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Foreword
There are three indisputable facts about mental health in this
country. First, it’s an issue that touches all of us and our families.
Everyone knows someone who suffers from a brain illness, although it
is rarely discussed. Second, it’s an issue that underlies virtually every
major public policy issue we’re trying to tackle—and often aren’t very
good at tackling: homelessness, criminal justice, family dysfunction;
the plight of veterans; children who fall behind in school because of
undiagnosed conditions.
And third, despite facts 1 and 2, mental health is not a political
priority across our nation. Few governors, legislators, or other elected
leaders choose to embrace and elevate this critical cause. It remains
the underattended public policy issue of our time.
Over nearly three decades in elected office in California, I have
worked alongside other committed advocates to raise the profile of
mental health care as an issue central to the well-being of our
communities. In 2004, as a member of the State Assembly, I proudly
authored California’s Mental Health Services Act, legislation that
levied a tax on millionaires to fund a vast expansion in treatment and
services. The act now generates more than $2.2 billion a year and has
helped drive major advances in both early intervention and crisis care
for people living with mental illness. It is making a difference—which
underscores a fourth essential fact about mental health: We know
what to do, but lack the unified vision and political will necessary to
do more of it, to scale up and standardize best practices across the
nation.
 For years now, given the leaps forward in medical research and the
evolution of public awareness, we have been hoping to reach a
tipping point in mental health care—that magical moment when we
have cast aside the stigma, prioritized prevention and early
intervention, and established a system of care for brain health as
urgent and robust as the one we have built for physical health. We’re
getting closer. But we’re not there yet, for a variety of reasons. Among
the most crucial: Even as our understanding of and ability to treat
mental illness has matured, our health care workforce can’t come close
to meeting demand for psychiatric services.
The way forward requires leadership not only from elected officials
but also from our medical community. It requires new ways of
thinking about how and where we deliver mental health services. It
means knocking through the silos and ensuring that the primary care
providers who see the majority of patients have the basic training they
need to address both body and mind. And it means weaving those
front-line providers into a seamless continuum of care so people with
serious mental illness have access to more specialized services.
I am grateful for the leadership of Dr. Robert McCarron and his
distinguished writing partners as we work to innovate our health care
workforce to address the broad gaps in mental health services. What
they have produced here—the 2nd edition to their seminal text on
primary care psychiatry—reflects an impressive breadth of expertise
and an abiding commitment to treating the whole person. I am
grateful, as well, to the generations of physicians who will draw on
this training to inform their practice. Together, we can forge a new
paradigm for care, one built on the concept that there is no health
without brain health.

-- Darrell Steinberg

Founder, Steinberg Institute

 Darrell Steinberg is Mayor of Sacramento, former President Pro Tem of
the California State Senate, and founder of the Steinberg Institute, a
nonprofit organization dedicated to advancing the cause of brain health.
Preface
Dear Colleague,

