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Pediatric
Radiology
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Ioannis V. Davros, BFA.
Savannah College of Art and Design
Future Books in the Rotations in Radiology Series
Cardiac Imaging
Charles White, Linda Haramati, Joseph J.S. Chen,
and Jeffrey Levky
Chest Imaging
Melissa Rosado de Christensen, SanjeevBhalla, Gerald Abbott,
and Santiago Martinez-Jiminez
Gastrointestinal Imaging
Angela Levy, Koenraad Mortele, and Benjamin Yeh
Rotations in Radiology
Pediatricc
Radiology Edited by
Angelisa Paladin, MD
Associate Professor of Radiology
University of Washington School of Medicine
Seattle Children’s Hospital
Seattle, WA
Caroline W. T. Carrico, MD
Associate Professor of Radiology
Duke University School of Medicine
Duke Children’s Hospital and Health Center
Durham, NC
1
3
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide.
With offices in
Argentina Austria Brazil Chile Czech Republic France Greece
Guatemala Hungary Italy Japan Poland Portugal Singapore
South Korea Switzerland Thailand Turkey Ukraine Vietnam
9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
Contents
31. Distal Bowel Obstruction in the 50. Posterior Urethral Valves 203
Newborn 125 Loren A. Murphy, Jeffrey C. Hellinger, and
Caroline Carrico Monica Epelman
32. Meconium Peritonitis 130 51. Urachal Abnormalities 207
Charles Mason Maxfield Kamaldine Oudjhane
33. Necrotizing Enterocolitis 133 52. Multicystic Dysplastic Kidney 211
Beverly P. Wood Lynn Ansley Fordham
34. Esophageal Atresia and 53. Autosomal Recessive Polycystic Kidney
Tracheoesophageal Fistula 137 Disease 214
Amy N. Dahl and Kristin Fickenscher Linda Bloom and Kassa Darge
35. Hypertrophic Pyloric Stenosis 140 54. Autosomal Dominant Polycystic Kidney
Angelisa M. Paladin Disease 217
36. Appendicitis 143 Linda Bloom and Kassa Darge
Angelisa M. Paladin 55. Wilms’ Tumor 220
37. Ileocolic Intussusception (Idiopathic) 147 Marguerite T. Parisi
Mohammed B. Shaikh 56. Hydrometrocolpos 224
and Monica Epelman Stuart Morrison
38. Liver Masses 152 57. Neonatal Adrenal Hemorrhage 228
Amy Mehollin-Ray Sudha P. Singh
39. Bilary Atresia 156 58. Neuroblastoma 231
Christopher Ian Cassady Marguerite T. Parisi
40. Choledochal Cyst 160 59. Genitourinary Rhabdomyosarcoma 237
Caroline Carrico Jamie L. Coleman
41. Neutropenic Colitis 165 60. Sacrococcygeal Teratoma 240
Adam Zarchan and Kristin Fickenscher Geetika Khanna
42. Pseudomembranous Colitis 168 61. Ovarian Torsion 243
Jennifer L. Williams Geetika Khanna
43. Inflammatory Bowel Disease 171 62. Epididymitis-Epididymoorchitis 246
Eric J. Feldmann, Monica Epelman, and Himabindu Mikkilineni and S. Pinar
Jeffrey C. Hellinger Karakas-Rothey
44. Gastrointestinal Duplication Cysts 177 63. Testicular Torsion 249
Ramesh S. Iyer Himabindu Mikkilineni and S. Pinar
45. Henoch-Schonlein Purpura 180 Karakas-Rothey
Monther S. Qandeel and Laura Z. Fenton 64. Pyelonephritis 253
Kailyn Kwong Hing and Paul Babyn
65. The Exstrophy-Epispadias Complex 258
Section 5: Genitourinary 185 Heather N. McCaffrey, Jeffrey C. Hellinger,
and Monica Epelman
46. Vesicoureteral Reflux 185
Michael E. Arch
Section 6: Musculoskeletal 263
47. Ureteropelvic Junction Obstruction 189
Lynn Ansley Fordham 66. Pediatric Fractures 265
48. Ureteropelvic Duplications 193 Adam Delavan and Laura Z. Fenton
Caroline Carrico 67. Osteomyelitis and Chronic Recurrent
49. Renal Ectopia and Fusion 198 Multifocal Osteomyelitis 273
Erjola Shehu and Jeffrey C. Hellinger Mahesh Thapa and Sumit Pruthi
C o n te n t s ix
There are many excellent resources for pediatric radiol- prepared to think of pediatric disease on a grayscale rather
ogy now available as textbooks, online textbooks, online than black and white. Where necessary, original illustra-
courses, etc. Why create yet another book about pediatric tions were created by a team of 8 medical illustrators from
radiology? Our thoughts were this: let’s set out to create the the Department of Medical Illustration and Photography at
most comprehensive resource for the radiology resident, the Cleveland Clinic, where a common style was adopted to
an adult student of radiology who may not know his or her ensure uniformity. Lastly, embracing the philosophy of the
future career path, but who is curious about pediatric radi- new certification process, our medical physicist and I care-
ology and who must also pass a test at the end of training. fully crafted individualized “related physics” sections for
And let’s cast a wide net to gather content from experts from each of the 120 topics offered in this book. This is the book I
around the country to eliminate regional bias. Using adult needed when I was a resident. And this will hopefully serve
learning principles, we chose to present the most relevant as the foundation for a future enduring electronic resource.
