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Atlas of Small Animal
Diagnostic Imaging
 Atlas of Small Animal
Diagnostic Imaging
CLIFFORD R. BERRY, DVM,
DACVR (DI)
Clinical Assistant Professor, Diagnostic Imaging
Department of Molecular Biomedical Sciences
College of Veterinary Medicine
North Carolina State University
Raleigh, NC, USA
Courtesy Professor of Diagnostic Imaging
College of Veterinary Medicine
University of Florida
Gainesville, FL, USA
Edited by
NATHAN C. NELSON, DVM, MS,
DACVR (DI AND EDI)
Clinical Professor, Diagnostic Imaging
Department of Molecular Biomedical Sciences
College of Veterinary Medicine
North Carolina State University
Raleigh, NC, USA
MATTHEW D. WINTER, DVM,
DACVR (DI)
Veterinary Consultants in Telemedicine
Cambridge, UK
Department of Small Animal Clinical Sciences
College of Veterinary Medicine
University of Florida
Gainesville, FL, USA
This edition first published 2023
© 2023 John Wiley & Sons, Inc.

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, except as permitted by
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go/permissions.

The right of Clifford R. Berry, Nathan C. Nelson, and Matthew D. Winter to be identified as the author of the edito-
rial material in this work has been asserted in accordance with law.

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John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA

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The contents of this work are intended to further general scientific research, understanding, and discussion only
and are not intended and should not be relied upon as recommending or promoting ­scientific method, diagnosis,
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Library of Congress Cataloging-­in-­Publication Data

Names: Berry, Clifford R., editor. | Nelson, Nathan, 1972- editor. |
Winter, Matthew D. (Matthew Damian), editor.
Title: Atlas of small animal diagnostic imaging / edited by Clifford R.
Berry III, Nathan Nelson, Matthew D. Winter.
Description: Hoboken, NJ : Wiley, 2023. | Includes bibliographical
references and index.
Identifiers: LCCN 2022027172 (print) | LCCN 2022027173 (ebook) | ISBN
9781118964408 (cloth) | ISBN 9781118964422 (adobe pdf) | ISBN
9781118964415 (epub)
Subjects: MESH: Diagnostic Imaging–veterinary | Animal
Diseases–diagnostic imaging | Animals, Domestic | Diagnosis,
Differential | Atlas | Case Reports
Classification: LCC SF757.8 (print) | LCC SF757.8 (ebook) | NLM SF 757.8
| DDC 636.089/60754–dc23/eng/20230103
LC record available at https://lccn.loc.gov/2022027172
LC ebook record available at https://lccn.loc.gov/2022027173

Cover Image: © Clifford R. Berry and Elodie Huguet

Cover Design by Wiley

Set in 9.5/12.5pt SourceSans Pro by Straive, Pondicherry, India

 In general, this textbook is dedicated to those radiologists who have gone before us and shown us the
“light” for the acquisition and interpretation of radiographs. They have shown us the “art and science”
of diagnostic imaging. Some of those would include Drs Norman Ackerman, Timothy O’Brien, David
Hager, Ronald Burk, and the many others who are memorialized on the veterinary radiology website
(https://acvr.org/in-memoriam/). We would be remiss not to also dedicate this text to the next generation
of veterinary radiologists and diagnostic imagers who can build on some of these foundations and
provide new materials and insights to the “art and science” of diagnostic imaging in veterinary
medicine. We trust that your futures in veterinary imaging are as fruitful and rewarding as the
careers that we have had so far in this field.
– Kip

This book is dedicated to my wife and love of my life, Brigitt, who has put up with this veterinary radiology
stuff all our adult lives. There will be a special place in heaven for her with her patience. To God be
the Glory (John 3:16)!
– Nate

To Laura, Claire, Paul, and Sylvia, my bright lights in a dark room.

– Matt

To my wife, Brandy. Without her love, support, and twinkling spirit, none of this would be possible.
To my children, Mia and Damian, who make me the proudest person on the planet.
To my entire family, who have supported me always.
To all veterinarians and veterinary paraprofessionals that give of themselves day
in and day out – you are Superheroes.
 Contents
CONTRIBUTORS IX
8 Imaging of Joint and Tendon Diseases 104
ACKNOWLEDGMENTS X
Nathan C. Nelson
PREFACE XI
ABOUT THE COMPANION WEBSITE XII
9 Fractures and Fracture Healing 131
Nathan C. Nelson
SECTION I INTRODUCTION AND PHYSICS
10 Aggressive Bone Disease 149
Erin Porter and Nathan C. Nelson
1 The Science, Art, and Philosophy of
Radiographic Interpretation 3
11 Imaging of the Head 166
Matthew D. Winter
Nathan C. Nelson

2 Physics of Diagnostic Imaging 10

12 Imaging of the Spine 213
Elizabeth Huyhn, Elodie E. Huguet,
Nathan C. Nelson
and Clifford R. Berry

SECTION III THORAX

3 Computed Tomography and Magnetic
Resonance Imaging 16
Elodie E. Huguet, Elizabeth Huyhn, 13 Anatomy, Variants, and Interpretation
and Clifford R. Berry Paradigm 255
Clifford R. Berry and Elizabeth Huyhn
4 Ultrasonography 27
Elizabeth Huyhn, Elodie E. Huguet, 14 Extrathoracic Structures 307
and Clifford R. Berry Clifford R. Berry and Federico R.
Vilaplana Grosso
5 Nuclear Scintigraphy 36
Elizabeth Huyhn, Elodie E. Huguet, 15 Pleural Space 329
and Clifford R. Berry Clifford R. Berry and Elodie E. Huguet

16 Pulmonary Parenchyma 346

SECTION II MUSCULOSKELETAL
Clifford R. Berry and Elodie E. Huguet

6 Anatomy, Variants, and Interpretation 17 Mediastinum 392

Paradigm 43 Silke Hecht
Nathan C. Nelson
18 Cardiovascular System 444
7 Developmental Orthopedic Disease 79 Elodie E. Huguet, Sandra Tou,
Elizabeth Huynh and Clifford R. Berry

vii
viii Contents

19 Feline Thorax 497 24 Spleen 634

Martha M. Larson and Clifford R. Berry Cintia R. Oliveira

25 Gastrointestinal Tract 667

SECTION IV ABDOMEN Seamus Hoey

20 Anatomy, Variants, and Interpretation 26 Pancreas 687

Paradigm 545 Cintia R. Oliveira and Nathan C. Nelson
Elodie E. Huguet, Clifford R. Berry,
and Robson Giglio 27 Urogenital Tract 720
Elizabeth Huynh
21 Extraabdominal Structures and
the Abdominal Body Wall 598 28 Adrenal Glands and Lymph Nodes 758
Matthew D. Winter Elizabeth Huynh

22 The Peritoneal and Retroperitoneal APPENDIX I MUSCULOSKELETAL REVIEW PARADIGM 790

Space 605 APPENDIX II THORACIC RADIOLOGY CHECKLIST 791
APPENDIX III ABDOMINAL RADIOLOGY CHECKLIST 795
Matthew D. Winter
INDEX 798
23 Hepatobiliary Imaging 616
Matthew D. Winter
 Contributors
C L I F F O R D R . B E R RY, D V M , D A C V R M A RT H A M . L A R S O N , D V M , M S , D A C V R
Clinical Assistant Professor, Diagnostic Imaging Professor of Radiology
Department of Molecular Biomedical Sciences Department of Small Animal Clinical Sciences
College of Veterinary Medicine VA-­MD College of Veterinary Medicine
North Carolina State University Virginia Tech
Raleigh, NC, USA Blacksburg, VA, USA

R O BS O N G I G L I O , D V M , M S , P H D , D A C V R N AT H A N C . N E LS O N , D V M , M S , D A C V R ( D I , E D I )
Assistant Professor, Radiology Clinical Professor, Diagnostic Imaging
College of Veterinary Medicine Department of Molecular Biomedical Sciences
University of Georgia College of Veterinary Medicine
Athens, GA, USA North Carolina State University
Raleigh, NC, USA
F E D E RI CO R . VI LAPLAN A GRO SSO , LV,
DE CV D I , DACV R CINTIA R. OLIVEIRA, DVM, DACVR
Clinical Associate Professor, Diagnostic Imaging VetsChoice Radiology
Department of Small Animal Clinical Sciences Madison, WI, USA
College of Veterinary Medicine
University of Florida E R I N P O RT E R , D V M , D A C V R ( D I , E D I )
Gainesville, FL, USA Clinical Associate Professor, Diagnostic Imaging
Department of Small Animal Clinical Sciences
S I L K E H E C H T, D V M , M S , D E C V D I , D A C V R College of Veterinary Medicine
Professor, Diagnostic Imaging University of Florida
Department of Small Animal Clinical Sciences Gainesville, FL, USA
College of Veterinary Medicine
University of Tennessee S A N D R A TO U, D V M , D A C V I M ( I N T E R N A L
Knoxville, TN, USA ­M E D I C I N E A N D C A R D I O LO G Y )
Veterinary Cardiologist
S E A M US H O E Y, M V B , D E CV D I , DACV R ( D I A N D E D I ) Department of Clinical Sciences
Lecturer/Assistant Professor College of Veterinary Medicine
School of Veterinary Medicine North Carolina State University
University College Dublin Raleigh, NC, USA
Veterinary Science Centre
Dublin, Ireland M AT T H E W D . W I N T E R , D V M , D A C V R
Chief Medical Officer
E LO D I E E . H U G U E T, D V M , D A C V R Vet-­CT
Clinical Assistant Professor, Diagnostic Imaging Orlando, FL, USA
Department of Small Animal Clinical Sciences Clinical Associate Professor, Diagnostic Imaging
College of Veterinary Medicine Department of Small Animal Clinical Sciences
University of Florida College of Veterinary Medicine
Gainesville, FL, USA University of Florida
Gainesville, FL, USA
E L I Z A B E T H H UY N H , D V M , M S , D A C V R
Veterinary Radiologist
VCA West Coast Specialty and Emergency Animal Hospital
Fountain Valley, CA, USA

ix
Acknowledgments
We would like to acknowledge our colleagues, residents,
interns, and students who have asked the right questions and
helped us to shape our interpretation paradigms for diagnostic
imaging. A special shout out to the radiologists at the Univer-
sity of Florida, Michigan State University, and North Carolina
State University for their insights and help in our formulation of
Roentgen abnormalities, tying things together, and prioritizing
differentials. Of course, our programs would not be complete
without the veterinary imaging technicians who go above and
beyond the call of duty daily to ensure quality studies without
compromising patient care. A special shout out to the techni-
cians at the University of Florida, Michigan State University, and
North Carolina State University, especially Danielle Maruagis,
x
Bobbie Davis, Mary Wilson, and Theresa Critcher. The residents
over the years have always pushed us to be better and we
greatly appreciate that.
We want to acknowledge the incredible patience of the
editors and staff at Wiley Blackwell, especially Merryl Le Roux
and Erica Judisch, who have not relented in their efforts to help
us and have believed in this project from the beginning.
We want to acknowledge Elodie Huguet, DVM, DACVR,
for doing the textbook cover and the section pages for us.
She is incredibly gifted in art and gave us great images to work
with for these areas. We greatly appreciate you and your
­talents, Elodie.
Thank you.

Why another diagnostic imaging textbook? There are many
excellent textbooks on veterinary imaging that have been pub-
lished previously and are still moving forward, with historical
editions being replaced with new ones. We felt that this text
should be first and foremost an introduction to diagnostic
imaging, although most of the text deals primarily with radiol-
ogy. But more importantly, this textbook was meant to be an
atlas so that we could show not necessarily the “classic” cases
but some average cases and how the same disease can look dif-
ferently depending on the stage of the disease at the time when
the images are made. Being an atlas, this textbook is not a com-
prehensive overview of all the different diseases that one may
find in the literature, but should serve as an approach for “com-
mon things occurring commonly.” And when there is overlap
between different disease presentations on the radiographs,
formulating a prioritized differential diagnosis list is given
precedence. It is hoped that the book will serve as a foundation
upon which the reader can add layers of information (science)
and clinical experience (art) over the course of their career in
veterinary medicine.
Preface
It would be impossible to present all the potential images
that a patient will present with any given disease process,
whether dealing with multicentric lymphoma or elbow dys-
plasia. Again, this atlas will form a foundational pillar upon
which other pillars can be built. We recognize that “pattern
recognition” is a lower-­order learning technique, but it is criti-
cal for building the foundation of interpretation of diagnostic
images that occurs each time a new set of images is made.
As with all published works, there will be mistakes in this
book. We have tried our best to minimize those mistakes, but
take the ultimate responsibility for errors.
We wish you the best in your future endeavors and hope
that this textbook can play some role in the diagnostic imaging
part of your veterinary medicine career.
CLIFFORD R. BERRY (KIP)
NATHAN C. NELSON (NATE)
MATTHEW D. WINTER (MATT)
xi
 About the Companion Website
This book is accompanied by a companion website.

www.wiley.com/go/berry/atlas

The website includes figures from the book as downloadable PowerPoint slides and Radiology templates (Appendices I, II, III).

xii
 SECTION I

Introduction and Physics

 CHAPTER 1

The Science,
Art, and
Philosophy of
Radiographic
Interpretation
Matthew D. Winter
Department of Small Animal Clinical Sciences, College
of Veterinary Medicine, University of Florida, Gainesville,
FL, USA

Introduction of the philosophies shared by the editors of this textbook

regarding radiographic interpretation.

Diagnostic imaging is an art and a science. The science of

­diagnostic imaging is didactic information that is learned dur-
ing veterinary training. The art is the experiential learning that
takes place over the course of a lifetime as one interprets radio-
graphs and the ability to extract information from an image.
As one studies radiographs, one moves from a lower order of
learning (pattern recognition) to a higher level of interpretation
where different aspects of the interpretation process impact the
final conclusions. Then, the interpretation is filtered through
the clinical information relevant to the patient at hand.
Interpretation of a radiograph should be directed by a par-
adigm. An interpretation paradigm is a map that guides you
along a path of thorough and complete evaluation of a radio-
graph. The paradigm is an essential tool to use for evaluation
of all radiographic studies, and examples are provided in each
section. This chapter presents an approach to and overview
Why Radiographs?
Why bother with radiography, or diagnostic imaging in general?
Specifically, radiography is relatively fast and readily available
as a diagnostic imaging test. The procedures for most stand-
ard examinations are well defined, and expectations for the
capabilities of the modality are relatively well understood. In
the realm of diagnostic imaging tests, it is also inexpensive
and noninvasive, a rapid test to perform. Therefore, it is a
great tool to monitor and stage disease and evaluate anatomy.
We also use radiographs to document the results of patient
management, to figure out if a treatment is working or not.
And of course, when possible, we use radiographs to actually
­diagnose disease.

Atlas of Small Animal Diagnostic Imaging, First Edition. Edited by Clifford R. Berry, Nathan C. Nelson, and Matthew D. Winter.
© 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/berry/atlas

3
4 S ECT IO N I Introduction and Physics

Most often, imaging is used to decrease the level of

​​ Cone of certainty
­ ncertainty about a diagnosis. In most cases, we do not end up
u Specific diagnosis
with a definitive diagnosis, but we do use the imaging findings
as well as any other information to narrow the list of probable
diseases. We do this by gathering data. If we think of each
individual finding as a test, with each of those tests as having a
particular value, then when we add them together, we should
hopefully paint a picture or pattern of disease. So, think of each
finding as a piece of a larger pattern. As we fit more and more of
these diagnostic puzzle pieces together, the pattern becomes
more clear. As that pattern emerges, hopefully we can recog-
nize that it is consistent with a specific disease, or perhaps a
subset of diseases. The result should be a shorter list of poten-
tial or probable pathologic processes (differential diagnoses),
and we can direct our next steps accordingly.