Psychiatric disorders such as mood, anxiety, and substance use

disorders are among the leading causes of morbidity worldwide.
People with these common disorders most frequently present to and
are treated by nonpsychiatrists, or primary care providers. Although
primary care practitioners deliver the majority of behavioral
healthcare in the United States, most only get a brief exposure to the
basics of psychiatry during limited formal training. As awareness,
recognition, and acceptance of psychiatric disorders increase, the gap
between the number of patients who need psychiatric care and the
supply of mental health practitioners will continue to grow
exponentially. The resultant strain on the public and private mental
health systems can, in part, be addressed with a practical, easy-to-use
educational tool that will help primary care and mental health trainees
and providers feel more comfortable and confident when assessing
and treating the most commonly encountered conditions in primary
care psychiatry.
Since the first edition publication of the Primary Care Psychiatry, the
psychiatric workforce has further diminished, with projections to only
worsen over the next decade. This second edition of Primary Care
Psychiatry, now affiliated with the Association of Medicine and
Psychiatry, aims to educate nonpsychiatric health care professionals in
the diagnosis, treatment, and general conceptualization of adult
psychiatric disorders. Most of the authors are dually trained in
psychiatry and either family medicine, internal medicine, or
psychosomatic medicine. This book illustrates a practical approach to
primary care psychiatry because it is principally written by practicing
primary care physicians who are also psychiatrists. Because we know
first-hand what it is like to work in the primary care setting, we have
distilled a large volume of information into a practical and focused
overview of primary care psychiatry.
Primary Care Psychiatry, 2nd Edition covers the essential psychiatric
conditions found in the primary care setting and can therefore be
easily used as part of a psychiatric and behavioral health curriculum
for trainees of various clinical disciplines. In Section I, we include a
framework by which “primary care psychiatry” can most effectively
be practiced. This includes an overview on collaborative care,
preventive care for those who have severe mental illness, and a guide
to cultural considerations in medicine. We continue to emphasize the
AMPS screening tool as a core educational foundation, as it can easily
be used to diagnose the most commonly encountered psychiatric
conditions: Anxiety, Mood, Psychotic, and Substance-related
disorders. Section II provides a clinically relevant overview on the
most common psychiatric disorders, with helpful diagnostic and
therapeutic practice pointers. In Section III, we present a user-friendly
approach to the fundamentals of primary care psychiatric treatment.
Special topics such as geriatric psychiatry, child psychiatry, suicide
risk assessment, somatic symptom disorders, insomnia, sexual
dysfunction, and technology in medicine are all presented in Section
IV. The e-book companion includes additional resources such as
CME multiple choice questions with answers. These tools promote
optimal learning and teaching.
We strongly believe in a biopsychosocial treatment approach that
enables patients to learn and utilize lifelong skills that will result in
decreased morbidity and often recovery from mental illness. It is our
sincere hope that this book gives you the tools needed to provide
exceptional psychiatric patient care, while in a busy nonpsychiatric
clinical setting. If you have any suggestions on how we can improve
future editions, please let us know.

Robert M. McCarron, DO, DFAPA

Glen L. Xiong, MD
Shannon Suo, MD
Paul Summergrad, MD
Philip R. Muskin, MD, MA, DLFAPA
Sarah Rivelli, MD, FACP
Acknowledgments
We would like to thank the Association of Medicine and Psychiatry
for their endorsement of Primary Care Psychiatry, 2nd Edition. We are
also grateful to the many authors who took the time to share their
knowledge. This book would not be in print without their passion to
provide empathic, high-quality patient care and teaching. We are
extremely appreciative of the talented and highly professional Wolters
Kluwer editorial staff, particularly Emily Buccieri and Rebecca S.
Gaertner.
We would like to acknowledge Ruth Benca, MD, PhD, and Robert
E. Hales, Chairs of Psychiatry at the University of California, Irvine
and the University of California, Davis, respectively. We also dedicate
this book to two mentors, friends, and innovative leaders in the field
of psychiatry: Captane Thomson MD, Founding President, California
Psychiatric Association and Roger Kathol, MD, Founding President,
Association of Medicine and Psychiatry. This educational guide could
not have been done without the support of Matthew Reed, MD,
MSPH (Assistant Editor) and Shawn Hersevoort, MD (Assistant
Editor). We are also most grateful for the administrative support from
Wendy Cant, MBA.

Robert M. McCarron, DO, DFAPA

Glen L. Xiong, MD
Contributing Authors
Lawrence Adler, MD, Assistant Professor, Department of Psychiatry (Geriatric), University
of Maryland School of Medicine, Baltimore, Maryland

Rachel J. Ammirati, PhD, Assistant Professor, Department of Psychiatry and Behavioral

Sciences, Emory University School of Medicine, Atlanta, Georgia

Mary Elizabeth Alvarez, MD, MPH, Assistant, Department of Psychiatry, Medical College
of Wisconsin, Milwaukee, Wisconsin

Amy Barnhorst, MD, Vice Chair for Community Mental Health, Department of Psychiatry
and Behavioral Sciences, University of California, Davis, California

Jessica A. Beauchene, MD, Staff Psychiatrist, Department of Center for Discovery, Granite
Bay, California

Gregory D. Brown, MD, Department of Psychiatry and Behavioral Science, Department of

Medicine, Duke University, Durham, North Carolina

Vincent F. Capaldi, II, ScM, MD, Associate Professor, Department of Psychiatry and
Internal Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Puja L. Chadha, MD, Assistant Professor, Psychiatry and Behavioral Sciences, University of
California, Davis, California