and current information within context of the resident
experience- first to give the granular facts and illustrate the Janet R. Reid MD, FRCPC
findings in a templated succinct style, but to then suggest an Patricia Borns Chair for Radiology Education
“imaging strategy” to provide guidance while navigating the Associate Professor of Radiology
waters of a pediatric rotation; to give a soundbite summary University of Pennsylvania
in “key points” but to go beyond this in presenting “imag- The Children’s Hospital of Philadelphia
ing pitfalls” and “common variants” so that they could be Philadelphia, PA
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Foreword
Pediatric imaging has grown tremendously in scope and organized into 8 main anatomic sections including a sec-
practice since I began my own career in 1985. At that time, tion on systemic disease encompassing important multi-
MRI was in its infancy, producing blurred, artifact-filled system diseases such as cystic fibrosis, sickle cell disease,
images needing hours to acquire, usually requiring seda- child abuse, and others. Each section is divided into concise
tion or general anesthesia. Although radiation dose reduc- chapters on specific disease entities, organized around the
tion has always been a part of the pediatric radiologists’ concepts of clinical presentation, anatomic considerations,
mantra, the use of lower kVp and girth-based mA settings imaging findings, strategies, and variants. Each chapter
for CT scanning, as well as pulsed fluoroscopy were not in also provides topical insights into the physical principles
our armamentarium. Current practice requires the inte- of the appropriate imaging techniques to help with dose
grated use of multiple modalities to reach a diagnosis in an and image optimization. By doing so, the curriculum of the
efficient, cost-effective, non-invasive and safe manner, with American Association of Physicists in Medicine is effec-
particular attention paid to minimizing radiation dose. tively embedded into each chapter by matching relevant
This current paradigm results in a strong need for a read- topics with each of the 120 chapters. Many chapters contain
able, introductory text for trainees beginning their explora- anatomic drawings that further explain the basis of imag-
tion of pediatric imaging. There are few high quality review ing findings. These are excellent, original illustrations that
texts for residents and fellows that have been properly peer help to clarify complex imaging concepts. The style is well
reviewed and checked for accuracy and error. Pediatric suited for trainees. It is streamlined, up to date and quite
Radiology fits this bill quite well. Dr. Janet Reid, the editor readable.
of this work is no stranger to pediatric radiology education. Pediatric Radiology fills an important niche as an acces-
She has taken many of the concepts she developed for the sible introduction to pediatric imaging, and will serve as
widely recognized and used “Children’s Hospital Cleveland an excellent reference for medical students, for fellows and
Clinic Pediatric Radiology” educational website* and residents in radiology, and for the general radiologist who
applied them to the current textbook. practices pediatrics.
The resulting book presents high quality, state of the
art imaging with current information that will serve as a George A. Taylor, M.D.
very useful review of the specialty of pediatric imaging. John A. Kirkpatrick Professor of Radiology (Pediatrics)
Every chapter has been reviewed and carefully edited for Harvard Medical School
authenticity, currency and quality. Pediatric Radiology is Radiologist-in-Chief Emeritus, Boston Children’s Hospital
authored by a cross-section of practicing pediatric radiolo- Boston, MA
gists from around the United States, and reflects the broad
diversity of our specialty. Pediatric Radiology is logically *https://www.cchs.net/pediatricradiology/
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Another Random Document on
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"I don't know what you mean now," he said, "about not wanting me
to help you, but you did say that the other day and you must take
the consequences. I don't want to help you in any way, of course,
that you don't want to be helped, but I am sure there is something I
can do for you. And in any case I'm going on coming to see you until
I'm stopped by physical force—even then I'm going on coming."
"I'll tell you this," she said suddenly. "I don't want you to come
because mother wants you to, and every one whom mother wants
me to like is horrid. Why does she want you to come?"
"I'm sure I don't know," said Henry, surprised. "She can't know
anything about me at all."
"She does. She's found out in these two days. She said yesterday
afternoon she wondered you hadn't come, and then this morning
again."
Henry said: "Won't you take me as I am? Your mother doesn't know
me. I want to be your friend. I've wanted to from the first moment I
saw you in Piccadilly Circus."
"In Piccadilly Circus?"
"Yes. That's where I first saw you the other afternoon and I followed
you here."
That seemed to her of no importance. "Friend?" she said frowning
and staring in front of her. "I don't like that word. Two or three have
wanted to be friends. I won't have friends. I won't have anybody. I'd
rather be alone."
"I can't hurt you," said Henry very simply. "Why every one laughs at
me, even my sister who's very fond of me. They won't laugh, one
day, of course, but you see how it is. There's always ink on my nose,
or I tumble down when I want to do something important. You'd
have thought the army would have changed that, but it didn't."