Imaging Findings as Tests Non-Specific Change

FIGURE 1.1 The “cone of certainty.” A nonspecific change at the

As mentioned, tests can be characterized by their value, and
that value is best described by sensitivity, specificity, and accu-
racy as tested against a normal and abnormal population of
animals. If we think of each radiographic finding as a test, we
realize that each finding can be associated with a certain num-
ber of true and false positives as well as true and false negatives
when compared to a gold standard [1]. The gold standard would
be the test considered to be the best available to diagnose a
given disease. That said, the test may be relatively unavailable,
too expensive, or perhaps very invasive, and therefore cannot
always be done. The sensitivity or specificity for each and every
finding for each and every disease are not always known, but
we do have data for some of this, and we often can extrapolate.
We also have our clinical experience and diagnostic acumen to
draw on, which continue to grow over time. As more and more
clinical research is done, we get new information on the value
of findings as tests through science. Perhaps most importantly,
the combination of findings can be most powerful as a diagnos-
tic tool, and can further increase the sensitivity, specificity, and
accuracy of radiography as a diagnostic tool for a given disease.
It is important to recognize that some individual findings may
be very nonspecific, and that they are not exact for any particular
disease and can be features of many different, completely unrelated
diseases [1]. This means that, individually, they do not contribute
to the reduction of uncertainty that we hope to attain. However,
when we combine multiple findings, the added value of each find-
ing narrows our scope in the “cone of certainty” (Figure 1.1).
For example, an unstructured interstitial pulmonary
pattern that is moderate in severity and hilar in distribution
could result in a large list of potential differential diagnostic
considerations from multiple etiologies. If we combine this
finding with other radiographic changes, such as left-­sided
cardiomegaly, elevation of the carina on the lateral images,
widening of the caudal bronchi on the ventrodorsal image and
enlargement of the pulmonary veins in a dog, our differential
list narrows very quickly to pulmonary edema secondary to
mouth of the funnel does not help narrow the list of differential
diagnoses. However, a series of findings added together improves
our degree of certainty, narrowing the list of diagnoses at the tip
of the cone. There are few diseases for which imaging findings are
pathognomonic. However, a series of findings with varying degrees of
value can result in a short and prioritized list of differential diagnoses
that aid in decision making, clinical progress, and improved patient care.
left-­sided cardiac disease. Depending on other signalment and
physical examination findings (small breed dog with a grade
IV/V pansystolic cardiac murmur), our differential list narrows
even more to mitral valve degenerative disease (endocardiosis)
with secondary left heart failure.
This is why one of the most important and fundamental
interpretation skills is learning to describe abnormal radio-
graphic anatomy in an organized and systematic fashion. Being
systematic and organized helps us to recognize patterns that
might otherwise elude us.
Describing Abnormalities:
Roentgen Signs
The fundamental language of radiographic interpretation is the
Roentgen signs. These are the six features that we describe for
every organ or body system that we evaluate: location, size,
shape, number, margin, and opacity. The definitions as well as
some terminology for use in description of abnormalities are
listed in Table 1.1. Figure 1.2 is a radiograph that contains all
radiographic opacities.
Opacity is the term we use to characterize the relative radio-
graphic density of an organ or structure. The relative physical
density of a structure and the atomic number of its components
will dictate how many x-­rays are stopped, or attenuated, within
 CHAPTER 1 The Science, Art, and Philosophy of Radiographic Interpretation 5

TA B LE 1 .1 Roentgen signs, definitions, and terminology.

Roentgen sign Definitions Abnormal descriptive terminology

Size The relative extent or dimensions of an organ or object on the Enlarged
image. This can be an absolute measurement in mm or cm, or may Increased in size
be a ratio formed by comparison to a standard (i.e., vertebrae,
pelvic diameter). The description should always be relative to the Small
expectation of normal for a given species and breed Reduced in size
Distended
Dilated

Shape The external shape or contour of an organ or object. Most organs Round or rounded
have a narrow range of normal shapes. Intestines are tubular, Oval
­kidneys are, well, kidney shaped, etc.
Rectangular
Triangular
Fusiform
Broad-­based
Amorphous

Number A value representing quantity or amount. In its simplest form, we Value (i.e., 3 pulmonary nodules)
might identify that there are 2 kidneys, 7 lumbar vertebrae, or Increased in number (compared to
10 pulmonary nodules. But we also might use this to characterize normal or a prior study)
the specific quantity of cardiac chambers or liver lobes enlarged or
affected by disease Decreased in number
Numerous

Margin The edge or border of a structure or organ. Smooth

Well-­defined
Ill-­defined
Regular
Irregular
Sharp
Normal or abnormal contour

Location Place or position. Most organs have a normal, expected position that Normal
can be altered by disease. In many cases, the position of an organ Displaced (dorsally, ventrally, laterally, to
may be altered by an adjacent abnormality. Recognizing this is key the left, etc.)
to understanding the lesion. Knowledge of radiographic anatomy is
of the utmost importance. Remember that “Anatomy is Power!”

Opacity The relative ability to attenuate x-­rays. There are five radiographic Gas, fat, soft tissue/fluid, mineral/
opacities. Relative differences in the soft tissue opacity of organs are bone, metal
often related to physical density or thickness

the x-­ray beam as it passes through a patient. Gas has a small
physical density and does not attenuate x-­rays. Therefore, things
that contain gas are black, or less opaque on a radiograph. We see
this in the lungs and the gastrointestinal tract. We should note the
presence of gas where it is unexpected. Fat is more dense than gas
and attenuates more x-­rays. Therefore, it appears gray on radio-
graphs. Soft tissue attenuates even more x-­rays than fat, and has
the same density as fluid. It is important to realize that soft tissue
structures (e.g. aortic walls) and fluid (e.g. the blood within the
aorta) cannot be distinguished radiographically. As with gas, it is
always important to document the presence of fluid in a space in
which it does not belong or is excessive (pleural space, peritoneal
space, retroperitoneal space, subcutaneous tissues).
Next on the opacity continuum is mineral. Bone is prob-
ably the most recognizable mineral opacity on a radiograph, but
recall that many processes result in accumulation of abnormal
mineral, including but not limited to dystrophic mineralization,
metastatic mineralization, uroliths, nephroliths, etc. At the end of
the continuum is metal. Metal attenuates, or stops, all x-­rays, and
therefore appears white (radiopaque) on a radiograph. Examples
are barium, microchips, surgical plates, and some foreign bodies.
In addition to describing abnormal opacities, one may also
identify the relative uniformity of an organ or structure by using
terms such as homogeneous or heterogeneous. The presence of
variable opacities in a structure that is normally uniform can be
described in terms of heterogeneity. Recognizing heterogeneity in
a normally homogeneous structure can be an important finding.
While the above process is described in the context of radio-
graphic interpretation, this tool set is similar for all imaging
modalities. The Roentgen approach is still the method by which
abnormalities should be characterized, though we modify
the terminology around the Roentgen sign of opacity, which
6 S ECT IO N I Introduction and Physics

Relative consistency (optical density on the

TA B L E 1. 2
image) by modality.

Modality Characteristic Terminology

Radiographs Opacity Gas, fat, soft tissue,
­mineral, metal

Ultrasound Echogenicity Hyperechoic,

hypoechoic,
anechoic

Computed Attenuation/density Hyperattenuating/

tomography hyperdense
Hypoattenuating/
hypodense

Magnetic ­ (Signal) Intensity Hyperintense, increased

resonance signal intensity
imaging Hypointense, decreased
signal intensity

Nuclear Radiopharmaceutical Increased/decreased

medicine Uptake radiopharmaceutical
Activity uptake

abnormalities. Your knowledge base and clinical acumen will

FIGURE 1.2 Postoperative lateral radiographic image of the right
crus of a dog that contains all radiographic opacities. Gas is evident
outside the patient, but also notice the subcutaneous gas cranial
to the femur and caudal to the distal tibia (arrowheads). Gas is also
superimposed/within the musculature caudal to the crus (open
arrowheads). Fat is present in the subcutaneous tissues (asterisk).
The musculature of the limb is soft tissue opaque. The variable shades of
soft tissue are related to thickness. The femur, tibia, fibula, tarsal and
metatarsal bones are mineral opacity. The implants are metal opaque.
represents the relative signal or consistency of an object as
defined by its ability to attenuate x-­rays. Other imaging modal-
ities also characterize the consistency of tissue relative to the
signal that they generate (Table 1.2).
Using this tool set is predicated on our understanding
of normal radiographic anatomy, and the many normal
breed and species variations that exist. You can imagine that
a dachshund and Great Dane will differ dramatically from
one another, yet still be normal for the breed. Each of these
Roentgen signs can be normal or abnormal and, depend-
ing on the type of abnormality we describe, can help paint
a picture of disease. This tool set also requires careful and
intentional application. It is very easy and tempting to skip
portions of the process, which can result in clinical errors. Fol-
lowing a regular, standardized, and consistent approach to
image evaluation will ensure that you are thorough, and that
you understand your findings.
The standard approach begins with the interpretation par-
adigm, or map, that guides you through the anatomy present in
the image. This map ensures that you do not skip any portion
of the process, and you use the appropriate tools to describe
help you determine the value of each finding. Connecting the
abnormal findings to abnormal pathophysiologic mechanisms
is the next step, allowing you to generate differential diagnoses
and, ultimately, your next clinical step.
General Interpretation
Concepts
There are a few concepts that will come up regularly as we
review images. In Figure 1.3 the image on the left has a plastic
container and two surgical gloves filled with water. One glove is
suspended over the box, while the fingers of the other glove are
immersed in the container. On the right, the same two water-­
filled gloves are there, and you’ll notice that some of the fingers
overlap. Remember, water is soft tissue/fluid opaque, therefore
these items should attenuate the same number of x-­rays and
therefore have the same opacity. However, you’ll notice that
not all of these areas have the same exact opacity. In the upper
left of the first image (Figure 1.3A), you see that in the region
of the image where the glove and the container overlap, the
opacity is greater than the container alone. In the right image
(Figure 1.3B), where the fingers overlap, you see that the opac-
ity is greater, and that the palms of the gloves are more opaque
than the individual fingers. This is because there is a difference
in the physical thickness of these regions, and that difference
translates to a difference in x-­ray attenuation. The thicker part
attenuates more x-­rays than the thinner part, despite the fact
that both are fluid. When multiple soft tissue opaque structures
are superimposed on one another, the overall attenuation of
x-­rays is additive, and is called summation.
 CHAPTER 1 The Science, Art, and Philosophy of Radiographic Interpretation 7

A B

FIGURE 1.3 Radiographs of a plastic container and two surgical gloves filled with water (A) and of two surgical gloves in which the fingers have
various degrees of superimposition (B). In both gloves, there are small gas bubbles (black arrowheads). In (A), note that the thumb in the lower right
of the image and the palm of the glove in the upper left are more opaque than the water in the container due to summation (S). The index finger
of the glove in the lower right (-­) is less opaque than the thumb and the palm of the same glove. Some of this can be explained by summation, but
some is also a result of differences in the physical thickness of these structures. The margins of the fingers of the glove in the upper left are almost
completely lost in the container. These margins are border effaced as they are immersed in the water. Both the fingers and the water in the container
have the same opacity. The thumb of the glove in the upper left (+) is also very opaque. This thumb is viewed “end-­on”, as if pointing down at the
container, creating even greater summation in this orientation. The margins of this thumb remain visible, as it is not immersed in the water. In
(B), note that in the regions in which the fingers of the two gloves overlap, the overall opacity is increased compared to the individual fingers
alone (S). This is another example of summation. Note that the margins of these digits are all well defined. While there is summation, there is gas
surrounding each digit, highlighting the margins. There is no border effacement here. Also, the palms of each glove (+) appear slightly more opaque
than the digits. This is due to the greater physical thickness of the palms compared to the digits. There is more water for the x-­rays to penetrate,
therefore more x-­rays are attenuated, creating a more opaque region despite the fact that this is the same material (water).

