier for it. Mind you, I don’t agree with him about Hale and Hale’s crowd. Father had the old-fashioned ideas of his generation, you know, and of course all progress seemed a sort of vandalism to him. I daresay if he’d ever met Hale he’d have had his eyes opened a bit, and seen things quite differently. Hale was always jolly decent about him, too— he’d read some of his stuff, and had quite a sort of admiration for it, in a way. Said it was reactionary, and all that, but perfectly sound in its own way, you know—scholarly, and all that kind of muck.”
“Have you written to Hale?”
“No. Of course, in a way it’s an awfully awkward situation for me, having to tell him why I’m not coming back to him, and so on. I thought I’d pop up and see him as soon as it could be managed. Of course there are arrangements to be made——”
The boy broke off, in a fresh access of bewilderment and grief.
“I simply can’t realize he’s gone, Owen. I say—you do think he was happy, don’t you?”
“Yes.”
“That promise of mine meant a lot to him. I’m so thankful that I’ve got that to remember. You might say, in a way, considering how much he always thought of us, that some of his children had rather let him
down, in a way I mean, Lucilla and I were the only two there, out of the five of us. Of course, David, poor chap, had gone already, and Val and Flossie couldn’t very well help themselves—and yet there it was! Do you suppose that when he said—that—about ‘all safe, all happy’—he was thinking of us?”
“Yes, I do.”
“It’s a comfort to know his mind was at rest. He wouldn’t have said that if I hadn’t made that promise, you know,” said Adrian.
“Look here, Adrian, hadn’t you better try and get some sleep? There’ll be things to be done, later, you know, and you and I—if you’ll let me help—must try and take some of it off Lucilla’s hands.”
All the child in Adrian responded to the transparent lure. He drew himself up.
“Thanks awfully, Owen. I shall be only too glad of your help. There’ll be a good deal for me to see to, of course, so perhaps I’d better lie down for an hour or two while I can. What about Lucilla?”
“Would you like to come and find her?”
The boy shuddered violently.
“Not in there—I couldn’t,” he said piteously. They went upstairs together.
As they passed the door of the Canon’s room, it was cautiously opened and the nurse came outside and spoke to Adrian.
“The doctor should be here presently. I want him to see Miss Morchard. She turned faint a little while ago, and I’ve got her into her room, but I’m afraid she’s in for a breakdown. I’ve seen them like this before, after a long strain, you know.”
The woman’s tone was professionally matter-of-fact.
“Had I better go to her?” said Adrian, troubled, and seeming rather resentful at the fresh anxiety thrust upon him.
“I shouldn’t, if I were you. It’ll only upset her She’s broken down a bit —hysterical. It’ll relieve her, in the end. I shan’t leave her now, till the doctor comes.”
Lucilla hysterical!
Owen, almost more amazed than concerned, watched the nurse depart to what she evidently looked upon as a fresh case.
“Well, I can’t do anything, I suppose,” said Adrian miserably
“Go to bed,” Quentillian repeated. “Shall I draft out some telegrams for you, and let you see them before they go? It’s no use sending them to the post-office before eight.”
“Don’t you want to sleep yourself?”
“Not just now, thanks.”
“Well, I’ll relieve you at seven. Send someone to call me, will you?— though I don’t suppose I shall sleep.”
The boy trailed into his room, disconsolate and frightened-looking.
Owen Quentillian, searching for writing materials, found them on the table in the Canon’s study, a table scrupulous in its orderliness, each stack of papers docketed, each article laid with symmetrical precision in its own place.
Owen would not sit there, where only the Canon had sat, under the crucifix mounted on the green velvet plaque. He went instead to another, smaller table, in the embrasure of a window, and sat there writing until the morning light streamed in upon him.
Then he laid down the pen, with a sense of the futility of activities that sought to cheat reflection, and let his mind dwell upon that which subconsciously obsessed it.
Canon Morchard had died as he had lived—an optimist. An invincible faith in the ultimate rightness of all things had been his to the end, and perhaps most of all at the end.
Quentillian envisaged the Canon’s causes of thankfulness.
He had seen his children as “safe” and “happy.” Was it only because he had wanted so to see them?
David, who was dead, had been mourned for, but the Canon had been spared the deepest bitterness of separation. He had known nothing of the gulf widening between his own soul and that of his eldest son....
A fool’s paradise?
He had seen Lucilla as safe and happy.
And yet Lucilla’s life was over, unlived. As she herself had said, her chances had gone by. Torquay remained. It was not very difficult to imagine her days there. An old lady—the placid kindness accorded by the aged to the middle-ageing—the outside interests of a little music, a few books, a flower-garden—the pathetic, vicarious planning for scarcely-seen nephews and nieces—the quick, solitary walks, cut short by the fear of being missed, and then, as years went on, more solitude, and again more solitude.
Lucilla had said: “I’m not an optimist now—but I’m free.”
From the bottom of his heart Owen recalled with thankfulness the fact of Lucilla’s freed spirit.
It was the best that life would ever hold for her now.
His thoughts turned to Flora.
Quentillian could not envisage her life: eternally secluded, eternally withdrawn. She was lost to them, as they were lost to her.
Subconsciously, he was aware of associations connected with Flora’s vocation upon which he preferred not to dwell. He knew, dimly, intuitively, that Lucilla’s merciless clarity of outlook had seen Flora less as a voluntary sacrifice than as the self-deluded victim of fanaticism.
But no doubts had crossed the Canon’s mind on Flora’s behalf. He had known no distrust of her craving for self-immolation, no dread of reaction coming too late.