She smiled then. "No, you don't look as though you'd hurt anybody.
But I don't want to trust people. It only means you're disappointed
again."
"You can't be disappointed in me," Henry said earnestly. "Because
I'm just what you see. Please let me come and see you. I want it
more than I've ever wanted anything in my life."
They both heard then steps on the stair. They stopped and listened.
The room was at once ominous, alarmed.
Henry felt danger approaching, as though he could see beyond the
door with his eyes and found on the stair some dark shape,
undefined and threatening. The steps came nearer and ceased. Two
were there listening on the other side of the door as two were
listening within the room.
He felt the girl's fear and that suddenly stiffened his own courage. It
was almost ludicrous then when the door opened and revealed the
stout Mrs. Tenssen, clothed now in light orange and with her an old
man.
Henry saw at once that however eagerly she had hitherto expected
him she was not easy at his presence just now. His further glance at
the old man showed him at once an enemy for life. In any case he
did not like old men. The War had carried him with the rest upon the
swing of that popular cry "Every one over seventy to the lethal
chamber."
Moreover, he personally knew no old men, which made the cry much
simpler. This old man was not over seventy, he might indeed be still
under sixty, but his small peak of a white beard, his immaculate
clothing and his elegantly pointed patent leather shoes were
sufficient for Henry. Immaculate old men! How dared they wear
anything but sackcloth and ashes?
Mrs. Tenssen, whose orange garments shone with ill-temper, shook
hands with Henry as though she expected him instantly to say:
"Well, I must be going now," but he found himself with an admirable
pugnacity and defiant resolve.
"I called as I said I would," he observed pleasantly. "And I came in
by the door and not by the window," he added, laughing.
She murmured something, but did not attempt to introduce him to
her companion.
He meanwhile had advanced with rather mincing steps to the girl,
was bowing over her hand and then to Henry's infinite disgust was
kissing it. Then Henry forgot all else in his adoration of the girl. He
will never forget, to the end of whatever life that may be granted
him, the picture that she made at that moment, standing in the
garish, overlighted room, like a queen in her aloofness from them
all, from everything that life could offer if that room, that old man,
that woman were truly typical of its gifts. "It wasn't only," Henry said
afterwards to Peter, "that she was beautiful. Millie's beautiful—more
beautiful I suppose than Christina. But Millie is flesh and blood. You
can believe that she has toothache. But it was like a spell, a
witchery. The beastly old man himself felt it. As though he had tried
to step on to sacred ground and was thrown back on to common
earth again. By gad, Peter, you don't know how stupid he suddenly
looked—and how beastly! She's remote, a vision—not perhaps for
any one to touch—ever . . .!"
"That," said Peter, "is because you're in love with her—and Millie's
your sister."
"No, there's more than that. It may be partly because she's a
foreigner—but you'd feel the same if you saw her. Her remoteness,
as though the farther towards her you moved the farther away she'd
be. Always in the distance and knowing that you can come no
nearer. And yet if she knew that really she wouldn't be so frightened
as she is. . . ."
"It's all because you're so young, Henry," Peter ended up.
But young or no Henry just then wasn't very happy. The old man
with his shrill voice and his ironic, almost cynical determination to be
pleased with everything that any one did or said (it came, maybe,
from a colossal and patronizing arrogance)—reminded Henry of the
old "nicky-nacky" Senator in Otway's Venice Preserved which he had
once seen performed by some amateur society. He remained entirely
unclouded by Mrs. Tenssen's obvious boredom and ill-temper, moods
so blatantly displayed that Henry in spite of himself was crushed.
The girl showed no signs of any further interest in the company.
Mrs. Tenssen sat at the table, picking her teeth with a toothpick and
saying, "Indeed!" or "Well I never!" in an abstracted fashion when
the old man's pauses seemed to demand something. Her bold eyes
moved restlessly round the room, pausing upon things as though
she hated them and sometimes upon Henry who was standing,
indeterminately, first on one foot and then on another. Something
the old man said seemed suddenly to rouse her:
"Well, that's not fair, Mr. Leishman—it's not indeed. That's as good as
saying that you think I'm mean—it is indeed. Oh, yes, it is. You can
accuse me of many things—I'm not perfect—but meanness! Well you
ask my friends. You ask my friend Mrs. Armstrong who's known me
as long as any one has—almost from the cradle you might say.
Mean! You ask her. Why, only the other day, the day Mr. Prothero
was here and that young nephew of his, she said, 'Of all the
generous souls on this earth, for real generosity and no half-and-half
about it, you give me Katie Tenssen.' Of course, she's a friend as you
might say and partial perhaps—but still that's what she said and
——"
The old man had been trying again and again to interrupt this flood.
At last, because Mrs. Tenssen was forced to take a breath, he broke
in:
"No. No. Indeed not. Dear, dear, what a mistake! The last thing I
was suggesting."
"Well, I hope so, I'm sure." The outburst over, Mrs. Tenssen relapsed
into teeth-picking again.
Henry saw that there was nothing more to be got from the situation
just then.