Also note that the fingers that are immersed in the water-­
filled container are not visible. This is because the fingers are
surrounded by the same opacity, and the margins of the fingers
have become border effaced. This means that the margins of
two structures of the same opacity, when in contact with one
another, cannot be differentiated as separate structures (called
border effacement). This is why you will not see hepatic veins
or portal veins in the liver, why you will not differentiate fluid in
the urinary bladder or intestines from the wall of those struc-
tures, or why you cannot see the individual chambers of the
heart on a plain radiograph. These changes are seen commonly
on radiographs, so make sure that you have an understanding
of these radiographic concepts.
Organizing Information/
Abnormalities
It is important to organize data to assist in pattern recognition.
The process of organization can be divided into four parts:
the description of abnormalities, the conclusion or summary
statement, the differential diagnosis list, and next steps. The
first step, the description, is the process of using Roentgen
signs to evaluate anatomic abnormalities noted in the image.
The second step, the conclusion, consists of interpreting the
findings individually and in the context of other abnormalities
and recognizing patterns. In the third step, we construct a list
of probable diseases that have pathophysiologic mechanisms
that could explain the imaging abnormalities or that fit the
pattern observed.
There are a large number of possible radiographic pre-
sentations for a disease process. Although this text is an atlas,
it cannot present all possibilities, just common examples of
them. Part of the reason for this is the timeline of the disease
process. The image created during radiography represents a
snapshot in the timeline of a disease process. When are we tak-
ing the image relative to the severity of disease? Other factors
such as individual variations in response to disease (dealing
with a biological system) as well as the severity of disease are
important factors.
In the final part, one must strategically select next steps
that might help to arrive at a definitive or final diagnosis,
or list possible treatment options for the disease process
that is the primary consideration based on the signalment,
8 S ECT IO N I Introduction and Physics
physical examination, and other tests done in assessing
the patient.
In the description, you will use Roentgen signs to identify
and describe any abnormalities on the image. Be sure to use
all available projections and ensure there is a complete study
(technique and position are critical).
In the next section, you draw conclusions based on your
observations. For example, you may have described a soft
tissue bulge in the region of the left atrium and lateral displace-
ment of the principal bronchi on the ventrodorsal/dorsoventral
image. Your conclusion on this could be “left atrial enlarge-
ment.” If you also described a bulge or enlargement in the
region of the left ventricle and an increase in apical to basilar
length of the heart with dorsal displacement of the carina, you
might also conclude that there is “left ventricular enlargement.”
If you indeed have both, you might draw a broader conclusion
of “left-­sided cardiomegaly.” This broader conclusion will feed
into the next step, defining your differential diagnoses.
For differential diagnoses, one must reflect on the conclu-
sions, and list the most probable diseases that might explain
the conclusions or summary statements by trying to tie all the
concluding statements together as one disease process. To con-
tinue with the above example, you would list the most probable
diseases that could cause left-­ sided cardiomegaly, with
consideration of the patient’s signalment. If this is a 12-­year-­old
toy poodle, you would likely list myxomatous degeneration of
the mitral valve as the primary differential diagnosis. If this is
a 6-­month-­old lab, you might consider congenital dysplasia
of the mitral valve primarily. If this is a 10-­year-­old German
shepherd, you might consider endocarditis. And if this is an
8-­year-­old domestic shorthair cat, you might consider feline
cardiomyopathy in all its various forms, which you might pri-
oritize based on likelihood and prevalence. Other diseases may
also be on your list, and the prioritization of this list should be
filtered through all the other information available at the time
of interpretation. As new data is presented, always review the
differential list. New information could serve to eliminate or
reprioritize your differentials.
As you consider your differentials, remember that the goal
is to reduce the level of uncertainty. However, you do not want
to inadvertently or erroneously eliminate diseases that should
remain in contention as possible causes of the patient’s disease
pattern. One way to accomplish this is to consider broad cate-
gories of disease first and then decide if any can or should be
eliminated. This process is incredibly important as it keeps us
from excluding diseases that we might dismiss due to any of
our biases.
One scheme is the DAMN IT V mnemonic. Each letter
stands for one or more general disease categories that might
account for the constellation of data that you have before you
(Table 1.3). For those potentially offended by this scheme,
you might choose to use CITIMITVAN, which functions in the
same way (Table 1.4). Always evaluate these lists as you gen-
erate differentials to be sure that a disease process is not over-
looked. Equally, try to eliminate categories for which a disease
Acronym for different disease etiologies
TA B L E 1. 3
(DAMN IT V).
D Degenerative/developmental
A Anomalous (congenital)/autoimmune
M Metabolic
N Neoplastic/nutritional
I Inflammatory/infectious/iatrogenic/idiopathic
T Trauma/toxic
V Vascular
Acronym for different disease etiologies
TA B L E 1. 4
(CITIMITVAN).
C Congenital
I Inflammatory
T Trauma
I Infectious
M Metabolic
I Idiopathic/iatrogenic
T Toxic
V Vascular
A Autoimmune
N Neoplasia/nutritional
in the specific patient is highly unlikely, improbable, or even
nonexistent.
Within each of these broad categories, consider specific
disease types that might explain your imaging findings and
conclusions. In our cardiac example, we considered con-
genital, degenerative, and infectious etiologies for left-­sided
cardiac enlargement, and would prioritize them based on the
information we have about the patient, including species,
breed, and age. Always run through this list to be sure you
do not unintentionally exclude diseases that may explain the
patient’s history, clinical signs, and imaging findings.
Finally, you need to determine your next steps. These
may be additional diagnostics, or may consist of therapeutic
options. In our example, echocardiography might be the next
best step in truly determining the underlying pathology and
creating a treatment plan. This will obviously differ depend-
ing on the diseases that we identify or suspect. To continue the
example, if the patient is in left heart failure and has clinical
signs related to the radiographic changes identified, one
should always stabilize the patient prior to other diagnostic
tests that might add to respiratory stress and compromise the
patient further.
 CHAPTER 1
Pitfalls of Interpretation
Many interpretation pitfalls have been characterized. Some
are called different names by different specialists. Aware-
ness of the major pitfalls can be important in their avoid-
ance. While the following list is not exhaustive, it serves as
a reminder of the more common pitfalls and biases that
you may encounter as you continue on the journey toward
becoming a radiologist. These are biases that should be
avoided. One way to do this is to present the case and radio-
graphic images to a colleague without the clinical informa-
tion (history and signalment) to hear their interpretation and
conclusions. This will help to eliminate some of the biases
presented below.
Framing Bias
Framing bias is a particularly common error. The problem pre-
sented in the clinical history may erroneously or incompletely
implicate a particular system that influences both the evalu-
ation and interpretation process [2]. A patient is presented
for acute vomiting, and the owner suspects that the dog ate
something that they can no longer find. We are programmed
to look for the foreign body, and we may be sensitized or
biased to identify something abnormal in the gastrointestinal
tract. The problem may be elsewhere, and if the clinical con-
text we were given was a bit different, we may have directed
our search differently. This is why some radiologists choose to
review the history and clinical findings after their first review
of a study.
Confirmation Bias
We are often guilty of confirmation bias, which is simply look-
ing for evidence that supports what you already know, or think
you know [2]. It is human nature to see only what we actively
look for; who does not prefer to have their opinions or ideas
validated rather than refuted? When our awareness is raised by
new knowledge, whether that is a new journal article identify-
ing a novel finding or an addition to our process that forces rec-
ognition of previously ignored features, we hopefully increase
our ability to diagnose diseases.
References
1. Scrivani, P.V. (2002). Assessing diagnostic accuracy in veterinary
imaging. Vet. Radiol. Ultrasound 43: 442–448.
The Science, Art, and Philosophy of Radiographic Interpretation 9
Satisfaction of Search
Satisfaction of search bias is also common. It is the tendency to
halt the search for abnormalities once one has been found [2].
Often patients have more than one abnormality, and while not
all abnormalities may be related to the clinical complaint, addi-
tional findings may further support a diagnosis. Alternatively,
additional findings may implicate an occult process that has not
yet declared itself clinically. The radiologist’s goal is always to
provide a complete diagnostic assessment of the study at hand.
Availability Bias
Availability bias is probably less common but still prevalent. Also
known as heuristic bias, this error occurs when we allow easily
recalled experiences to have a large influence on our thinking. It
makes us consider diseases that we know about and recall eas-
ily, even if they do not apply specifically to a particular case [2].
Inattention Bias
Inattention bias is also called a location-­related error. It is the
inability to recognize an abnormal finding within the study
because it does not appear in the purposefully evaluated area,
or is at the periphery of the study [2]. This is a particular risk
when one does not follow an interpretation paradigm, which
can help ensure that the entire image is examined thoroughly.
Conclusion
Diagnostic image interpretation is exciting, challenging, and
fun. This chapter has introduced the concepts on which to build
a successful interpretation paradigm for evaluating all forms of
imaging. Interpretation paradigms will be presented for each of
the sections in this book (musculoskeletal, thorax, and abdo-
men). These paradigms should be used as a starting point for
ensuring complete evaluation of the radiographic images.
The formulation of conclusions or summaries, differentials
and next steps is a critical piece of the puzzle when interpret-
ing radiographic studies. Remember that this process involves
continuous learning strategies, and journal clubs/evaluations
should be a routine part of the practice of a veterinarian.
2. Gunderman, R.B. (2009). Biases in radiologic reasoning. Am.
J. Roentgenol. 192: 561–564.
 CHAPTER 2

Physics of
Diagnostic
Imaging
Elizabeth Huyhn1, Elodie E. Huguet2, and
Clifford R. Berry3
1
VCA West Coast Specialty and Emergency Animal Hospital,
­Fountain Valley, CA, USA
2
Department of Small Animal Clinical Sciences, College of
Veterinary Medicine, University of Florida, Gainesville, FL, USA
3
Department of Molecular Biomedical Sciences, College
of ­Veterinary Medicine, North ­Carolina State University,
Raleigh, NC, USA

Overview: Uses Computed tomography uses ionizing radiation recon-

structed by a computer to create multiple transverse images of

and Advantages
Radiography is an imaging technique that uses x-­ray attenu-
ation within veterinary patients to obtain two-­dimensional
images of internal organs and to assess for the presence or
absence of disease. Radiography in veterinary medicine can be
subdivided into projectional radiography, computed tomogra-
phy (CT), and fluoroscopy.
Projectional radiography utilizes electromagnetic or ion-
izing radiation to obtain static two-­dimensional images of a
three-­dimensional patient (body part), which in and of itself
presents projection artifacts that have to be properly inter-
preted as normal or abnormal. Common uses for projection
radiography in veterinary medicine include thoracic, abdom-
inal, musculoskeletal, and contrast imaging (Figure 2.1).
the patient based on the various physical densities compared
with the normal attenuation of water (called a Hounsfield
unit or HU).
Fluoroscopy also utilizes ionizing radiation to obtain
dynamic, real-­time images (usually limited by a frame rate of
30 frames/second) that are viewed over time. This modality is
used to observe the movement of contrast through the esoph-
agus, cardiac structures, or different vessels, as well as diag-
nosing dynamic diseases such as a collapsing trachea.
Contrast radiography can be used in projectional radiog-
raphy, computed tomography, and fluoroscopy to supplement
information gained from these modalities. Types of contrast
radiography include positive contrast and negative contrast.
Common positive contrast agents used include barium sul-
fate paste or liquid or iodine (i.e., nonionic, iodinated positive
contrast medium). In radiography, positive contrast is metallic,

Atlas of Small Animal Diagnostic Imaging, First Edition. Edited by Clifford R. Berry, Nathan C. Nelson, and Matthew D. Winter.
© 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/berry/atlas

10
 A

D E

FIGURE 2.1 (A) Left lateral thoracic radiograph in a normal dog. (B) Right lateral abdominal radiograph in a normal dog. (C) Ventrodorsal
pelvis radiograph in a normal dog. (D) Right lateral abdominal radiograph after barium positive contrast administration in a normal dog.
(E) Ventrodorsal abdominal radiograph after barium positive contrast administration in the same patient. Note the positive barium contrast in
the stomach (black arrow), duodenum (black arrowheads), and some segments of the jejunum.
12 S ECT IO N I Introduction and Physics

so it increases the visibility of the organ or vessel within which
it is introduced (Figure 2.1). Negative contrast agents typically
used are room air or carbon dioxide which is gas opaque (radio-
lucent) on the image (Figure 2.2). Double-­contrast studies can
be done using a combination of positive and negative contrast
media to give optimal detail of a mucosal surface such as the
urinary bladder (Figure 2.3) [1].
Digital projectional radiography is used as a common
­first-­step modality in diagnostic imaging as it is relatively
affordable and can be obtained quickly. Digital radiography has
an increased dynamic range which implies that the anatomy
has varying density values that can be visualized. Using a
broad scale contrast display, all the anatomy can be seen in
the radiographic image within the displayed range of optical
densities. The displayed densities can be adjusted according
to the contrast and brightness of the image. The contrast and
brightness of the image are attained through window width
and window level. If changes to the window width are made,
the contrast of the image will change; when the window width
narrows, there is increase in the displayed contrast. If changes
to the window length are made, the brightness of the image
will change.
Basics of X-­Ray
Interaction in Matter
To understand how radiographs are made, it is important to
recognize how photons interact with matter. Photons can
interact with matter via (i) coherent scattering, (ii) photoelec-
tric effect, (iii) Compton scattering, (iv) pair production, and
(v) photodisintegration [2]. Pair production and photodisinte-
gration have no relevance to diagnostic radiology so they will
not be reviewed further.

A B

FIGURE 2.2 (A) Survey ventrodorsal abdominal radiograph. (B) Ventrodorsal abdominal radiograph after a pneumocolon. Note the
distinguishing margins of the colon (black arrows) in relation to the fluid-­and gas-­dilated segments of the small intestine (black arrowheads).

FIGURE 2.3 Double contrast medium cystogram outlining the
inner mucosal wall with negative contrast medium (room air) and
there is a central pool of positive iodinated contrast medium for the
evaluation of cystoliths, clots, masses, etc.
Coherent Scattering (Figure 2.4)
Coherent scattering is not useful in the production of a radio-
graphic image. When a photon interacts with an object with
subsequent directional change, the object does not absorb
the photon but rather scatters it, and consequently degrades
the image and increases personnel exposure if present
within the x-­ray room at the time of exposure. The goal of
all radiographic procedures would be “hands free” imaging,
where all personnel are out of the x-­ray room at the time the
­exposure is made.
γ
FIGURE 2.4 Coherent scatter. Note the incoming photon (γ) is
absorbed then immediately reemitted with minimal direction and
energy change. This photon may result in radiographic film fog and is
only significant at very low diagnostic x-­ray energies.
CHAPTER 2 Physics of Diagnostic Imaging 13
Photoelectric Effect (Figure 2.5)
Photoelectric effect is the most important type of photon
­interaction that produces a radiographic image. The photon
striking the patient is completely absorbed by an inner k-­shell
electron without scatter. The photons that are not absorbed or
attenuated create the radiographic image. Differential absorp-
tion is based on the physical density, patient thickness, atomic
number (Z), and the energy (kVp) of the x-­ray beam.
Compton Scattering (Figure 2.6)
When a photon interacts with a peripheral shell electron of an
atom, this electron is ejected, and the photon is then scattered
in any direction at a lower energy. The probability of a Comp-
ton reaction increases with increasing photon energy. If Comp-
ton absorption predominates in a reaction, the radiographic
image will have poor contrast, degrading the image. Compton
scattering will also increase personnel exposure.
Radiation Safety
Basic principles of radiation safety should always be prac-
ticed when making radiographic images (Table 2.1). All levels
of ionizing radiation should be considered dangerous and the
ALARA (As Low As Reasonably Achievable) principle should be
observed at all times [3].
The three major principles of ALARA are time, distance, and
shielding. Time is important to reduce the time of exposure.
e–
FIGURE 2.5 Photoelectric effect. Note the incoming photon (γ)
interacting with the orbital electron in the inner shell. The orbital
electron (e-­) becomes dislodged (the energy of the incoming photon
must be greater than or equal to the electron’s energy). The incoming
photon gives up all its energy and the ejected electron is now a
photoelectron. The photoelectron can interact with other atoms
which results in increased patient dose, contributing to biological
damage. When the orbital electron is dislodged, the vacancy is
filled by an electron from the outer shell. Once the vacancy is filled,
that electron releases its energy in the form of a characteristic
photon. Emission of characteristic photons continues until the atom
becomes stable.
14 S ECT IO N I Introduction and Physics
γ However, personnel excluded from the x-­ray room during an
e–
γ gloves, thyroid shield, and eyeglasses. Lead aprons and gloves
FIGURE 2.6 Compton scatter. Note the incoming photon (γ) is
partially absorbed in an outer shell electron, which absorbs enough
energy to break the binding energy, and then becomes ejected (e−).
The ejected electron is a Compton electron. The incoming photon (γ)
continues on a different path with less energy as scattered radiation.
The scattered photon can interact with other atoms via photoelectric
effect or Compton scattering.
Principles of radiation safety for
TA BLE 2 .1
veterinary medicine.
1. The use of “hands free” exposures (all personnel out of the
x-­ray room at the time of x-­ray exposure of the patient) should
be the goal of every practice.
2. Sandbags, sponges, tape, and positioning devices should
be used to accomplish “hands free” exposures. Adequate
sedation or general anesthesia should be used when
appropriate.
3. Collimate the primary beam to the area of interest, recognizing
that the smaller the collimated field, the greater the reduction
in x-­ray scatter.
4. All personnel operating the equipment should be properly
trained in usage of the equipment, proper anatomic posi-
tioning, technique, and transfer of images to different worksta-
tions and work environments (i.e., telemedicine).
5. If personnel are in the room at the time of the exposure, then:
• always wear lead apron, gloves, and thyroid shields
• always wear radiation detection badges to monitor exposure
and adhere to strict guidelines for rotating personnel in radi-
ology to minimize exposure to any one individual
• never have any part of the personnel in the primary x-­ray
beam even if wearing lead (lead only protects against scatter
radiation, not the primary beam)
• personnel must be over 18 years of age
• pregnant personnel should never be used for holding
patients for x-­ray studies.
Note: all states will have different regulations related to radiation safety and
it is incumbent upon the end user to determine these rules and laws for the
individual practice.
exam include those younger than 18 years old and pregnant
individuals. All personnel involved with radiography should
wear a radiation detection badge and appropriate shielding
(gloves, apron, thyroid shields) when making exposures. If
the distance is doubled between the personnel and radiation
source, the radiation exposure is reduced by a factor of four
(called the inverse square law). The most effective personal
shielding for radiation personnel is lead-­impregnated aprons,
are designed exclusively to protect against scattered radiation
and must never be placed in the primary beam because they do
not attenuate high-­energy x-­rays [3, 4].
Digital Radiography
Digital imaging is the current standard of care for diagnos-
tic radiography, replacing analog film-­screen combinations
that have been used for decades in human and veterinary
­medicine [5, 6].
Digital detectors fall into two broad categories: computed
radiography (CR) and digital radiography (DR). The DR cat-
egory is really a misnomer as CR is a form of DR. In CR, an
imaging plate (also called the PSP or photostimulable plate)
and cassette are placed on the tabletop or in the table tray
for radiographic exposures. After an exposure is made, the CR
cassette is processed through a reader and the reader then
produces an image based on the digital information stored
in the imaging plate. This information is then erased and
reloaded into the cassette for the next exposure. In DR (direct
or indirect), photon-­ sensitive hardware within the digital
plate directly interacts with the photons that are not attenu-
ated by the patient.
The digital systems (DR) available currently include hard-
wired and wireless indirect, direct or CCD (charge coupled
device) types of detectors. A full explanation of these is beyond
the scope of this text, but needless to say, digital radiography is
here to stay and has replaced the older analog systems.
Limitations
The primary limitation of projectional radiography is the
superimposition of organs causing summation or border
effacement (flattening of a three-­dimensional object into a
two-­dimensional image). Orthogonal projections are made
to help create a three-­dimensional image in the interpreter’s
brain. Radiography is a great first step to diagnosing and treat-
ing diseases in veterinary patients. When referring to digital
radiography, the main disadvantage in relation to film-­screen
radiography is decreased spatial resolution, but enhancement
techniques are used to improve the perceived spatial ­resolution
of an image.