Jeremy DeMartini, MD, Assistant Clinical Professor, Department of Psychiatry, University

of California, Davis, California

Lindsey Enoch, MD, Assistant Professor, Department of Psychiatry, Department of

Internal Medicine, University of Washington, Seattle, Washington

Jane P. Gagliardi, MD, MHS, Associate Professor, Department of Psychiatry and

Behavioral Sciences, Department of Medicine, Duke University School of Medicine, Durham,
North Carolina

Mary Margaret Gleason, MD, Associate Professor, Department of Psychiatry and

Behavioral Sciences, Tulane University School of Medicine, New Orleans, Los Angeles
 Visit https://ebookmass.com
now to explore a rich
collection of eBooks and enjoy
exciting offers!
Ana Hategan, MD, Associate Clinical Professor, Department of Psychiatry and Behavioural
Neurosciences, Division of Geriatric Psychiatry, McMaster University, Hamilton, Ontario,
Canada

Jaesu Han, MD, Clinical Professor, Department of Psychiatry and Human Behavior,
University of California at Irvine Orange, California

D. Brian Haver, MS, Doctoral Candidate, Department of Clinical Psychology, Mercer

University, Atlanta, Georgia

Shelly L. Henderson, PhD, Associate Clinical Professor, Department of Family and

Community Medicine, University of California, Davis, California

Jennifer A. Hersevoort, MD, Staff Psychiatrist, Department of Psychiatry, Pacific Coast

Psychiatric Associates, San Francisco, California

Shawn Hersevoort, MD, MPH, Clinical Professor (VCP), Department of Psychiatry &
Behavioral Sciences, University of California at Davis, Sacramento, California

Calvin H. Hirsch, MD, Professor of Clinical Internal Medicine and Public Health Sciences,
Division of General Medicine (Geriatrics), Department of Internal Medicine, University of
California, Davis Medical Center, Davis, California

Poh Choo How, MD, PhD, Health Sciences Assistant Professor, Department of Psychiatry
and Behavioral Sciences, University of California, Davis, California

Kimberly Kavanagh, MD, Triple Board Resident, Departments of Psychiatry & Behavioral
Sciences and Pediatrics, Tulane University School of Medicine, New Orleans, Los Angeles

Craig R. Keenan, MD, Professor, Department of Medicine, University of California, Davis

School of Medicine, Davis, California

Chandan Khandai, MD, Consultation Liaison Psychiatry Fellow, University of Washington

- School of Medicine, Seattle, Washington

Christine E. Kho, MD, Resident Physician, Internal Medicine and Psychiatry, UC Davis
Medical Center, Sacramento, California

Jea-Hyoun Kim, MD, Psychiatrist, Department of Behavioral Health, Santa Clara Valley
Medical Center, San Jose, California

Alan Koike, MD, MSHS, Heath Sciences Clinical Professor, Department of Psychiatry and
Behavioral Sciences, University of California, Davis School of Medicine, Davis, California

Rohail Kumar, MD, Triple Board Resident, Departments of Psychiatry & Behavioral
Sciences and Pediatrics, Tulane University School of Medicine, New Orleans, Los Angeles
Martin H. Leamon, MD, Clinical Professor, Department of Psychiatry and Behavioral
Sciences, University of California, Davis, California

Anna Lembke, MD, Associate Professor, Department of Psychiatry and Behavioral

Sciences, Stanford University, Stanford, California

Philippe T. Lévy, MD, Resident Physician, Department of Internal Medicine, Psychiatry

and Behavioral Sciences, University of California, Davis, Sacramento, California

Simone T. Lew, MD, MS, Internal Medicine/Psychiatry Resident, Department of Internal

Medicine, Department of Psychiatry and Behavioral Sciences, University of California, Davis,
California

Molly Lubin, MD, Assistant Clinical Professor, Department of Psychiatry, University of

Wisconsin, Madison, Wisconsin

Anne B. McBride, MD, Assistant Clinical Professor, Psychiatry and Behavioral Sciences,
University of California, Davis, California

Robert M. McCarron, DO, DFAPA, Professor and Vice Chair of Education and Integrated
Care, Program Director, Psychiatry Residency Program, Director, Train New Trainers
Primary Care Psychiatry Fellowship, Department of Psychiatry and Human Behavior,
University of California, Irvine School of Medicine, President, California Psychiatric
Association, Past President, Association of Medicine and Psychiatry