"I must be going," he said. "Important engagement."
Mrs. Tenssen shook him by the hand. She regarded him with a wider
amiability now that he was departing.
"Come and see us again," she said. "Any afternoon almost."
By the door he turned, and suddenly the girl, from the far end of the
room, smiled. It was a smile of friendship, of reassurance and, best
of all, of intimacy.
Under the splendour of it he felt the blood rush to his head, his eyes
were dimmed, he stumbled down the stairs, the happiest creature in
London.
The smile accompanied him for the rest of that day, through the
night, and into the Duncombe library next morning. That morning
was not an easy one for Henry. He arrived with the stern
determination to work his very hardest and before the luncheon bell
sounded to reduce at least some of the letters to discipline and
sobriety. Extraordinary the personal life that those letters seemed to
possess! You would suppose that they did not wish to be made into
a book, or at any rate, if that had to be, that they did not wish the
compiler of the work to be Henry. They slipped from under his
fingers, hid themselves, deprived him of dates just when he most
urgently needed them, gave him Christian names when he must
have surnames, and were sometimes so old and faded and yellow
that it was impossible to make anything out of them at all.
Sir Charles had as yet shown no sign. Of what he was thinking it was
impossible to guess. He had not yet given Henry any private letters
to write, and the first experiment on the typewriter was still to be
made. One day soon he would spring, and with his long nose
hanging over the little tattered, disordered piles on Henry's table
would peer and finger and examine: Henry knew that that moment
was approaching and that he must have something ready, but this
morning he could not concentrate. The plunge into life had been too
sudden. The girl was with him in the room, standing just a little way
from him smiling at him. . . .
And behind her again there were Millie and the Platts, and Peter and
the three Graces, and the Romantic Novel and even Mr. King—and
behind these again all London with its banging, clattering, booming
excitement, the omnibuses running, the flags flying, the Bolshevists
with their plots, and the shops with their jewels and flowers, the
actors and actresses rehearsing in the theatres, the messenger boys
running with messages, the policemen standing with hands
outstretched, the newspapers announcing the births and the deaths
and the marriages, D'Annunzio in Fiume, the Poles in Warsaw
fighting for their lives, the Americans in New York drinking secretly in
little back bedrooms and the sun rising and setting all over the place
at an incredible speed.
It was of no use to say that Henry had nothing to do with any of
these things. He might have something to do with any one of them
at any moment. Stop for an instant to see whether the ground is
going to open in Piccadilly Circus and you are lost!—or found!—at
any rate, you are taken, neck and crop, and flung into life whether
you wish it or no. And Henry did wish it! He loved this nearness and
closeness, this sense of being both one of the audience and the
actors at one and the same time! Meanwhile the letters, with their
gentle slightly scornful evocation of another world, only a little
behind this one, and in its own opinion at any rate, infinitely superior
to it, were waiting for his concentration.
Then the Duncombe family itself was beginning to absorb him, with
its own dramatic possibilities. At luncheon that day he was made
forcibly aware of that drama.
Lady Bell-Hall had from the first stirred his eager sympathies. He
was so very sorry for the poor little woman. He did so eagerly wish
that he could persuade her to be a little less frightened at the
changes that were going on around her. After all, if Duncombe Hall
had to be sold and if she were forced to live in a little flat and have
only one servant, did it matter so terribly? Even though Soviets were
set up in London and strange men with red handkerchiefs and long
black beards did sit at Westminster there would still be many
delightful things left to enjoy! Her health was good, her appetite
quite admirable and the Young Women's Christian Association and
Society for the Comfort of Domestic Servants and the League of Pity
for Aged Widowers (some among many of Lady Bell-Hall's interests)
would in all probability survive many Revolutions or, at least, even
though they changed their names, would turn into something
equally useful and desirous of help. He longed to say some of these
things to her.
His opportunity suddenly and rather uncomfortably arrived.
Lady Bell-Hall in appearance resembled a pretty little pig—that is,
she had the features of a pig, a very young pig before time has
enveloped it in fat. And so soft and pink were her cheeks, so round
her little arms, of so delicate a white her little nose, so beseechingly
grey her eyes that you realised very forcibly how charming and
attractive sucklings might easily be. She sat at the end of the round
mahogany table in the long dark dining-room, talked to her
unresponsive brother and sometimes to Henry in a soft gentle voice
with a little plaint in it, infinitely touching and pathetic, hoping
against hope for the best.
To-day there came to the luncheon an old friend of the family, whose
name Henry had once or twice heard, a Mr. Light-Johnson.
Mr. Light-Johnson was a long, thin, cadaverous-looking man with
black sleek hair and a voice like a murmuring brook. He paid no
attention to Henry and very little to Duncombe, but he sat next to
Lady Bell-Hall and leaned towards her and stared into her face with
large wondering eyes that seemed always to be brimming with
unshed tears.
There are pessimists and pessimists, and it seems to be one of the
assured rules of life that however the world may turn, whatever
unexpected joys may flash upon the horizon, however many terrible
disasters may be averted from mankind, pessimists will remain
pessimists to the end. And such a pessimist as this Henry had never
before seen.