References
1. Wallack, S. (2003). Handbook of Veterinary Contrast Radiography.
San Diego, CA: Veterinary Learning Systems.
2. Bushberg, J.T. (2012). The Essential Physics of Medical Imaging. 5.
Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.
3. Centers for Disease Control and Prevention (2015). ALARA – As Low
As Reasonably Achievable. www.cdc.gov/nceh/radiation/alara.html. 6.
4. Thrall, D.E. and Widmer, W.R. (2018). Radiation protection
and physics of diagnostic radiology. In: Textbook of Veterinary
CHAPTER 2 Physics of Diagnostic Imaging 15
Diagnostic Radiology, 7e (ed. D.E. (e.) Thrall). St Louis, MO:
Elsevier.
Robertson, I.D. and Thrall, D.E. (2018). Digital radiographic imag-
ing. In: Textbook of Veterinary Diagnostic Radiology, 7e (ed. D.E.
(e.) Thrall). St Louis, MO: Elsevier.
Widmer, W.R. (2008). Acquisition hardware for digital imaging.
Veterinary Radiology and Ultrasound, 49: s2–s8.
 CHAPTER 3

Computed
Tomography and
Magnetic
Resonance
Imaging
Elodie E. Huguet1, Elizabeth Huyhn2, and
Clifford R. Berry3
1
Department of Small Animal Clinical Sciences, College of Veterinary
Medicine, University of Florida, Gainesville, FL, USA
2
VCA West Coast Specialty and Emergency Animal Hospital,
­Fountain Valley, CA, USA
3
Department of Molecular Biomedical Sciences, College of ­Veterinary
Medicine, North Carolina State University, Raleigh, NC, USA

Overview of other anatomic structures. The field of view can be selected

to give detailed transverse images of the internal organs and
areas of interest. The transverse images made during a CT study
The use of cross-­sectional imaging modalities, such as com-
can also be reconstructed into sagittal, dorsal, and oblique
puted tomography (CT) and magnetic resonance imaging
imaging planes and also used to create three-­dimensional
(MRI), has changed the landscape of diagnostic imaging in
images of the anatomy of interest.
veterinary medicine over the past several decades. This chap-
Computed tomographic exams are usually done in anes-
ter will provide an overview (not meant to be comprehensive)
thetized or heavily sedated patients to prevent motion arti-
of the basics in acquisition and interpretation of these cross-­
fact, unnecessary repeated examinations and consequently
sectional imaging techniques.
reexposure to ionizing radiation for the patient and possibly
personnel. With recent advances in technology, a CT can be

Computed Tomography done relatively quickly, which is beneficial for a veterinary

Overview: Uses and Advantages
Computed tomography is a diagnostic imaging modality that
creates transverse images of a patient without superimposition
patient under general anesthesia. CT is often the best imaging
modality for detecting a variety of neoplasms since the
images allow confirmation of the presence of subtle abnor-
malities that are potentially not seen on radiographs. CT can
also determine size and location for surgical and radiation
therapy planning.

Atlas of Small Animal Diagnostic Imaging, First Edition. Edited by Clifford R. Berry, Nathan C. Nelson, and Matthew D. Winter.
© 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/berry/atlas

16
 CHAPTER 3 Computed Tomography and Magnetic Resonance Imaging 17

Contrast passes through the material. The linear transformation of the

Iodine-­based contrast media are categorized according to
osmolarity (high, low, or iso-­), ion formation ability (ionic or
nonionic), and the number of benzene rings within the chemi-
cal structure (monomer and dimer) [1]. The most commonly
used contrast medium for CT in the United States is nonionic,
iodinated contrast medium such as iohexol (Omnipaque®) or
iopamidol (Isovue®).
Nonionic, iodinated contrast agents cause less discom-
fort and fewer adverse reactions compared with ionic agents.
Adverse reactions to nonionic iodinated contrast medium
are rare. When nonionic iodinated contrast medium is given
intravenously, adverse reactions include but are not limited
to twitching, sinus tachycardia, supraventricular tachycardia,
and hyperventilation [2]. When this medium is given intra-
thecally, adverse reactions include alterations in heart rate
and respiratory rate, prolonged apnea, muscle fascicula-
tions, muscle rigidity, seizures, and worsening of neurologic
condition [3].
Basic Physics
Similar to radiographs, CT also exhibits variable absorption
of x-­rays depending on the physical density of the tissues
being imaged. The unit used to express CT values is stand-
ardized from the physical densities of tissues compared with
water and is called the Hounsfield unit (HU). HUs are obtained
from a linear transformation of measured attenuation coeffi-
cients. An attenuation coefficient is quantified as the measure
of how easily a density of material can be penetrated by an
x-­ray beam. It quantifies the weakening of the beam when it
attenuation coefficients is based on the subjectively assigned
densities of air and pure water. The radiodensity of distilled
water and air at standard temperature and pressure is 0 HU
and −1000 HU, respectively. On a CT image, the scale can run
from −1000 HU for air to ≥2000 HU for dense osseous struc-
tures (Figure 3.1).
The CT image is divided into an array of pixels in the x-y
imaging plane. The pixel, short for picture element, is the basic
unit of the displayed 2D image. Each pixel represents a voxel,
or volume element, which is a 3D volume of tissue described
by x, y and z dimensions. Each voxel attenuates the x-ray beam
based on the average density of the tissue contained within it.
Based on this attenuation, a gray scale value is assigned to the
representative pixel in the image.
Window level (WL) is the CT number or HU at the midpoint
of the gray-­scale display window. The WL is set at the attenu-
ation of the structure being assessed. For example, if bone is
being assessed, the WL must be high (Table 3.1). Window width
(WW) determines the contrast of an image, with narrower win-
dows resulting in greater contrast [4]. The WW is selected based
on what is being compared. If the attenuation of the structures
being compared is widely variable, the WW is wide. If the atten-
uation of the structures being compared is similar, the WW is
narrow (Figure 3.2).
MPR Reconstructions and 3D
Renderings
Initial CT images are acquired in the transverse or axial plane
using a volumetric data set; in other words, anatomy is
scanned in the x-­y plane in relation to the bore of the CT machine

Structures Metal (+1000 HU and higher)

Mineral (+400 to +1000 HU)

Soft tissue (+30 to +60 HU)

Fluid (0 to +30 HU)

Pure water (0 HU)

Fat (–60 to –100 HU)

Lung (–400 to –600 HU)

–1000 –500 0 +500 +1000

Hounsfield units (HU)

FIGURE 3.1 Hounsfield units (HU) scale. Note the HU range for different anatomic structures.
18 S ECT IO N I Introduction and Physics

(z-­axis of the patient). These sets of initial axial images contain

Window width and window level in
TA BLE 3 .1 information in three dimensions and are used to reconstruct
Hounsfield units (HU).
images to be displayed in different planes (­ Figure 3.3). In veteri-
Structures Window Window nary medicine, sagittal and dorsal plane reconstructed images
of interest width (HU) level (HU) are typically made from the volumetric data set of axial images
Lung 1500 −400 at the CT computer prior to review of the data set. This data
set (raw data) typically consists of axial images with a section
Soft tissue 400 +50
thickness of ≤1 mm, preferably with an overlapping interval as
Bone 1600 +500 the spatial resolution of the sagittal or dorsal plane images is
usually reduced compared to the axial plane [5]. The in-­plane
pixel dimensions approximate the x-­y-­axis resolution, but the
+250 slice thickness limits the z-­axis resolution. Sagittal and dorsal
multiplanar reformatted (MPR) images combine the x-­or y-­axis
dimensions of the CT image with image data along the z-­axis,
and therefore a mismatch in spatial sampling and resolution
+150

occurs during reconstruction with significantly thick slices (3, 5,

or 10 mm slice thickness) [4].
Image contrast

Multiplanar reformations enable images to be displayed

WW 300

in a different orientation from the original one. These mul-

WL +100 tiplanar reformations include maximum-­ intensity projec-
tion (MIP) (Figure 3.4), minimum-­intensity projection (MinIP)
(Figure 3.5), surface rendering (Figure 3.6), volume rendering
(VR) (Figure 3.7), and virtual endoscopy (Figure 3.8).
–150

Maximum-­ intensity projection enables the evaluation

–50
FIGURE 3.2 Example of window width (WW) and window
level (WL). Note that arbitrarily the WL is set at 100 HU and the
WW is 300 HU, there is 150 HU above and 150 HU below the gray
scale (150 + 150 = 300). In this case, greater than +250 HU will be
hyperattenuating (toward the white part of the image contrast scale)
and less than −50 HU will be hypoattenuating (toward the black part
of the image contrast scale).
of each voxel (volume element within the image) along a
line from the viewer’s eye through the volume of data and to
select the maximum voxel value, essentially transforming a
two-­dimensional image into a three-­dimensional image with
increased conspicuity of the most attenuating structures, such
as bone and contrast medium [6]. MIP is helpful when assessing
the pulmonary parenchyma for pulmonary metastatic disease.
The relative attenuation of a pulmonary metastatic nodule
is increased compared to normal aerated pulmonary tissue,
thereby increasing its conspicuity on MIP images.

A B C

FIGURE 3.3 Skull CT of a dog in bone algorithm. A: Transverse plane of the skull at the level of the tympanic bullae. B: Dorsal plane of the
skull at the level of the cribriform plate. Note the dotted line demarcating the region where the transverse plane intersects from Figure 3.3a.
C: Sagittal plane of the skull along the midline. Note the dotted line demarcating the region where the transverse plane intersects from
Figure 3.3a.
 CHAPTER 3 Computed Tomography and Magnetic Resonance Imaging 19

FIGURE 3.4 Maximum-­intensity projection (MIP) of the thorax
in a dog in the dorsal plane at 32 mm slice thickness. Note the
increased conspicuity of the hyperattenuating tissues of the
bone, heart, and pulmonary vasculature after contrast medium
administration.
FIGURE 3.5 Minimum-­intensity projection (MinP) of the thorax
in the same dog as Figure 3.4 in the dorsal plane at 32 mm slice
thickness. Note the increased conspicuity of the hypoattenuating
tissues of the bronchi and pulmonary parenchyma.

FIGURE 3.6 Surface rendering. Hyperattenuating

values are selected for this surface rendering with
visualization of the osseous structures and organs
with contrast medium enhancement.

FIGURE 3.7 Volume rendering (VR) image of the thorax of a dog

using Horos®, an open source media image software (HorosTM, https://
horosproject.org/). Note the visualization of the heart and thoracic
vasculature mimicking a lateral thoracic radiograph.
20 S ECT IO N I Introduction and Physics
FIGURE 3.8 Virtual endoscopy of the carina of a dog using Horos. Note that the top left image is a transverse plane, the top right image is
a dorsal plane, and the bottom left image is a sagittal plane, all denoting the pink caliper and green cross-­hairs to delineate the carina as the
region of interest. The bottom right is the image produced using the three planes to create a 3D intraluminal image of the carina, mimicking a
tracheoscopy/bronchoscopy image.
Minimum-­ intensity projection images are multiplanar
slab images produced by displaying the lowest attenuation
value through an object toward the viewer’s eye, which is the
opposite to MIP [7]. For MinP images, the most hypoattenuating
structures are represented and are useful in detecting subtle
pulmonary changes and otherwise hypoattenuating lesions.
Surface rendering is a process in which apparent surfaces
are determined within the volume of data and an image repre-
senting the derived surfaces is displayed [6, 8].
Volume rendering takes the entire volume of data, sums
the contributions of each voxel along a line from the viewer’s
eye through the data set, and displays the resulting composite
for each pixel of the display [6, 8]. To optimize the anatomic
structures, VR enables modulation of WW and level, opacity, and
percentage classification, and enables the interactive change of
perspective of three-­dimensional rendering in real time [6].
Virtual endoscopy is a computer simulation of an endoscopic
perspective obtained by processing volumetric data [6]. Virtual
endoscopy can be used to assess hollow viscus organs noninva-
sively, such as the respiratory tract and gastrointestinal tract.
Gated Studies
Electrocardiographic gated CT examinations are done on
patients with aortic arch or other cardiovascular pathology.
The benefits of gated cardiac CT include the removal of motion
artifact with high temporal and spatial resolution in patients
with variable heart rates. Two methods of cardiac gated CT
exist: (i) prospective EKG-­triggered sequential CT scanning and
(ii) retrospective EKG-­gated spiral scanning [9].
Prospective EKG-­triggered sequential CT scanning syn-
chronizes the motion of the heart to acquire data in the ­diastolic
phase. In the diastolic phase, cardiac motion is very minimal.
Retrospective EKG-­ gated spiral scanning synchronizes the
movement of the heart by using a simultaneously recorded EKG
tracing. The advantage of retrospective over prospective is that
retrospective provides an isotopic, three-­dimensional data set
of the cardiac volume without intervals and misregistration of
data because it acquires information during all phases of the
cardiac cycle [9].
Safety
Safety guidelines for personnel operating the CT are similar
to those used in routine radiography and based on the basics
of radiation safety and protection as outlined in Chapter 2.
Compared to MRI, CT acquisition times are much shorter, so
the patient can be either heavily sedated or undergo general
­anesthesia for diagnostic CT imaging.
Limitations
Some limitations of CT include the high cost of purchas-
ing and maintaining a CT machine. The inner workings of a
CT machine are complex, thus requiring a specialist who is
 CHAPTER 3 Computed Tomography and Magnetic Resonance Imaging 21