Myo Thwin Myint, MD, Assistant Professor, Department of Psychiatry and Behavioral
Sciences and Department of Pediatrics, Tulane University, New Orleans, Louisiana

Keeban C. Nam, MD, Chief Fellow Physician, Department of Psychiatry, Child and
Adolescent Fellowship, University of California, Irvine, Orange, California, Amy Newhouse,
MD, Assistant Professor, Department of Psychiatry and Behavioral Sciences, Department of
Medicine, Duke University School of Medicine, Durham, North Carolina

Chinyere I. Ogbonna, MD, MPH, Adjunct Faculty, Department of Psychiatry and

Behavioral Sciences, Stanford University, Stanford, California

John C. Onate, MD, Professor, Department of Psychiatry, UC Davis

Jeremy A. Parker, MD, Clinical Faculty, Department of Psychiatry, California Pacific

Medical Center, San Francisco, California

Cameron Quanbeck, MD, Associate Medical Director, Department of Behavioral Health

and Recovery Services, San Mateo County Health System, Cordilleras Mental Health
Rehabilitation Center, Redwood City, California

Jeffrey T. Rado, MD, MPH, Associate Professor, Department of Psychiatry and Behavioral
Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL

Shaun P. Rafael, DO, Resident Physician, Department of Psychiatry and Behavioral

Sciences, University of California, Davis, California

Y. Pritham Raj, MD, Associate Professor, Departments of Internal Medicine and

Psychiatry, Oregon Health & Science University, Portland, Oregon

Anna Ratzliff, MD, PhD, Associate Professor, Department of Psychiatry and Behavioral
Sciences, University of Washington, Seattle, Washington

Matthew Reed, MD, MSPH, Assistant Dean for Student Affairs, Assistant Professor,
Department of Psychiatry, University of California, Irvine, California

Kate M. Richards, MD, Psychiatry-Family Medicine Resident, Department of Psychiatry

and Behavioral Sciences, Department of Family and Community Medicine, University of
California,, Davis, California

Sarah Rivelli, MD, FACP, Past President, Association of Medicine and Psychiatry,
Assistant Professor, Program Director, Internal Medicine-Psychiatry Residency, Medical
Director, Psychiatry Clinical Services, Duke University Hospital, Director, Medicine-
Psychiatry and Hospital Psychiatry Clinical Professional Unit, Department of Psychiatry and
Behavioral Sciences, Department of Medicine, Duke University School of Medicine, Durham,
NC

David Safani, MD, MBA, Assistant Professor, Department of Psychiatry and Human
Behavior, UC Irvine School of Medicine, Irvine, California

Bharat R. Sampathi, BA, Medical Student, University of California, Irvine School of

Medicine, Irvine, California

Eleasa A. Sokolski, MD, Resident Physician, Department of Psychiatry and Behavioral

Sciences, Department of Internal Medicine, UC Davis Medical Center, Davis, California

Shannon Suo, MD, Past President, Central California Psychiatric Society, Health Sciences
Clinical Professor, Program Director, Family Medicine/Psychiatry Residency, Co-Director,
Train New Trainers Primary Care Psychiatry Fellowship, Department of Psychiatry and
Behavioral Sciences, University of California, Davis School of Medicine, Sacramento, CA

Maria L. Tiamson-Kassab, MD, DFAPA, FACLP, Clinical Professor, Department of

Psychiatry, University of California, San Diego, La Jolla, California

Hendry Ton, MD, MS, Professor, Department of Psychiatry and Behavioral Sciences,
University of California, Davis, California

Ramanpreet Toor, MD, Assistant Professor, Department of Psychiatry and Behavioral

Sciences, University of Washington, Seattle, Washington

Martha C. Ward, MD, Assistant Professor, Department of Psychiatry & Behavioral

Sciences, Emory University School of Medicine, Atlanta, Georgia

Scott G. Williams, MD, FACP, FAPA, FAASM, Director for Medicine, Fort Belvoir
Community Hospital, Associate Professor of Medicine and Psychiatry, Uniformed Services,
University of the Health Sciences, Bethesda, Maryland