He had an irritating, tantalizing habit of lifting a spoonful of soup to
his lips and then putting it down again because of his interest in
what he was saying.
"What I feared last Wednesday," he said, "has already come true."
"Oh dear!" said Lady Bell-Hall. "What is that?"
"The Red Flag is flying in East Croydon. The Workers' Industrial
Union have commandeered the Y.M.C.A reading-room and have
issued a manifesto to the Croydon Parish Council."
"Dear, dear! Dear, dear!" said Lady Bell-Hall.
"It is a melancholy satisfaction," said Mr. Light-Johnson, "to think
how right one was last Wednesday. I hardly expected that my words
would be justified so quickly."
"And do you think," said Lady Bell-Hall, "that the movement—taking
Y.M.C.A. reading-rooms I mean—will spread quickly over London?"
"Dear Lady," said Mr. Light-Johnson, "I can't disguise from you that I
fear the worst. It would be foolish to do any other. I have a cousin,
Major Merriward—you've heard me speak of him—whose wife is a
niece of one of Winston Churchill's secretaries. He told me last night
at the Club that Churchill's levity!—well, it's scandalous—Nero
fiddling while Rome burns isn't in it at all! I must tell you frankly that
I expect complete Bolshevist rule in London within the next three
months."
"Oh dear! oh dear!" said Lady Bell-Hall. "Do have a little of that
turbot, Mr. Johnson. You're eating nothing. I'm only too afraid you're
right. The banks will close and we shall all starve."
"For the upper classes," said Mr. Johnson, "the consequences will be
truly terrible. In Petrograd to-day Dukes and Duchesses are acting
as scavengers in the streets. What else can we expect? I heard from
a man in the Club yesterday, whose son was in the Archangel forces
that it is Lenin's intention to move to London and to make it the
centre of his world rule. I leave it to you to imagine, Lady Bell-Hall,
how safe any of us will be when we are in the power of Chinese and
Mongols."
"Chinese!" cried Lady Bell-Hall. "Chinese!"
"Undoubtedly. They will police London or what is left of it, because
there will of course be severe fighting first, and nowadays, with
aerial warfare what it is, a few days' conflict will reduce London to a
heap of ruins."
"And what about the country?" asked Lady Bell-Hall. "I'm sure the
villagers at Duncombe are very friendly. And so they ought to be
considering the way that Charles has always treated them."
"It's from the peasantry that I fear the worst," said Mr. Light-
Johnson. "After all it has always been so. Think of La Vendée, think
of the Russian peasantry in this last Revolution. No, there is small
comfort there, I'm afraid."
Throughout this little conversation Duncombe had kept silent. Now
he broke in with a little ironic chuckle; this was the first time that
Henry had heard him laugh.
"Just think, Margaret," he said, "of Spiders. Spiders is our gardener,
Light-Johnson, a stout cheery fellow. He will probably be local
executioner."
Light-Johnson turned and looked at his host with reproachful eyes.
"Many a true word before now has been spoken in jest, Duncombe,"
he said. "You will at any rate not deny that this coming winter is
going to be an appalling one—what with strikes, unemployment and
the price of food for ever going up—all this with the most
incompetent Government that any country has ever had in the
world's history. I don't think that even you, Duncombe, can call the
outlook very cheerful."
"Every Government is the worst that any country's ever had," said
Duncombe. "However, I daresay you're right, Light-Johnson. Perhaps
this is the end of the world. Who knows? And what does it matter if
it is?"
"Really, Charles!" Lady Bell-Hall was eating her cutlet with great
rapidity, as though she expected a naked Chinaman to jump in
through the window at any moment and snatch it from her. "But
seriously, Mr. Light-Johnson, do you see no hope anywhere?"
"Frankly none at all. I don't think any one could call me a pessimist.
I simply look at things as they are—the true duty of every man."
"And what do you think one ought to do?"
"For myself," said Light-Johnson, helping himself to another cutlet, "I
shall spend the coming winter on the Riviera—Mentone, I think. The
Income Tax is so scandalous that I shall probably live in the south of
France during the next year or two."
"And so shoulder your responsibilities like a true British citizen," said
Duncombe. "I'm sure you're right. You're lucky to be able to get
away so easily."
Light-Johnson's sallow cheeks flushed ever so slightly. "Of course, if I
felt that I could do any good I would remain," he said. "I'm not the
sort of man to desert a sinking ship, I hope. Sinking it is, I fear. The
great days of England are over. We must not be sentimentalists nor
stick our heads, ostrich-wise, in the sand. We must face facts."
It was here that Henry made his great interruption, an interruption
that was, had he only known it, to change the whole of his future
career. He had realized thoroughly at first that it was his place to be
seen and not heard. Young secretaries were not expected to talk
unless they were definitely needed to make a party "go." But as
Light-Johnson had continued his own indignation had grown. His
eyes, again and again, in spite of himself, sought Lady Bell-Hall's
face. He simply could not bear to see the little lady tortured—for
tortured she evidently was. Her little features were all puckered with
distress. Her eyes had the wide staring expression of a child seeing a
witch for the first time. Every word that Light-Johnson uttered
seemed to stab her like a knife. To Henry this was awful.