FIGURE 3.9 PET-­CT in a patient diagnosed with osteosarcoma. (A) Oblique lateral MIP image with the cranial aspect of the patient at the top
and the dorsal aspect on the right side of the image. It shows a primary osteosarcoma lesion in the left tibia (long black arrow), a metastatic
lesion to the left radius (short black arrow), and a metastatic lesion to the articular process of L1 vertebra (star). In the soft tissues adjacent to the
left tibia, there is a hot spot, indicating hypermetabolism of the left popliteal lymph node. (B) Transverse CT image in a bone window, showing
osteolysis and periosteal proliferation of the primary tibial neoplasm. The image to the right is a fused PET-­CT image at the same location
showing the hypermetabolic activity of the neoplasm. (C) Transverse CT image in soft tissue window showing soft tissue swelling with contrast
enhancement surrounding the mass. The image on the right is a fused PET-­CT image at the same location showing hypermetabolic activity of
the bone and soft tissue abnormalities. (D) Transverse CT image in a bone window showing osteolysis and expansion of the articular process of
L1 and sclerosis of the pedicle. The image on the right is a fused PET-­CT image at the same location showing the hypermetabolic activity in the
articular process. Source: Courtesy of Elissa K. Randall, DVM, MS, DACVR.

designated to operate the machine. Another disadvantage
of the CT images in relation to other modalities is that the
spatial resolution is poorer than film and dental radiographs,
which limits assessment of details. Additionally, CT is best
used to assess osseous structures than soft tissue structures
when compared to MRI. However, for angiographic studies, CT
provides the best spatial resolution and anatomic detail when
compared with MRI.
PET-­CT
Positron emission tomography-­CT is a combined modality using
the technology of CT and nuclear scintigraphy (Figure 3.9). The
combined method uses small amounts of radiopharmaceu-
ticals to evaluate organ and tissue function by overlaying the
nuclear scintigraphy image over a more anatomically detailed
CT image. This allows veterinarians to evaluate specific organ
anatomy and tissue function at the same time.
Magnetic Resonance Imaging
Overview
The use of MRI in veterinary medicine has grown in response
to the increased availability and speed of MRI systems [10–13].
Based on the detected response of nuclei within atoms to a
strong magnetic field created by the MRI unit, images of normal
anatomic structures and pathology can be produced with good
contrast and anatomic resolution. MRI can be used to image a
wide range of body systems and is most used to evaluate struc-
tures of the central and peripheral nervous system. In some
22 S ECT IO N I Introduction and Physics
cases, MRI may provide a useful assessment of the cardiovas-
cular and musculotendinous structures.
Specific paramagnetic contrast agents may be adminis-
tered to increase the conspicuity of cardiovascular structures
and soft tissue pathology. Gadolinium contrast medium is
used in veterinary medicine and consists of gadolinium ions
bound to variable brand-­dependent chelating agents, which
counteract the toxic effects of gadolinium. Gadolinium con-
trast medium is injected intravenously and excreted through
the renal system. In patients with renal insufficiency, gado-
linium contrast medium should be used with caution. Some MR
sequences, such as phase contrast MR-­angiography or time-­of-­
flight, may be used to increase the signal intensity of the vascu-
lature without using contrast agents.
In order to decrease motion artifacts associated with respi-
ration or cardiac contractions, the acquisition of MRI sequences
can be synchronized to the respiratory or cardiac cycles using
different gating techniques. The images may then be reviewed
and correlated to the phase of the respiratory or cardiac cycle
during which the images were prospectively acquired.
Magnetic resonance imaging is noninvasive and does not
use ionizing radiation, so it has favorable safety benefits for
patients and veterinary personnel. Due to the increased time
required to acquire MRI images and the inherent sensitivity of
MRI to motion, general anesthesia is necessary to optimize the
quality of MRI images. MRI systems used in veterinary medicine
commonly range between 0.2 and 3 tesla. MRI systems of lower
field strengths have made MRI more affordable and easier to
integrate in veterinary practices. However, trade-­offs of low-­
field MRI systems include loss of image resolution and longer
scan and anesthesia times.
An understanding of the physics of MRI is important for
interpretation of MRI images. The brightness or signal intensity
of different tissues in the body is dependent on their response
to different changes in a magnetic field generated by the MRI
unit. A detailed explanation of these principles is beyond the
scope of this text but we aim to provide an understanding of
the fundamental physical principles and characteristics of
commonly used MR pulse sequences.
Basic Principles
The different parts of the MRI system are illustrated and
described in Figure 3.10. When an electric current is transmitted
through a wire loop or coil configuration, a magnetic field is cre-
ated perpendicular to its axis in accordance with Faraday’s law.
The strength of the magnetic field is directly proportional to the
applied current and is maintained by reducing the resistance of
wires through cooling to near absolute zero temperatures. The
act of conducting an electric current through this mechanism
is known as superconductivity and is effectively achieved with
liquid helium (approximately −270 °C boiling point).
Specific atoms within the body, such as the proton, have a
specific magnetic field generated by the rotation of proton nuclei
about their axis. The magnetic moment of a nucleus is a vector
Quench pipe
Active shielding
Main Magnet
Shim coil
Gradient coil
Body coil
Receiver
coil
FIGURE 3.10 Schematic drawing of the different components of
the MRI system (main magnet). See text for details.
measurement of the direction and strength of this magnetic
field. The most abundant and important nucleus used in MRI
is hydrogen (H+). Under normal circumstances, the magnetic
moments of these hydrogen atoms are randomly orientated
within tissues. When the magnetic field of a hydrogen atom is
exposed to the magnetic field created by the MR system, the
magnetic moments align with the stronger externally applied
magnetic field. The magnetic moments of hydrogen atoms
in the body will align in a similar longitudinal plane (z-­axis) as
the magnetic field; some will align in the same direction as the
magnetic moment of the external magnetic field, while others
will oppose the direction of the external magnetic field. The net
magnetization vector represents the difference in direction of
these magnetic moments.
When a radiofrequency (RF) pulse with a particular strength
and duration is applied, the hydrogen nuclei will be excited, and
the net magnetic vector will move away at a particular angle
from the longitudinal plane of the external magnetic field. Con-
currently, the net magnetic vector will continue to precess in
a plane transverse to the external magnetic field. As the net
magnetic vector precesses in a transverse plane, it will gen-
erate a RF signal into the receiver coil. The strength of the MR
signal is proportional to the degree of magnetization present in
the transverse plane. When the RF pulse ceases, the net magne-
tization vector realigns into a longitudinal plane, parallel to the
external magnetic field, through a process called T1 recovery.
Simultaneously, the net magnetization vector spirals inward as
the angle of the net magnetization vector decreases, resulting
in a loss of transverse magnetization, or T2 decay. Variations in
T1 relaxation and T2 decay times exist in different tissues and
in order to demonstrate contrast between normal anatomy
and pathology, these differences are exploited.
Image contrast is dependent on the repetition time (TR) and
echo time (TE) of a RF pulse sequence. The TR is measured in
 CHAPTER 3 Computed Tomography and Magnetic Resonance Imaging 23

milliseconds (ms) and represents the time interval between two water (Figure 3.11). On the other hand, images acquired with a
consecutive RF pulses. In comparison, the TE is the time interval long TR and long TE are T2 weighted with increased signal inten-
between the RF pulse and the peak signal intensity of the RF sity in fat (Figure 3.12). When a long TR and short TE is selected,
energy released during relaxation, also measured in milliseconds fat cannot be contrasted from water; therefore, the signal inten-
(ms). Different contrast is generated between fat and water due sity generated is instead dependent on the proton density, or
to their different T1 recovery and T2 decay times. The T1 recovery number of hydrogen nuclei, in tissues (Figure 3.13).
and T2 decay time are prolonged in water when compared to fat T2* decay occurs when traverse magnetization is
(Table 3.2). Therefore, images acquired with a short TR and short dephased due to magnetic field inhomogeneities. Dephasing
TE are T1 weighted with increased signal in tissues containing with T2* decay occurs at a faster rate than with T2 decay. While
small, variations in the magnetic field contribute to T2* decay
and may be exacerbated by the presence of ferromagnetic
Repetition time (TR) and echo time (TE) objects, such as implants.
TA B LE 3 .2
to create T1, T2, and proton density contrast. The two principal types of MR pulse sequence acquired
are spin-­echo (SE) and gradient-­echo (GRE). Small variations in
TR TE
these two MR pulses produce a wide array of MR sequences,
T1 weighting Short Short some with characteristics beneficial for the recognition of
T2 weighting Long Long normal anatomic and pathologic structures. Within a single
TR, both proton density and T2 weighted can be generated to
Proton density Long Short
reduce the acquisition time.

Fat
Hemorrhage
Paramagnetic
contrast agents

Gray matter
darker than
white matter

Bone
Fluid
Air

A B

FIGURE 3.11 T1-­weighted image (A) and schematic drawing (B) of a transverse image from a normal canine brain. In the schematic drawing,
notice the intensities of the different structures relative to each other.

Fluid

White matter
darker than
gray matter

Bone
Fat
Air

A B

FIGURE 3.12 T2-­weighted image (A) and schematic drawing (B) of a transverse image from a normal canine brain. In the schematic drawing,
notice the intensities of the different structures relative to each other.
24 S ECT IO N I Introduction and Physics
FIGURE 3.13 Proton density (PD)-­weighted transverse image of a
canine brain.
Spin-­Echo Sequences In SE sequences, transverse
magnetization is created by an ­initial 90° RF pulse, which
is succeeded by dephasing after cessation of the RF pulse.
Dephasing occurs as T2* decay. To rephase the magnetic
moments, a 180° rephasing RF pulse is applied so that mag-
netic moments with a lower precessional frequency lead
faster magnetic moments, which eventually “catches up.”
The recovery of in-­phase magnetization in the transverse
plane results in signal detection at peak intensity within the
receiver coil.
In fast or turbo spin-­echo sequences, multiple 180° RF
pulses are applied in succession within a TR to repeatedly
rephase the magnetic moments and generate maximum signal
within the receiver coil. The number of successive 180° RF pulses
is referred to as the echo train length and greatly reduces the
acquisition time.
Inversion recovery sequences are acquired by applying an
initial 180° RF pulse instead of a 90° RF pulse to align the magne-
tization vector in an opposite direction within the longitudinal
plane. The magnetic moments are then allowed to relax until
a 90° RF pulse is applied to create heavily T1-­weighted images
with nulling either fat or water. Signal is maximized in the
transverse plane by applying an additional 180° rephasing
RF pulse. The time interval between the 180° RF pulse and the
90° RF pulse is known as the inversion time (TI). In the short tau
inversion recovery (STIR) sequence, fat is nulled by applying a
90° RF pulse at a TI when fat has only transverse magnetization.
The magnetic moment of hydrogen atoms in fat recovers full
longitudinal magnetization, resulting in no signal detection.
Similarly, fluid attenuated inversion recovery sequences (FLAIR)
are acquired after the application of a 90° RF pulse once water
has recovered full transverse magnetization (Figure 3.14). The
TE is then adjusted to detect transverse magnetization while
FIGURE 3.14 FLAIR image from a normal canine brain where the
fluid is attenuated using an inversion recovery sequence.
water has only longitudinal ­magnetization, thereby ­having
no signal.
Gradient-­Echo Sequences In GRE sequences, trans-
verse magnetization is generated by a RF pulse often with a flip
angle of less than 90 degrees, thereby having both longitudi-
nal and transverse magnetization. Once the RF pulse ceases,
T2* decay occurs rapidly and results in a signal called the free
induction decay (FID). By applying another magnetic field with
a gradient in the transverse or phase direction, the magnetic
moments with a slower precessional frequency speed up and
the faster magnetic moments are slowed, so that the magnetic
moments rephase which results in maximum signal intensity in
the transverse plane. By reversing the gradient, the magnetic
moments can be dephased in a similar fashion.
Because GRE sequences use gradients to rephase and
dephase transverse magnetization, T2* decay or field inhomo-
geneities have a considerable impact on the acquired image, as
evidenced by the presence of magnetic susceptibility artifact.
The paramagnetic properties of hemosiderin in blood cause
magnetic susceptibility artifacts, which are useful when trying
to differentiate hemorrhage from other types of fluid.
One of the main advantages of GRE sequences is the
decreased scan time, mostly attributed to faster rephasing of
transverse magnetization with the use of gradients, instead of a
180° RF pulse. T1 and T2* weighting can be acquired with particular
flip angles and timing parameters described in Table 3.3. Specific
T1 and T2* weighting parameters are described in Table 3.4.
Based on the motion of water in tissues, the rate of diffusion
of water can be differentiated with diffusion-­weighted imaging
(Figure 3.15A). In tissues with restricted water motion, such as
those subject to ischemic damage, a high signal intensity will
appear on the image. When water is unrestricted, the signal
intensity will be decreased. Apparent diffusion coefficient (ADC)
 CHAPTER 3 Computed Tomography and Magnetic Resonance Imaging 25

TA B LE 3 .3
Signal intensity of tissues in T1-­weighted Image Formation
and T2-­weighted images.
Using gradients, the signal intensities are located in space along
Signal intensity T1-­weighted T2-­weighted two axes in the phase and frequency encoding directions. In the
High Fat* Fluid three-­dimensional space the images are acquired, and the third
Hemorrhage axis serves as the slice selection gradient to determine the thick-
Paramagnetic contrast ness and track the position of a slice along its axis. The signals
agents, such as detected are digitalized by encoding the frequencies detected in
gadolinium a two-­dimensional graph, known as K space. The frequencies in
Neurotransmitters in
the pituitary K space are arranged so that centrally located frequencies have
a high signal intensity and low contrast resolution, whereas
Medium Gray matter darker White matter peripherally located frequencies have a low signal intensity
than white matter darker than
gray matter
and high contrast resolution. The frequencies are then extrapo-
lated from K space to form an image via a process call Fourier
Low Bone Bone transformation.
Fluid Fat
Air Air

* When using Fast Spin Echo or Turbo Spin Echo techniques, fat has high signal Safety
intensity on T2 weighted images due to J-coupling.
While MRI does not generate ionizing energy, the RF pulse used
to shift the vector of nuclei transfers energy to the patient and
Flip angle, repetition time (TR), and can be measured as the specific absorption rate (SAR). The SAR
TA B LE 3 .4 echo time (TE) to create T1 and T2*
represents the rate at which this energy (watts) is distributed
­gradient-­echo contrast.
into a certain tissue mass (kilograms). The SAR is exponentially
Flip angle TR TE related to the MRI field strength, so that it is equal to the field
T1 weighting Large Short Short strength squared (Bo2) when all other variables are maintained
constant. For example, if the field strength is doubled, the SAR
T2* weighting Small Long Long
is increased by a factor of four. When exposed to elevated SAR
levels, thermal injuries have been reported in human patients.
mapping is often used in conjunction to remove T2-­weighted The prevalence of these effects remains uncertain in veteri-
contrast on ADC maps and create an image with signal inten- nary patients.
sities opposite to those seen on diffusion-­ weighted images While the magnetic field created by the MRI system has
(Figure 3.15B). When interpreted in conjunction with diffusion-­ tremendous diagnostic utility, the magnetic field acts as a
weighted images, ADC maps can help determine the chronicity large magnet capable of attracting ferromagnetic objects. The
of an ischemic event. strength of the magnetic field created by the MRI unit will attract

A B

FIGURE 3.15 Diffusion-­weighted image (A) and calculated ADC map (B) of the midbrain from a normal dog.
26 S ECT IO N I Introduction and Physics
ferromagnetic objects at extremely high speed, exposing patients
and personnel to the risk of projectile injuries. Therefore, it is
important that all ferromagnetic objects are properly labeled as
MRI unsafe and kept away from the MRI room. MRI may be contra-
indicated with particular surgical implants, which may experience
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 CHAPTER 4

Ultrasonography
Elizabeth Huyhn1, Elodie E. Huguet2,
and Clifford R. Berry3
1
VCA West Coast Specialty and Emergency Animal ­Hospital,
­Fountain Valley, CA, USA
2
Department of Small Animal Clinical Sciences, C ­ ollege of
­Veterinary Medicine, University of Florida, ­Gainesville,
FL, USA
3
Department of Molecular Biomedical Sciences, College of
­Veterinary Medicine,
North ­Carolina State University, Raleigh, NC, USA

Overview: Uses and Ultrasound can be used to assess all abdominal organs and
the heart. The use of echocardiography to assess the cardiovas-

Advantages cular structures will be discussed in the cardiovascular chapter.