Glen L. Xiong, MD, Clinical Professor (VCP), Department of Psychiatry & Behavioral
Sciences, University of California at Davis, Alzheimer’s Disease Center, Department of
Neurology
Abbreviations
AA Alcoholics Anonymous
AAI Appearance Anxiety Inventory
ACBT Abbreviated cognitive behavioral therapy
ACT Assertive community treatment
AD Alzheimer disease
ADHD Attention deficit hyperactivity disorder
ADLs Activities of daily living
AFP Alpha-fetal protein
AIMS Abnormal Involuntary Movement Scale
AMPS Anxiety, Mood, Psychosis, and Substance use disorders
ANA Antinuclear antibody
APA American Psychiatric Association
AUDs Alcohol use disorders
AUDIT The Alcohol Use Disorders Identification Test
ARFID Avoidant/restrictive food intake disorder
ASD Acute stress disorder
BA Behavioral activation
BDI Beck Depression Inventory
BDD Body dysmorphic disorder
BED Binge eating disorder
BPD Borderline personality disorder
BZDs Benzodiazepines
CAD Coronary artery disease
CBC Complete blood count
CBT Cognitive behavioral therapy
CDT Carbohydrate-deficient transferrin
CES-D Center for Epidemiological Studies Depression Scale
ChEIs Cholinesterase inhibitors
CIR Clutter Image Rating Scale
CIWA-A Clinical Institute Withdrawal Assessment for Alcohol
COPD Chronic obstructive pulmonary disease
CT Computerized tomography
CVAs Cerebrovascular accidents
DA-2 Dopamine type 2
DBSA Depressive and Bipolar Support Alliance
DBT Dialectical behavior therapy
DCSAD Diagnostic Classification of Sleep and Arousal Disorders
DLB Dementia with Lewy bodies
DRIs Dopamine reuptake inhibitors
DSD Dementia syndrome of depression
DSM-IV- Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision
TR
DSM-5 Diagnostic and Statistical Manual of Mental Disorder, 5th edition
DTs Delirium tremens
DTR Dysfunctional thought record
ECG Electrocardiogram
ECT Electroconvulsive therapy
ED Emergency department
EDO Eating disorder
EPDS Edinburgh Postnatal Depression Scale
EPS Extrapyramidal symptoms
ERP Exposure response prevention
FDA Food and Drug Administration
FGA First-generation antipsychotics
FTD Frontotemporal dementia
FTLD Frontotemporal lobar degeneration
GABAA Gamma-aminobutyric acid type A
GAD Generalized anxiety disorder
GAD-7 Generalized Anxiety Disorder Scale
GDS Geriatric Depression Scale
GERD Gastroesophageal reflux disease
GGT Gamma-glutamyltransferase
GI Gastrointestinal
HADS Hospital Anxiety and Depression Scale
HAM-D Hamilton Rating Scale for Depression
HD Huntington disease
HIV Human immunodeficiency virus
HPI History of present illness
HRS Hoarding Rating Scale
HRT Habit reversal treatment
ICD International Classification of Diseases
ICSD International Classification of Sleep Disorders
IM Intramuscular
IOM Institute of Medicine
IPT Interpersonal psychotherapy
LAI Long-acting injectable
LEP Limited English proficiency
LGBTQ Lesbian, gay, bisexual, transgender, queer
LSD Lysergic acid
MADRS Montgomery–Asberg Depression Rating Scale
MAOIs Monoamine oxidase inhibitors
MCI Mild cognitive impairment
MDD Major depressive disorder
MDMA Methylenedioxymethamphetamine
MDQ Mood Disorder Questionnaire
MET Motivational enhancement therapy
MGH-HS Massachusetts General Hospital Hair Pulling Scale
MI Motivational interviewing
MMSE Mini-Mental State Examination
MoCA Montreal Cognitive Assessment
MRI Magnetic resonance imaging
MSE Mental Status Examination
NAMI National Alliance for Mental Illness
NaSSA Noradrenergic and specific serotonergic antidepressant
NIAAA National Institute on Alcohol Abuse and Alcoholism
NDRI Norepinephrine–dopamine reuptake inhibitor
NMDA N-methyl-D-aspartate
NMS Neuroleptic malignant syndrome
NNRTIs Nonnucleoside reverse transcriptase inhibitors
NOS Not otherwise specified
NPI Neuropsychiatric Inventory
NPSs Neuropsychiatric symptoms
OCD Obsessive–compulsive disorder
OCF Outline for Cultural Formulation
OCPD Obsessive–compulsive personality disorder
OSAH Obstructive sleep apnea–hypopnea
PANDAS Pediatric autoimmune neuropsychiatric disorder associated with group A
streptococci
PCP Phencyclidine; Primary care provider
PD Panic disorder
PET Positron emission tomography
PHQ Patient Health Questionnaire
PLMD Periodic limb movement disorder
PORT Patient Outcomes Research Team
PSP Progressive supranuclear palsy