"They are not facts. They are not facts!" he cried. "After every war
there are years when people are confused. Of course there are. It
can't be otherwise. We shall never have Bolshevism here. Russian
conditions are different from everywhere else. They are all ignorant
in Russia. Millions of ignorant peasants. While prices are high of
course people are discontented and say they're going to do dreadful
things. When everybody's working again prices will go down and
then you see how much any one thinks about Russia! England isn't
going to the dogs, and it never will!"
The effect of this outburst was astonishing. Light-Johnson turned
round and stared at Henry as though he were a small Pom that had
hitherto reposed peacefully under the table but had suddenly woken
up and bitten his leg. He smiled, his first smile of the day.
"Quite so," he said indulgently. "Of course. One can't expect every
one to have the same views on these matters."
But Lady Bell-Hall was astonishing. To Henry's amazement she was
angry, indignant. She stared at him as though he had offered a
deadly insult. Why, she wanted to be made miserable! She liked Mr.
Johnson's pessimism! She wished to be tortured! She preferred it!
She hugged her wound and begged for another turn on the wheel!
"Really, Mr. Trenchard," she said, "I don't think you can know very
much about it. As Mr. Light-Johnson says, we should face facts." She
ended her sentence with a hint of indulgence as though she would
say: "He's very, very young. We must excuse him on the score of his
youth."
The rest of the meal was most uncomfortable. Light-Johnson would
speak no more. Henry was miserable and indignant. He had made a
fool of himself, but he was glad that he had spoken! Lady Bell-Hall
would hate him always now and would prejudice her brother against
him—but he was glad that he had spoken! Nevertheless his cheese
choked him, and in embarrassed despair he took a pear that he did
not want, and because no one else had fruit ate it in an
overwhelming silence.
Then in the library he had his reward. Light-Johnson had departed.
"I shan't want you this afternoon, Trenchard," Duncombe said. Then
he added: "You spoke up well. That man's an ass."
"I shouldn't," he stammered, "have said anything. I don't know
enough. I only——"
"Nonsense. You know more than Light-Johnson. Speak up whenever
you have a mind to. It does my sister good."
And this was the beginning of an alliance between the two.
CHAPTER II
MILLIE AND PETER
And here are some extracts from a diary that Millicent kept at this
time.
April 14.—Just a week since I started with the Platts and I feel as
though I'd been there all my life. And yet I haven't got the thing
going at all. I'm in nearly the same mess as I was the first morning.
I'm not proud of myself, but at the same time it isn't my fault. Look
at the Interruptions alone! (I've put a capital because really they are
at the heart of all my trouble.) Victoria herself doesn't begin to know
what letting any one alone is. I seem at present to have an
irresistible fascination for her. She sits and stares at me until I feel as
though I were some strange animal expected to change into
something stranger.
And she doesn't know what silence means. She says: "I mustn't
interrupt your work, my Millie" (I do wish she wouldn't call me "my
Millie"), and then begins at once to chatter. All the same one can't
help being fond of her—at least at present. I expect I shall get very
impatient soon and then I'll be rude and then there'll be a scene and
then I shall leave. But she really is so helpless and so full of alarms
and terrors. Never again will I envy any one with money! I expect
before the War she was quite a happy woman with a small
allowance from her father, living in Streatham and giving little tea-
parties. Now what with Income Tax, servants, motor-cars, begging
friends, begging enemies, New Art and her sisters she doesn't know
where to turn. Of course Clarice and Ellen are her principal worries.
I've really no patience with Clarice. I hate her silly fat face, pink
blanc-mange with its silly fluffy yellow hair. I hate the way she
dresses, always too young for her years and always with bits stuck
on to her clothes as though she picked pieces of velvet and lace up
from the floor and pinned them on just anywhere.
I hate her silly laugh and her vanity and the way that she will recite
a poem about a horse (I think it is called something like "Lascar") on
the smallest opportunity. I suppose I can't bear seeing any one
make a fool of herself or himself and all the people who come to the
Platts' house laugh at her. All the same, she's the happiest of the
three women; that's because she's more truly conceited than the
others. It's funny to see how she prides herself on having learned
how to manage Victoria. She's especially sweet to her when she
wants anything and you can see it coming on hours beforehand.
Victoria is a fool in many things but she isn't such a fool as all that. I
call Clarice the Ostrich.
Ellen is quite another matter. By far the most interesting of them. I
think she would do something remarkable if she'd only break away
from the family and get outside it. Part of her unhappiness comes,
I'm sure, from her not being able to make up her mind to do this.
She despises herself. And she despises everybody else too. Men
especially, she detests men, although she dresses rather like them.
Victoria and Clarice are both afraid of her because of the bitter
things she says. She glares at the people who come to lunch and tea
as though she would like to call fire down and burn them all. It's
amusing to see one of the new artists (I beg their pardon—New
Artists) trying to approach her, attempting flattery and then falling
back aware that he has made one enemy in the house at any rate.