Ultrasound is a valuable and noninvasive modality used for
the identification and diagnosis of small animal diseases. With
advanced training and a good understanding of cross-­sectional
anatomy, ultrasound can also be used to thoroughly evaluate
anatomic structures and abnormalities based on their ­acoustic
impedance. In an emergency room setting, ultrasound is
­routinely used for the Thoracic or Abdominal Focused Assess-
ment with Sonography in Triage (TFAST or AFAST), for the
identification and tracking of abnormal fluid collections. The
portability of today’s ultrasound equipment allows for c­ age-­side
evaluation of veterinary patients. However, this is not the ideal
environment for complete abdominal u ­ ltrasound ­evaluations
to be done. Using a darkened, quiet room where dogs and cats
can be laid on their backs or in lateral ­recumbency for the scan
is important.
Ultrasound can provide information related to size, shape,
position, margin or contour, echogenicity, and echotexture of
the organ being evaluated. Other uses of ultrasound include
Doppler ultrasound, elastography, and use of ultrasound-­
specific contrast agents.
Basic Physics and Principles
of Ultrasound in Diagnostic
Imaging
Ultrasound consists of high-­frequency sound waves (MHz or
1 000 000 Hz), with the normal human hearing range being
between 2000 and 20 000 Hz. Ultrasound waves are thus not

Atlas of Small Animal Diagnostic Imaging, First Edition. Edited by Clifford R. Berry, Nathan C. Nelson, and Matthew D. Winter.
© 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/berry/atlas

27
28 S ECT IO N I Introduction and Physics
audible to the human ear. The ultrasound waves are generated
by nonionizing, mechanical compression and relaxation of a
special piezoelectric crystal inside the transducer that creates
a mechanical wave which then travels through the tissues. The
sound wave can be generated and recorded at a specific frame
rate, depending on the features that are engaged (abdomen
typically has a frame rate of 40–80 frames per second com-
pared with echocardiography which will have frame rates of
greater than 100 frames per second), allowing the evaluation of
static and dynamic structures.
The ultrasound wave will travel through and interact
with tissues in a number of different ways. Echoes (reflected
ultrasound waves) are created based on the specific intrinsic
property of tissue through which the sound wave is passing.
This property is called acoustic impedance (Z = physical
density of the tissue × the speed of sound in the tissue; defined
in units of Rayl [gm/m2 s]). These mechanical sound waves
return to the ultrasound probe, where they are detected and
converted from mechanical into electrical energy and then
changed into an anatomic image. This pulse–echo technique
results in the transducer “listening” for returning pulses 99%
of the time and generating outgoing (sending) pulses 1%
of the time.
The ultrasound beam is created by a series of piezoelec-
tric crystals arranged in a curved, linear, or annular format. The
first two arrangements are found in transducers used for the
abdomen and small body parts. The last is used specifically
for echocardiography where crystals do not act in unison but
can act independently. This results in the ability to do spectral
continuous wave Doppler ultrasound where independent
­ mitted further into the tissues.
­crystals send US waves 100% of the time and different crystals
receive and process incoming echoes 100% of the time (see
Doppler section of this chapter for more details).
Interaction of Sound Waves
in the Tissues
The ultrasound transducer creates pressure variations in the
form of ultrasound waves which travel through the tissues,
with resultant interactions being based on variations in physi-
cal properties within the tissue and between tissue boundaries.
These sound waves have a characteristic speed, frequency,
and wavelength with a relationship represented by the follow-
ing equation:
Wavelength λ (m) = speed of sound in tissues [c (m/s)]/­
frequency [f (MHz)]. The speed of sound propagating in soft
tissues is an average speed of sound and ultrasound machines
will use 1540 m/s as the average speed of sound in tissues. The
propagation speeds of sound vary for different tissue types as
listed in Table 4.1. The frequency corresponds to the number
of cycles, or complete waveform of the US wave, per second.
Ultrasound imaging transducers used in veterinary medicine
have a frequency ranging between 1 and 20 MHz (1 megahertz
[MHz] defined as 1 × 106 cycles per second or Hz).
 The propagation speeds of sound waves
TA B L E 4. 1
in d
­ ifferent tissues.
Tissue Propagation speed of sound (m/s)
Gas 331
Fat 1450
Liver 1549
Kidney 1561
Brain 1541
Blood 1570
Bone 4080
Multiple acoustic variables affect the way sound waves
travel in tissues, including pressure, physical density of the
tissue, and relative speed within the tissue as well as elastic
motion of the tissues themselves. As previously stated, reflec-
tion of ultrasound waves within and between tissues is based
on differences in acoustic impedance. The acoustic imped-
ance increases if the physical density of the tissue and/or
the ­propagation speed of the US sound wave increases. This
increase in different acoustic impedances will then result in
more ultrasound waves being reflected toward the transducer.
When the ultrasound waves travel in tissues, there are
five potential interactions: reflection, refraction, scattered,
absorption or no interaction and therefore the wave is trans-
• Reflection: occurs when there are differences in acoustic
impedance and the ultrasound wave is reflected back
toward the transducer (Figure 4.1). If there are no differences
in acoustic impedance, then the ultrasound waves are prop-
agated further into the tissues (called transmission). Reflec-
tors perpendicular to the incident beam of the ultrasound
waves are the best whereas incident ultrasound waves inter-
acting with acoustic boundaries that are parallel to ultra-
sound beam are poor reflectors. The larger the differences in
acoustic impedance, the greater the number of ultrasound
waves reflected. For example, there are large differences in
acoustic impedance between soft tissues (1.65 × 106 Rayls)
and bone or mineral (7.8 × 106 Rayls) that will result in reflec-
tion of all sound waves without transmission of waves to a
depth below the soft tissue–mineral interface.
• Refraction: refraction differs from reflection in that sound
waves being transmitted into bordering tissues with a
different acoustic impedance will undergo a change in
direction (Figure 4.2). These sound waves may eventu-
ally return to the transducer and provide misinformation
regarding the position of a tissue in relation to another.
This results in refraction artifacts on the image. The degree
of displacement or refraction of the sound wave is directly
proportional to the propagation speed of the second tissue
through which the sound wave travels.

Incident echo
Reflection
TISSUE
Transmission
FIGURE 4.1 Schematic diagram of the interaction of ultrasound
waves at different acoustic interfaces (tissue) whereby some of the
incident US waves are reflected toward the transducer and will be
used to create an image at depth.
Incident echo
TISSUE
Transmission Refraction
FIGURE 4.2 Schematic diagram of the interaction of ultrasound
waves at different acoustic interfaces (tissue) whereby some of the
incident US waves are refracted and continue into the tissue. These
US waves may never contribute to the image.
• Scattering: when the sound wave encounters irregular
­surfaces, heterogeneous tissues, or objects equal to or
smaller than the size of its wavelength, it can be redirected
in many directions (Figure 4.3). Some of these sound
waves may return to the transducer and result in loss of
resolution. In comparison, specular reflections occur
when sound waves encounter a smooth and flat interface
and are returned to the transducer without a change in
direction and therefore recorded accurately as to depth.
CHAPTER 4 Ultrasonography 29
Incident echo
Scatter
TISSUE
FIGURE 4.3 Schematic diagram of the interaction of ultrasound
waves at different acoustic interfaces (tissue) whereby some of
the incident US waves are scattered in different directions other
than being reflected toward the transducer and will not aid in
image creation.
• Absorption: sound waves attenuated in tissues may be
converted into heat, and therefore may not contribute to
the final image. Most of the sound waves attenuated in
tissues are absorbed. The heat generated consequently
contributes to some of the risks associated with ultra­
sonography and will be discussed later in this chapter.
Transducer Elements
and Characteristics
Piezoelectric crystals within the ultrasound transducer have
the unique characteristic of converting an applied voltage into
a pressure, or mechanical energy, and vice versa. The mechani-
cal energy created is in the form of high-­frequency sound waves
which are then returned to the probe and converted into an
electrical signal containing information used to create an image.
In addition to the piezoelectric crystals, the transducer
consists of the following elements (Figure 4.4).
• Damping material: located behind the piezoelectric element
to absorb scattered ultrasound energy and decrease the
amplitude and spatial pulse length of the ultrasound pulses
to increase the spatial resolution of the ultrasound beam.
The damping block removes weak echoes, and therefore
reduces noise. By doing so, the sensitivity of the ultrasound
probe to weak diagnostic echoes is also reduced.
• Matching material: reduces the impedance of the trans-
ducer element to increase the transmission of ultrasound
pulses from the probe into the patient. Without this layer,
most of the ultrasound pulses would be reflected at the
surface of the ultrasound probe and lost as heat.
30 S ECT IO N I Introduction and Physics
Damping material
Piezoelectric element
Matching material
FIGURE 4.4 Schematic diagram of the ultrasound transducer with
different layers of matching material, the actual piezoelectric crystals,
and damping material.
1st echo
2nd echo
No signal Harmonic signal
FIGURE 4.5 Harmonic signal creation within the tissues whereby
US waves double their frequency. The machine then “listens” for the
higher frequency harmonic signal. Harmonic imaging provides better
spatial resolution but at the expense of depth.
Patient preparation is also important to optimize the
transmission of sound waves into tissues. The patient should
be shaved to maximize contact of the transducer with the skin.
Additionally, coupling gel should be applied to remove any air
between the transducer and patient, which may impede the
transmission of sound waves into the tissues.
Ultrasound transducers with a wide bandwidth are used
to generate a range of variable and adjustable frequencies
to adjust the image resolution and depth. Additionally, ultra-
sound transducers with a wide bandwidth permit harmonic
imaging, which uses higher frequency pulses for the creation
of nonsinusoidal ultrasound echoes to enhance image quality
(Figure 4.5). Ultrasound transducers with a higher frequency
generate images with a higher resolution but have a lower
spatial pulse length and do not travel as far within the tissues,
decreasing the imaging depth. Conversely, lower frequency
transducers have a lower resolution but improved ability to
penetrate tissues.
Linear and sector array transducers are commonly used in
veterinary medicine and have advantages and disadvantages
described in Table 4.2 (Figure 4.6).
Image Formation
As previously discussed, sound waves returned to the trans-
ducer are converted back into an electrical signal and contain
information used to create an image. The information con-
tained within the electrical signal includes the location of ori-
gin and intensity of the returning sound wave. The intensity of
sound waves in a particular region is assigned a correspond-
ing gray-­scale value, with brighter (or more hyperechoic) pix-
els representing regions of increased intensity and darker (or
more hypoechoic) pixels representing regions of decreased
intensity.
Artifacts
Artifacts are incorrect representations of tissues on the image.
The misinformation associated with artifacts originates from
the attenuation or propagation characteristics of certain
sound waves based on their physical characteristics. There-
fore, structures on the ultrasound image may be false, absent,
misplaced or have an altered structural appearance or echo-
genicity. Some of the commonly encountered artifacts include
the following.
Shadowing is seen when tissues that are highly attenu-
ating or strong reflectors reduce or in some cases fully hinder
the passage of sound waves into deeper tissues. Subse-
quently, those tissues are falsely more hypoechoic (Figure 4.7).
Inversely, acoustic enhancement is observed when sound
waves pass through weakly attenuating structures, resulting
in stronger sound waves propagating through deeper tissues.
Therefore, those tissues are more hyperechoic in appearance
(Figure 4.8).
Reverberation artifacts commonly occur when sound
waves are reflected by gas, mineral, and metal. These materials
are strong reflectors, resulting in the return of high-­intensity
sound waves to the transducer. At the level of the transducer,
there is partial return of those sound waves into the tissues,
which once again reflect from the same strong reflector. The
sound waves ricochet between the strong reflector and trans-
ducer to create parallel lines in the far field of the strong
reflector on the image (Figure 4.9).
The mirror image artifact occurs when the sound waves
encounter a strong reflector, such as the diaphragm, and are then
reflected toward a structure, such as the liver. The ultrasound
beam is then redirected toward the strong reflector, where it is
again reflected and returned to the transducer. The delayed return
 CHAPTER 4 Ultrasonography 31

TA B LE 4 .2 Different types and characteristics of ultrasound transducers.