The funny thing is that she rather likes me, and that is all the
stranger because I understand from Brooker, the little doctor, that
she always disliked the secretaries. And I haven't been especially
sweet to her. Just my ordinary which Mary says is less than civility. .
..
April 16.—Ephraim Block and his friend Adam P. Quinzey (that isn't
his real name but it's something like that) to luncheon. I couldn't
help asking him whether he didn't think the "Eve" rather too large.
And didn't he despise me for asking! He told me that when he gets a
commission for sculpting in an open space, the tree that goes with
the "Eve" will be large enough to shelter all the school children of
Europe.
Although he's absurd I can't help being sorry for him. He is so
terribly hungry and eats Victoria's food as though he were never
going to see another meal again. Ellen tells me that he's got a
woman who lives with him by whom he's had about eight children.
Poor little things! And I think Victoria's beginning to get tired of him.
She's irritated because he wants her to pay for the tree and the
serpent as well as Eve herself. He says it isn't his fault that Victoria's
house isn't large enough and she says that he hasn't even begun the
Tree yet and when he's finished it it will be time enough to talk.
Then there are the Balaclavas (the nearest I can get to their names).
She's a Russian dancer, very thin and tall and covered with chains
and beads, and he's very fat with a dead white face and long black
hair. They talk the strangest broken English and are very depressed
about life in general—as well they may be, poor things. He thinks
Pavlowa and Karsavina simply aren't in it with her as artists and I
daresay they're not, but one never has a chance of judging because
she never gets an engagement anywhere. So meanwhile they eat
Victoria's food and try to borrow money off any one in the house
who happens to be handy. You can't help liking them, they're so
helpless. Of course I know that Block and the Balaclavas and
Clarice's friends are all tenth-rate as artists. I've seen enough of
Henry's world to see that. They are simply plundering Victoria as
Brooker says, but I'm rather glad all the same that for a time at any
rate they've found a place with food in it.
I shan't be glad soon. I'm beginning to realize in myself a growing
quite insane desire to get this house straight—insane because I don't
even see how to begin. And Victoria's very difficult! She loves Power
and if you suggest anything and she thinks you're getting too
authoritative she at once vetoes it whatever it may be. On the other
hand she's truly warm-hearted and kind. If I can keep my temper
and stay on perhaps I shall manage it. . . .
April 17.—I've had thorough "glooms" to-day. I'm writing this in bed
whither I went as early as nine o'clock, Mary being out at a party
and the sitting-room looking grizzly. I feel better already. But a visit
to mother always sends me into the depths. It is terrible to me to
see her lying there like a dead woman, staring in front of her, unable
to speak, unable to move. Extraordinary woman that she is! Even
now she won't see Katherine although Katherine tries again and
again.
And I think that she hates me too. That nurse (whom I can't abide)
has tremendous power over her. I detest the house now. It's so
gloomy and still and corpse-like. When you think of all the people it
used to have in it—so many that nobody would believe it when we
told them. What fun we used to have at Christmas time and on
birthdays, and down at Garth too. Philip finished all that—not that he
meant to, poor dear.
After seeing mother I had tea with father down in the study. He's
jolly when I'm there, but honestly, I think he forgets my very
existence when I'm not. He never asked a single question about
Henry. Just goes from his study to his club and back again. He says
that his book Haslitt and His Contemporaries is coming out in the
Autumn. I wonder who cares?
It makes me very lonely if one thinks about it. Of course there's dear
Henry—and after him Katherine and Mary. But Henry's got this
young woman he picked up in Piccadilly Circus and Katherine's got
her babies and Mary her medicine. And I've got the Platts I suppose.
...
All the same sometimes it isn't much fun being a modern girl. I
daresay liberty and going about like a man's a fine thing, but
sometimes I'd like to have some one pet me and make a fuss over
me and care whether I'm alive or not.
On the impulse of this mood, I've asked Peter Westcott to come and
have tea with me. He seems lonely too and was really nice at
Henry's the other day. Now I shall go to sleep and dream about
Victoria's correspondence.
April 18.—A young man to luncheon to-day very different from the
others. Humphrey Baxter by name; none of the aesthete about him!
Clean, straight-back, decently dressed, cheerful young man. Item,
dark with large brown eyes. At first it puzzled me as to how he got
into this crowd at all, then I discovered that he's rehearsing in a play
that Clarice is getting up, The Importance of Being Earnest. He plays
Bunbury or has something to do with a man called Bunbury—anyway
they all call him Bunny. He's vastly amused by the aesthetes and
laughs at them all the time, the odd thing is that they don't mind. He
also knows exactly how to treat Victoria, taking her troubles
seriously, although his eyes twinkle, and being really very courteous
to her.
The only one of the family who hates him is Ellen. She can't abide
him and told him so to-day, when he challenged her. He asked her
why she hated him. She said, "You're useless, vain and empty-
headed." He said, "Vain and empty-headed I may be, but useless no.