Types Characteristics Beam path diagrams

Linear probes Linear array transducer Ultrasound pulses are generated at
­ ifferent linearly arranged locations within
d
the ­ultrasound probe to create parallel
arrays, which produce a rectangular image
(Figure 4.6b)

Sector probes Phased array transducer Ultrasound pulses are generated from a single
point within the ultrasound probe and diverge
to fan out into the tissues and create a sector
image (Figure 4.6d)

Convex array transducer Ultrasound pulses are generated at ­different

locations along the convex surface of the
ultrasound probe to generate diverging arrays
and create a sector image (Figure 4.6f)

of the sound wave to the transducer results in duplication of the
structure on the other side of the strong reflector (Figure 4.10).
As previously discussed, refraction artifacts are seen when
sound waves being transmitted into bordering tissues with a
different acoustic impedance undergo a change in direction.
When returned to the transducer, these sound waves are later-
ally mispositioned on the image (Figure 4.11). The degree of dis-
placement or angle of refraction of the sound wave is directly
proportional to the propagation speed of the second tissue
through which the sound wave travels, so that tissues with a
lower acoustic impedance or density are more laterally dis-
placed on the image.
Weak sound waves, known as side or secondary lobes,
commonly propagate from the transducer in directions angled
away from the primary beam. Also originating from the trans-
ducer, grating lobes represent similar but stronger divergent
sound waves. Most often, these divergent sound waves go
undetected, unless they are reflected from a strong reflector,
particularly when imaging weakly attenuating regions, such as
the urinary bladder (Figure 4.12). Evaluation of body regions
in two planes helps to differentiate these artifacts from
pathology. Additionally, harmonic imaging improves lateral
resolution and reduces image artifacts, like reverberations,
and side or grating lobes.
Another random document with
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 Before proceeding to alter her play, Miss Mitford took the
precaution to secure and read Byron’s Two Foscari, and was
delighted to find that he had dealt with the subject at a point
subsequent to her own, so that the plays were not likely to clash.
Furthermore, she found little in Byron’s work to commend, and
thought it could scarcely meet with any success from representation.
“Altogether, it seems to me that Lord Byron must be by this time
pretty well convinced that the drama is not his forte. He has no spirit
of dialogue—no beauty in his groupings—none of that fine mixture of
the probable with the unexpected which constitutes stage effect in
the best sense of the word. And a long series of laboured speeches
and set antitheses will very ill compensate for the want of that
excellence which we find in Sophocles and in Shakespeare, and
which some will call Nature, and I shall call Art.” And as proof that
her judgment was not warped by petty jealousy—jealousy of Byron,
on her part, would indeed have been stupid—it is interesting to recall
the criticism which Macready made in his “Diaries” some years after,
when seriously reading Byron’s Foscari with a view to its adoption.
Under date April 24, 1834, he wrote:—“Looked into the Foscari of
Byron. I am of opinion that it is not dramatic—the slow, almost
imperceptible progress of the action ... will prevent, I think, its
success in representation.” In June, 1835, he wrote:—“Read over
Lord Byron’s Foscari, which does not seem to me to contain the
power, or rather the variety and intensity of passion which many of
his other plays do.”
Having satisfied herself that she had nothing to fear from Byron’s
work she once more applied herself to her own in the endeavour to
supply it with those elements in which she and her kindly critics knew
it to be deficient—but it was a labour. “I am so thoroughly out of heart
about the Foscari that I cannot bear even to think or speak on the
subject. Nevertheless, the drama is my talent—my only talent—and I
mean to go on and improve. I will improve—that is my fixed
determination. To be of some little use to those who are dearest to
me was the only motive of my attempt, and I shall persevere.”
 CHAPTER XVI

“GOD GRANT ME TO DESERVE SUCCESS”

Still working at high pressure with her magazine articles, Miss

Mitford was able to give the promised attention to Foscari, and in
June, 1822, dispatched it with its new fifth act—it was the seventh
revision of this particular act—to London and, this time, to Charles
Kemble for she now held the opinion that the play was not exactly
suited to Macready’s style. In the meantime, it was her intention to
write something more ambitious “a higher tragedy, with some fine
and splendid character, the real hero for Macready, and some
gallant-spirited youth, who may seem the hero, for Mr. Kemble.”
Having sent off the manuscript she tried hard to forget it and to
possess her soul in patience, but now and again in her letters—very
few, now that she was so busy—there are indications of her anxiety.
“If my Foscari were to succeed I should be tempted to have a pony-
chaise myself”—this because a friend had called and given her the
pleasure of a short ride—“I do so love a drive in a pony-chaise! You
know, everything that I want or wish I always say ‘if Foscari
succeeds.’ I said so the other day about a new straw bonnet, and
then about a white geranium, and then about a pink sash, and then
about a straw work-basket, and then about a pocket-book, all in the
course of one street.”
In August and September she paid flying visits to town to see
Kemble about the play and found him so charming that she
confessed—hoping no one would tell Mrs. Kemble!—she was the
least in the world in love with him and that he ranked second to
Napoleon in her imagination. He made her a promise that, subject to
the approval of Macready—then on an Italian tour—he would
produce the play the first of the season. “Nothing I believe, is certain
in a theatre till the curtain is fairly drawn up and let down again; but,
as far as I can see, I have, from the warm zeal and admirable
character of the new manager and his very clever and kind-hearted
lady, every reason to expect a successful début. Wish for me and
Foscari. You have all my kindest and gratefulest thoughts, though a
tremendous pressure of occupation will not allow me to express
them so often as I used to do.”
Unfortunately Kemble was unable to fulfil his promise, Macready
having arranged first for the production of another play, “but,” said
she, “Charles Kemble, my dear Charles Kemble says—almost
swears—it shall be acted this season, and with new dresses and
new scenery. There has been a terrible commotion in consequence
of C. Kemble’s reluctance to delay. If it were not for my absolute faith
in him I should despair.”
Kemble kept his promise, as well as he was able, by producing the
play during the year 1826, but only at the expense of a quarrel with
Macready—a quarrel fanned by Mrs. Kemble who, although Miss
Mitford had written of her as “the clever, kind-hearted lady” was
subsequently described in a letter to Talfourd, as making statements
“so artificial, so made up, so untrue, so circular—if she had said a
great deal less without the fine words and the ‘Dear Madams’ I
should have believed her much more.”
At this juncture, and before there was any idea of the possibility of
friction between himself and Kemble, Macready had suggested to
Miss Mitford that she should write him a historical play and went so
far as to outline the plot. To have such a suggestion from the great
tragedian was in itself sufficient to send her into an ecstasy—here
was proof positive of his belief in her—and so, submitting the project
for Talfourd’s approval, and being urged by him to proceed, she set
to work at fever heat, towards the close of 1822, on the play of
Julian. It was strenuous work and all the while the author was torn
with the fear that she would not be able to produce anything worthy
of Macready. Dr. Valpy was being continually referred to for his
judgment on the various characters—whether they were too weak or
too strong—too prudish or too improper—and Talfourd was besought
to “speak the truth, fearlessly, and say whether I shall give it up.” At
last it was finished and was sent to Macready and Talfourd for their
judgment and criticism.
“My execution falls very short of your design,” she wrote; “but
indeed it is not for want of pains—I think one reason why it is so ill
done, is the strong anxiety I had to do well—to justify your and Mr.
Macready’s kind encouragement—the stimulus was too great.” Both
Macready and Talfourd made corrections and suggestions, which the
author duly acted upon and thereby won unstinted praise from her
two friendly critics. “I hope you and he are as right in your praise, as
in your censure—but I confess that I am not yet recovered from my
astonishment at the extent of your approbation—I am afraid you
overrate it—sadly afraid. And yet it is very delightful to be so
overrated. It would be a shame if I did not improve with the
unspeakable advantage of your advice and your kindness and all the
pains you have taken with me.”
On Julian, which she characterized as worth a thousand of
Foscari, she was ready to stake all her dramatic hopes and when, at
length, in February, 1823, Macready read the play in the green-room
and promised its production in ten days or a fortnight, her delight
was unbounded. It was produced in the second week of March, with
Macready as the principal character, and met with instant success.
The author went to town on a visit to her friend, Mrs. Hofland, in
Newman Street, that she might the better enjoy the exquisite pain
and pleasure of seeing her play presented for the first time. Although
she had sent and received many messages to and from Macready,
through their mutual friend Talfourd, she had not met him until this
occasion and it is no figure of speech to say that they were each
considerably struck with the other. Miss Mitford’s verdict on the
interview, conveyed in a letter to Sir William Elford, was “He is just
such another soul of fire as Haydon—highly educated, and a man of
great literary acquirements—consorting entirely with poets and
young men of talent. Indeed it is to his knowledge of my friend Mr.
Talfourd that I owe the first introduction of my plays to his notice.”
 The result to Miss Mitford in cash on the production of Julian was
£200, not a vast sum in the light of present-day successes, but still
very fair considering that it only ran for eight days, having to be
withdrawn in favour of another play. In any case the money was very
acceptable to the inmates of the little cottage at Three Mile Cross.
The endeavour to clear up outstanding debts weighed heavily on
Miss Mitford and, short of a reserve for the barest necessities, the
whole of her income was being devoted to that end. A few things of
value had been saved from the wreck of the Bertram House
establishment, notably some choice engravings, and those were
sent to Mrs. Hofland in London who had promised to warehouse
them until such time as the owners, having acquired a larger house,
might send for them. Any hope of this contingency, which Miss
Mitford may have entertained, had been dispersed by the year 1823,
and so we find her writing in June of that year begging Mrs. Hofland
to try and dispose of some of the pictures to Messrs. Hurst and
Robinson and to arrange for the sale of the rest either at Sotheby’s
or Robins’s.
It was indeed a most anxious year, notwithstanding the triumph of
Julian and the fact that its author was one of the most talked-of
women of the day.
 Mary Russell Mitford.
(From a painting by Miss Drummond, 1823.)
During her stay in London to witness the production of Julian and
at one of her interviews with Macready the two had discussed
another play project, various subjects for treatment being suggested
—among them that of Procida (subsequently abandoned because
Mrs. Hemans was found to be at work on it), and Rienzi which Miss
Mitford very much favoured but Macready did not as he thought her
outline of the plot would entail on her a greater strain than she could
stand. For a time the matter was left in abeyance, as she had much,
just then, wherewith to occupy her mind. Kemble was threatening
her with a lawsuit if, as she much desired, she withdrew Foscari—
she rather feared that its production after Julian would do her no
good—and she was so tossed about, as she said, between him and
Macready, “affronting both parties and suspected by both, because I
will not come to a deadly rupture with either,” that she got quite ill
with worry. To add to her miseries the editor of the Lady’s Magazine
absconded, owing her £40. “Oh! who would be an authoress!” she
wofully wrote to her old friend Sir William. “The only comfort is that
the magazine can’t go on without me [its circulation had gone up
from two hundred and fifty copies to two thousand since she had
written for it]; and that the very fuss they make in quarrelling over me
at the theatre proves my importance there; so that, if I survive these
vexations, I may in time make something of my poor, poor brains.
But I would rather serve in a shop—rather scour floors—rather nurse
children, than undergo these tremendous and interminable disputes
and this unwomanly publicity. Pray forgive this sad no-letter. Alas!
the free and happy hours, when I could read and think and prattle for
you, are past away. Oh! will they ever return? I am now chained to a
desk, eight, ten, twelve hours a day, at mere drudgery. All my
thoughts of writing are for hard money. All my correspondence is on
hard business. Oh! pity me, pity me! My very mind is sinking under
the fatigue and anxiety. God bless you, my dear friend! Forgive this
sad letter.”
It was truly a sad letter, so unlike the usually bright, optimistic
woman, that he would be dense indeed who failed to read in it other
than evidence of a strain almost too great for this gentle woman to
bear. And what of Dr. Mitford at this time? What was he doing in the
matter of sharing the burden which he alone, through negligence and
wicked self-indulgence, had thrust upon his daughter? Truly he was
now less often in town and the famous kennel was in process of
being dispersed—there was neither room nor food for greyhounds at
Three Mile Cross—but short of his magisterial duties, which were, of
course, unremunerated, his time was scarcely occupied. At last the
fact of his daughter’s worn-out condition seems to have been borne
in upon him and in her next letter to Sir William, dated in May, 1823,
she has the pleasure to record:
“My father has at last resolved—partly, I believe,
instigated by the effect which the terrible feeling of
responsibility and want of power has had on my health and
spirits—to try if he can himself obtain any employment that
may lighten the burthen. He is, as you know, active,
healthy, and intelligent, and with a strong sense of duty and
 of right. I am sure that he would fulfil to the utmost any
charge that might be confided to him; and if it were one in
which my mother or I could assist, you may be assured
that he would have zealous and faithful coadjutors. For the
management of estates or any country affairs he is
particularly well qualified; or any work of superintendence
which requires integrity and attention. If you should hear of
any such, would you mention him, or at least let me know?
The addition of two, or even one hundred a year to our little
income, joined to what I am, in a manner, sure of gaining
by mere industry, would take a load from my heart of which
I can scarcely give you an idea. It would be everything to
me; for it would give me what, for many months, I have not
had—the full command of my own powers. Even Julian
was written under a pressure of anxiety which left me not a
moment’s rest. I am, however, at present, quite recovered
from the physical effects of this tormenting affair, and have
regained my flesh and colour, and almost my power of
writing prose articles; and if I could but recover my old
hopefulness and elasticity, should be again such as I used
to be in happier days. Could I but see my dear father
settled in any employment, I know I should. Believe me
ever, with the truest affection,
“Very gratefully yours, M. R. M.”
A pathetic and tragic letter! At last the scales had dropped from
her eyes. And yet, though the letter is, as it stands, an implicit
condemnation of her father’s laziness, it is overburdened with
affectionate praise of him and a catalogue of virtues in all of which
his life had proved him notably and sadly deficient. Dr. Mitford,
regenerated, as presented by his daughter, cuts a sorry figure; for
him the art of “turning over a new leaf” was lost, if indeed he ever
practised it. Proof of this was forthcoming in the next letter
addressed to the same correspondent and written three months
later! “I hasten my dear and kind friend, to reply to your very
welcome letter. I am quite well now, and if not as hopeful as I used to
be, yet less anxious, and far less depressed than I ever expected to
feel again. This is merely the influence of the scenery, the flowers,
the cool yet pleasant season, and the absence of all literary society;
for our prospects are not otherwise changed. My dear father, relying
with a blessed sanguineness on my poor endeavours, has not, I
believe, even inquired for a situation; and I do not press the matter,
though I anxiously wish it, being willing to give one more trial to the
theatre. If I could but get the assurance of earning for my dear father
and mother a humble competence I should be the happiest creature
in the world. But for these dear ties, I should never write another line,
but go out in some situation as other destitute women do. It seems to
me, however, my duty to try a little longer; the more especially as I
am sure separation would be felt by all of us to be the greatest of all
evils.
“My present occupation is a great secret; I will tell it to you in strict
confidence. It is the boldest attempt ever made by a woman, which I
have undertaken at the vehement desire of Mr. Macready, who
confesses that he has proposed the subject to every dramatic poet
of his acquaintance—that it has been the wish of his life—and that
he never met with any one courageous enough to attempt it before.
In short, I am engaged in a grand historical tragedy on the greatest
subject in English story—Charles and Cromwell. Should you ever
have suspected your poor little friend of so adventurous a spirit? Mr.
Macready does not mean the author to be known, and I do not think
it will be found out, which is the reason of my so earnestly requesting
your silence on the subject. Macready thinks that my sex was, in
great part, the occasion of the intolerable malignity with which Julian
was attacked.” [A scathing article on Julian appeared in one of the
magazines and was considered, by both Macready and Miss Mitford,
to have been inspired, if not written, by Kemble.]
Continuing her letter Miss Mitford detailed how she proposed to
treat the subject and concluded with another appeal for interest in
securing her father employment:—“Pray, my dear friend, if you
should hear of any situation that would suit my dear father, do not fail
to let me know, for that would be the real comfort, to be rid of the
theatre and all its troubles. Anything in the medical line, provided the
income, however small, were certain, he would be well qualified to
undertake. I hope there is no want of duty in my wishing him to
contribute his efforts with mine to our support. God knows, if I could,
if there were any certainty, how willingly, how joyfully, I would do
all.... If I were better, more industrious, more patient, more
consistent, I do think I should succeed; and I will try to be so. I
promise you I will, and to make the best use of my poor talents. Pray
forgive this egotism; it is a relief and a comfort to me to pour forth my
feelings to so dear and so respected a friend; and they are not now
so desolate, not quite so desolate, as they have been. God grant me
to deserve success!”
Again how pathetic! And how tragic is this spectacle of a worn-out
woman of thirty-six, pleading for help and comfort, and promising,
like a little child, to be good and work hard; and that notwithstanding
her twelve hours a day at the self-imposed task—which she now
finds to be drudgery—or the terror with which she views this great
opportunity now offered her by Macready and which she dare not
refuse lest she be blamed for letting slip any chance of earning
money. And all that a worthless father may be shielded and the real
cause of the trouble be obscured.
To add to her burdens—her mother was taken suddenly and
seriously ill shortly after the above letter was written, necessitating
the most careful and vigilant nursing. Her complaint—spasmodic
asthma—was so bad that, as the daughter recorded, “I have feared,
night after night, that she would die in my arms.” Eventually she
recovered, but meanwhile, of course, all literary work had to be
abandoned, not only because of the constant attention which the
patient’s condition demanded but by reason of the “working of the
perpetual fear on my mind which was really debilitating, almost
paralyzing, in its effect.”
 CHAPTER XVII

OUR VILLAGE IS PUBLISHED

With her mother now convalescent, the year 1824 opened to find
Miss Mitford more composed in mind. She was still turning over in
her mind her friend Macready’s great commission, but as he had
bade her take plenty of time, she occupied herself with gathering
together and polishing the Lady’s Magazine articles on country life
with a view to their publication in volume form. Mr. George B.
Whittaker, of Ave Maria Lane—“papa’s godson, by-the-by”—was the
chosen publisher and we may be certain that there was much
fussing and discussion between the parties concerned before the
details were finally arranged. Mr. Whittaker was, according to his
godfather’s daughter, “a young and dashing friend of mine, this year
sheriff of London, and is, I hear, so immersed in his official dignities
as to have his head pretty much turned topsy-turvy, or rather, in
French phraseology, to have lost that useful appendage; so I should
not wonder now, if it did not come out, till I am able to get to town
and act for myself in the business, and I have not yet courage to
leave mamma.”
Had Mr. Whittaker known what was in store for him he would
probably have lost his head; but neither author nor publisher had the
faintest notion that the modest volume, then projecting, was to be the
forerunner of a series destined to take the world by storm and to be
the one effort—apart from dramatic and sonneteering successes,
which were to fade into obscurity—by which alone the name of Mary
Russell Mitford was to be remembered.
 Its modest title— Our Village—was the author’s own choice, and it
was to consist of essays and characters and stories, chiefly of
country life, in the manner of the Sketch Book, but without
sentimentality or pathos—two things abhorred by the author—and to
be published with or without its author’s name, as it might please the
publisher. “At all events,” wrote Miss Mitford to Sir William, “the
author has no wish to be incognita; so I tell you as a secret to be
told.”
“When you see Our Village,” she continued, “(which if my sheriff
be not bestraught, I hope may happen soon), you will see that my
notions of prose style are nicer than these galloping letters would
give you to understand.”
The excitement of preparing for the press revived her old interest
in life and stirred her once again to indulge in that free and
blithesome correspondence which had been so unceremoniously
dropped when her domestic troubles seemed so overpowering. Her
introduction to Macready had been followed by an introduction to his
sister whom, as usual, Miss Mitford found to be all that was
charming. In her impulsive fashion she quickly divined the characters
of both and wrote of her impressions to her confidant, Sir William.
“They are very fascinating people, of the most polished and delightful
manners, and with no fault but the jealousy and unreasonableness
which seem to me the natural growth of the green-room. I can tell
you just exactly what Mr. Macready would have said of me and
Julian. He would have spoken of me as a meritorious and amiable
person, of the play as a first-rate performance, and of the treatment
as ‘infamous!’ ‘scandalous!’ ‘unheard-of!’—would have heaped every
phrase of polite abuse which the language contains on the Covent
Garden manager; and then would have concluded as follows:—‘But
it is Miss Mitford’s own fault—entirely her own fault. She is, with all
her talent, the weakest and most feeble-minded woman that ever
lived. If she had put matters into my hands—if she had withdrawn
The Foscari—if she had threatened the managers with a lawsuit—if
she had published her case—if she had suffered me to manage for
her; she would have been the queen of the theatre. Now, you will
see her the slave of Charles Kemble. She is the weakest woman that
ever trode the earth.’ This is exactly what he would have said; the
way in which he talks of me to every one, and most of all to myself.
‘Is Mr. Macready a great actor?’ you ask. I think that I should answer,
‘He might have been a very great one.’ Whether he be now I doubt.
A very clever actor he certainly is; but he has vitiated his taste by his
love of strong effects, and been spoilt in town and country; and I
don’t know that I do call him a very great actor ... I have a physical
pleasure in the sound of Mr. Macready’s voice, whether talking, or
reading, or acting (except when he rants). It seems to me very
exquisite music, with something instrumental and vibrating in the
sound, like certain notes of the violoncello. He is grace itself; and he
has a great deal of real sensibility, mixed with some trickery.”

The old Wheelwright’s Shop at “Our Village,” in 1913.

As far as it goes, and based on so slight an acquaintance, the
portrait is not much short of the truth, as witness Macready’s own
diaries wherein, strong man that he was, he set down all his faults
and failings. But he was a much-provoked man, the reason being
that he never did, or could, descend to the low level of his
tormentors. As for his being, or not being, a great actor, Miss Mitford
must be forgiven her hasty judgment; posterity rightly disagrees with
her.
Spring was just merging into summer and the thoughts of jaded
and satiated townfolk were turning to the consideration of green
fields and smiling meadows when the first modest little volume of
Our Village issued shyly forth from George Whittaker’s office. “Cause
it to be asked for at the circulating libraries,” urged the designing
author of all her friends.
The book caught on; its pages were redolent of the country; its
colour was true and vivid; it told of simple delights and did for
Berkshire what no author had ever previously done for any place.
Charles Lamb, then in the full enjoyment of his fame as Elia, said
that nothing so fresh and characteristic had appeared for a long time.
Sir William Elford was delighted but ventured the suggestion that the
sketches would have been better if written in the form of letters, but
this the author denied by reminding him that the pieces were too
long, and too connected, for real correspondence; “and as to
anything make-believe, it has been my business to keep that out of
sight as much as possible. Besides which, we are free and easy in
these days, and talk to the public as a friend. Read Elia, or the
Sketch Book, or Hazlitt’s Table-Talk, or any popular book of the new
school, and you will find that we have turned over the Johnsonian
periods and the Blair-ian formality to keep company with the wigs
and hoops, the stiff curtseys and low bows of our ancestors. ‘Are the
characters and descriptions true?’ you ask. Yes! yes! yes! As true as
is well possible. You, as a great landscape painter, know that in
painting a favourite scene you do a little embellish, and can’t help it;
you avail yourself of happy accidents of atmosphere, and if anything
be ugly, you strike it out, or if anything be wanting, you put it in. But
still the picture is a likeness; and that this is a very faithful one, you
will judge when I tell you that a worthy neighbour of ours, a post
captain, who has been in every quarter of the globe, and is equally
distinguished for the sharp look-out and bonhomie of his profession,
accused me most seriously of carelessness in putting The Rose for
The Swan as the sign of our next door neighbour; and was no less
disconcerted at the misprint (as he called it) of B for R in the name of
our next town. A cela près, he declares the picture to be exact.
Nevertheless I do not expect to be poisoned. Why should I? I have
said no harm of my neighbours, have I? The great danger would be
that my dear friend Joel might be spoilt; but I take care to keep the
book out of our pretty Harriette’s way; and so I hope that that prime
ornament of our village will escape the snare for his vanity which the
seeing so exact a portrait of himself in a printed book might
occasion. By the way, the names of the villagers are true—of the
higher sketches they are feigned, of course.”
The sales were beyond the wildest dreams of the author and
publisher, for it was well reviewed in all the literary papers and
discussed in all the literary circles. “Where is Our Village?” was the
question folk were asking each other, and when the secret leaked
out, there was a constant stream of traffic from here, there and
everywhere to the quiet village of Three Mile Cross, whose
inhabitants were the last of all to discover that they had been “put
into a book.” What a theme for the cobbler over the way! How he
must have neglected his work to watch the congratulating visitors
who thronged the cottage opposite, all asking the beaming and
delighted author “How she thought of it?” and “Why she did it?” And
when, at length, a copy of the book itself found its way to the parlour
of the George and Dragon and the cobbler saw himself as “the
shoemaker opposite,” we can almost fancy we catch the gratified
light in his eye and hear his astonished—“Well! I’ll be jiggered!”
And since no letter to any of her numerous correspondents ever
contained so charming a description, here let us quote from Our
Village its author’s picture of her own dwelling:—“A cottage—no—a
miniature house, with many additions, little odds and ends of places,
pantries, and what-nots; all angles, and of a charming in-and-out-
ness; a little bricked court before one half, and a little flower-yard
before the other; the walls, old and weather-stained, covered with
hollyhocks, roses, honeysuckles, and a great apricot tree; the
casements full of geraniums (ah! there is our superb white cat
peeping out from among them); the closets (our landlord has the
assurance to call them rooms) full of contrivances and corner-
cupboards; and the little garden behind full of common flowers,
tulips, pinks, larkspurs, peonies, stocks, and carnations, with an
arbour of privet, not unlike a sentry-box, where one lives in a
delicious green light, and looks out on the gayest of all gay flower-
beds. That house was built on purpose to show in what an
exceeding small compass comfort may be packed.”
That is Miss Mitford’s miniature of her village home. Seeking it to-
day, the literary pilgrim would be sadly disappointed if he carried this
description in his mind. The walls have been stuccoed—that ugliest
of make-believes—and a wooden sign The Mitford springs from
between the windows in an attempt—honest enough, no doubt—to
compete with its neighbour The Swan, the sign of which swings all
a-creak over the garden-wall. It has lost its cottage aspect, the
windows are modern and even the chimney-pots have been
replaced by up-to-date pottery contrivances and a zinc contraption
which tries to look ornamental but is not—in striking contrast to the
village shop next door which is still the village shop as described by
Miss Mitford, “multifarious as a bazaar; a repository for bread, shoes,
tea, cheese, tape, ribands, and bacon”; full of that delightfully mixed
odour, a pot-pourri of eatables and wearables, which always
characterizes such establishments; proudly ruled by a Brownlow,
one of a line of Brownlows unbroken from long before Miss Mitford’s
day.
Inside, The Mitford is less of a disappointment, for most of the
rooms remain unchanged, and one quickly sees how truly its
delighted owner limned it when she wrote of its angles and in-and-
out-ness. Unhappily the garden behind has been spoiled by the
erection of a large hall wherein the gospel is preached, light
refreshments may be partaken of, and the youth of the village
assemble o’ nights to tighten their muscles on trapeze and horizontal
bar. In Miss Mitford’s day they achieved this end by following the
plough—but other times other manners, and we are not for blaming
them altogether. The pity is—and it is our only grumble—that when
that truly noble philanthropist, William Isaac Palmer, conceived the
notion of honouring Miss Mitford’s memory by preserving her
residence, he did not insist on a restoration which would have
perpetuated the external, as well as the internal, features of the
cottage.

Miss Mitford’s Cottage at Three Mile Cross, as it is to-day (1913), with the sign of
the Swan Inn on the one hand, and Brownlow’s shop on the other.
Was Our Village its author’s announcement to all and sundry, that
come what might, whether of want, drudgery, or disillusionment, she
could still carry her head high, look the world in the face— and
smile? Probably it was. A strong case can be made out for the view
that, apart altogether from her love of rurality, Our Village was a
deliberate glorification of the simple life which had been forced upon
her, a deliberate pronouncement that Home was still Home, though it
had been transferred from the magnificence of Bertram House with
its retinue of servants, to an extremely humble cottage set between a
village “general” on the one side and a village inn upon the other.
With all the success which now seemed to crowd upon our author,
the year was not without its anxieties for, shortly after her mother’s
recovery, her father was taken suddenly ill and, as was his wont on
such occasions, required a great deal of attention. He made a fairly
speedy recovery, however, and in July we read of him and Mrs.
Mitford taking exercise in a “pretty little pony-chaise” the acquisition
of which the daughter proudly records—it was a sign, however slight,
of amended fortunes. Late in the year, Dr. Mitford had a relapse and
became seriously ill, and even when convalescent was left so weak
that he was a source of considerable anxiety to his wife and
daughter. This illness must have convinced Miss Mitford that it would
be futile to count upon her father as a bread-winner, and that
conviction seems to have spurred her to work even harder than
before. The Cromwell and Charles play still simmered in her mind,
while there were a “thousand and one articles for annuals” to be
written, together with the working-up of a new tragedy to be called
Inez de Castro. Not satisfied with all that, she wrote in the July to
William Harness, asking whether he could influence Campbell, then
editing the New Monthly Magazine, to engage for a series—“Letters
from the Country,” or something of that sort—“altogether different, of
course, from Our Village in the scenery and the dramatis personae,
but still something that might admit of description and character, and
occasional story, without the formality of a fresh introduction to every
article. If you liked my little volume well enough to recommend me
conscientiously, and are enough in that prescient editor’s good
graces to secure such an admission, I should like the thing
exceedingly.”
Talfourd wrote urging her to a novel, but this she wisely declined,
and commenced to work, in great haste on still another tragedy
which had been suggested by a re-reading of Gibbon’s Decline and
Fall of the Roman Empire. It was no new project, for she had written
of it “in strict confidence” to Sir William Elford more than a year
before, but it had been left to lie fallow until an opportunity arose for
its execution. When the suggestion was made to Macready he at
once saw the possibilities in the theme and promised to give the play
his best consideration, although he made the significant suggestion
that not only should the author’s name be kept a dead secret, but
that the play should be produced under a man’s name because the
newspapers of the day were so unfair to female writers.
 Luckily the haste with which she had started on Rienzi soon
subsided, and it was not ready until 1826 when Macready took it and
the Cromwellian play with him on an American tour, promising to do
nothing with either unless they could be produced in a manner
satisfactory to the author. The original intention had been to produce
Rienzi at Covent Garden that year, but the idea was abandoned.
In the meantime preparations were well advanced for a second
series of Our Village, “my bookseller having sent to me for two
volumes more.” Eventually the series extended to five volumes, the
publication of which ranged over the years 1824 and 1832. Of these
volumes there appeared, from time to time, a number of most
eulogistic reviews, particularly noticeable among them being those of
“Christopher North” in the Noctes Ambrosianae of Blackwood’s
Magazine. In reviewing the third volume he wrote:—“The young
gentlemen of England should be ashamed o’ theirsells fo’ lettin’ her
name be Mitford. They should marry her whether she wull or no, for
she would mak baith a useful and agreeable wife. That’s the best
creetishism on her warks”—a criticism as amusing as it was true.
 CHAPTER XVIII

MACREADY AND RIENZI

In the previous chapter we mentioned that Rienzi was not ready until
1826 and that its production at Covent Garden during that year was
postponed because of a disagreement between Macready and
Young. As a matter of fact the play was finished to the mutual
satisfaction of its author, and her friends Talfourd and Harness, early
in 1825, but when submitted to Macready he would only accept it on
condition that certain rather drastic alterations were made. In this he
was perfectly justified for, be it remembered, he was not only an
actor of high rank but a critic of remarkable ability—a combination of
scholar and actor which caused him to be consulted on every point
connected with the drama and whose judgment was rarely wrong.
Upon hearing his decision Miss Mitford appears to have lost her
composure—we will charitably remind ourselves that she had put
much labour and thought into this play—and to have rushed off to
consult the two friends who, having read the play, had already
pronounced it ready for presentation. Upon hearing Macready’s
suggestions Harness was considerably piqued, the more so as in
addition to his clerical duties, he was, at this time, enjoying a
considerable reputation as a dramatic critic, his writings in the
magazines being eagerly looked for and as eagerly read when they
appeared. There is no doubt that he, backed up by Talfourd,
counselled Miss Mitford not to adopt Macready’s suggestions, but
Macready was not the man to brook interference from outsiders and
told Miss Mitford that not only must she alter the play in accordance
with his views, but without delay if she required him to produce it.
This naturally placed the author in an awkward position for she knew,