I oil the wheels." She said hers didn't need oiling and he said that if
ever they did need it she was to send for him. This little sparring
match was very light-hearted on his side, deadly earnest on hers.
The only other person who isn't sure of him is Brooker—I don't know
why.
Of course I like him—Bunny I mean. What it is to have some one
gay and sensible in this household. He likes me too. Ellen says he
goes after every girl he sees.
I don't care if he does. I can look after myself. She's a queer one.
She's always looking at me as though she wanted to speak to me.
And yesterday a strange thing happened. I was going upstairs and
she was going down. We met at the corner and she suddenly bent
forward and kissed me on the cheek. Then she ran on upstairs as
though the police were after her. I don't very much like being kissed
by other women I must confess; however, if it gives her pleasure,
poor thing, I'm glad. She's so unhappy and so cross with herself and
every one else.
April 20.—Bunny comes every day now. He says he wants to tell me
about his life—a very interesting one he says. He complains that he
never finds me alone. I tell him I have my work to do.
April 21.—Bunny wants me to act in Clarice's play. I said I wouldn't
for a million pounds. Clarice is furious with me and says I'm flirting
with him.
April 22.—Bunny and I are going to a matinee of Chu Chin Chow. He
says he's been forty-four times and I haven't been once. He likes to
talk to me about his mother. He wants me to meet her.
April 24.—Clarice won't speak to me. I don't care. Why shouldn't I
have a little fun? And Bunny is a good sort. He certainly isn't very
clever, but he says his strong line is motor-cars, about which I know
nothing. After all, if some one's clever in one thing that's enough.
I'm not clever in anything. . . .
April 25.—Sunday, I went over to luncheon to see whether I could
do anything for Victoria and had an extraordinary conversation with
Ellen. She insisted on my going up to her bedroom with her after
luncheon. A miserable looking room, with one large photograph over
the bed of a girl, rather pretty. Mary Pickford prettiness—and nothing
else at all.
She began at once, a tremendous tirade, striding about the room,
her hands behind her back. Words poured forth like bath-water out
of a pipe. She said that I hated her and that every one hated her.
That she had always been hated and she didn't care, but liked it.
That she hoped that more people would hate her; that it was an
honour to be hated by most people. But that she didn't want me to
hate her and that she couldn't think why I did. Unless of course I'd
listened to what other people said of her—that I'd probably done
that as every one did it. But she had hoped that I was wiser. And
kinder. And more generous. . . . Here she paused for breath and I
was able to get in a word saying that I didn't hate her, that nobody
had said anything against her, that in fact I liked her—— Oh no, I
didn't. Ellen burst in. No, no, I didn't. Any one could see that. I was
the only person she'd ever wanted to like her and she wasn't allowed
to have even that. I assured her that I did like her and considered
her my friend and that we'd always be friends. Upon that she burst
into tears, looking too strange, sitting in an old rocking-chair and
rocking herself up and down. I can't bear to see any one cry; it
doesn't stir my pity as it ought to do. It only makes me irritated. So I
just sat on her bed and waited. At last she stopped and sniffing a
good deal, got up and came over. She sat down on the bed and
suddenly put her arms round me and stroked my hair. I can't bear to
have my hair stroked by anybody—or at least by almost anybody.
However, I sat there and let her do it, because she seemed so
terribly unhappy.
I suppose she felt I wasn't very responsive because suddenly she
got up very coldly and with great haughtiness as though she were a
queen dismissing an audience. "Well, now you'd better go. I've made
a sufficient fool of myself for one day." So I got up too and laughed
because it seemed the easiest thing and said that I was her friend
and always would be and would help her anyway I could but that I
wasn't very sentimental and couldn't help it if I wasn't. And she said
still very haughtily that I didn't understand her but that that wasn't
very strange because after all no one else did, and would I go
because she had a headache and wanted to lie down. So I went.
Wasn't I glad after this to find Bunny downstairs. He suggested a
walk and as Victoria was sleeping on the Sunday beef upstairs I
agreed and we went along all through the Park and up to the Marble
Arch, and the sun was so bright that it made the sheep look blue
and the buds were waxy and there were lots of dogs and
housemaids being happy with soldiers and babies in prams and all
the atheists and Bolsheviks as cheery as anything on their tubs.
Bunny really is a darling. He sees all the funny things, just as I do; I
don't believe a word that Ellen says about him. He assures me that
he's only loved one girl in his life and that he gave her up because
she said that she wouldn't have babies. He was quite right I think.
He says that he's just falling in love again with some one else now.
Of course he may mean me and he certainly looked as though he
did. I don't care. I want to be happy and people to like me and
every one to love everybody. Why shouldn't they? Not
uncomfortably, making scenes like Ellen, but just happily with a
sense of humour and not expecting miracles. I said this to Bunny
and he agreed.
We had tea in a café in Oxford Street. He wanted to take me to a
Cinema after that but I wouldn't. I went home and read Lord Jim
until Mary came in. That's the book Henry used to be crazy about. I
think Bunny is rather like Jim although, of course, Bunny isn't a
coward. . . .
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