PTSD Posttraumatic stress disorder

RLS Restless leg syndrome
SAD Seasonal affective disorder
SAMe S-adenosyl methionine
SGA Second-generation antipsychotic
SIDs Substance-induced disorders
SNRIs Serotonin–norepinephrine reuptake inhibitors
SP Social phobia
SPECT Single photon emission computed tomography
SPS-R Skin Picking Scale—Revised
SRDs Substance-related disorders
SSRIs Selective serotonin reuptake inhibitors
STAR*D Sequenced Treatment Alternatives to Relieve Depression
SUDs Substance use disorders
TCAs Tricyclic antidepressants
TD Tardive dyskinesia
TMS Transcranial magnetic stimulation
TSC Trichotillomania Scale for Children
TSF Twelve-step facilitation
TSH Thyroid-stimulating hormone
UPS Unexplained physical symptoms
VaD Vascular dementia
WHO World Health Organization
Y-BOCS Yale–Brown Obsessive–Compulsive Scale
ZBI Zarit Burden Interview
ZDS Zung Depression Scale
Contents
Cover image

Title page

Copyright

Dedication

Foreword

Preface

Acknowledgments

Contributing Authors

Abbreviations

Section I Behavioral Health in the Primary Care Setting

Chapter 1 The Primary Care Psychiatric Interview

Clinical Significance

The Psychiatric Interview

Mental Status Examination

Physical Examination

Time-Saving Strategies

Chapter 2 Primary Care and Psychiatry: An Overview of the Collaborative Care Model
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 Introduction to Collaborative Care

The Collaborative Care Team

Delivering Care Using the Collaborative Care Principles

The Engaged Primary Care Provider: Critical to the Success of the Collaborative Care
Model Team

Practical Considerations for Collaborative Care Implementation

Conclusion

Cases and Questions

Chapter 3 Preventive Medicine and Behavioral Health

Components of Preventive Care

Summary

Chapter 4 The Patient and You: Psychological and Cultural Considerations

Clinical Significance

Structural Competence

A Structured Cultural Formulation

Conclusion

Section II Psychiatric Disorders

Chapter 5 Anxiety Disorders

Clinical Significance

Diagnosis

Anxiety Disorders Diagnostic Criteria Adapted from DSM-5

Biopsychosocial Treatment

Chapter 6 Obsessive–Compulsive and Related Disorders

Clinical Significance
 Diagnosis

Biopsychosocial Treatment

Cases and Questions

Chapter 7 Trauma-Related Disorders

Clinical Significance

Diagnosis

Biopsychosocial Treatment

Cases and Questions

Chapter 8 Mood Disorders—Depression

Clinical Significance

Diagnosis

Biopsychosocial Treatment

Cases and Questions

Chapter 9 Treatment-Resistant Depression

Introduction

Clinical Significance

Diagnosis

Biopsychosocial Treatment

Conclusion

Cases and Questions

Chapter 10 Psychiatric Disorders: Bipolar and Related Disorders

Clinical Significance

Diagnosis

Biopsychosocial Treatment

Cases and Questions

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"Two of 'em," ordered Max of the waiter that had answered his ring, "an'
don'd make 'em so stingy like most you fellers ofer this vay."

The man brought the liquor, placed it before them, and went away.

"Vell," said Max, raising his glass, smiling his thin smile, and
apparently forgetting that he had ever denied whiskey; "here ve are, ain't
it?"

If Mary was remembering another night and another drink she did not
say so; instead, as Max tilted his sleek head far back between his shoulders
and dropped the whiskey down his throat, her hand watched for the instant
when his gray eyes were on the ceiling and that instant poured the liquor
from her own glass to the floor. When her companion's head came forward
her fingers, wrapped about the glass, were just withdrawing it from her lips.

"I can drink that better'n I used to," she said.

Max grinned again. So long as she did not upbraid him for his part in it,
so long as she did not go into the details of its earlier stages, he had no
objection to hearing of her past, was even languidly curious about it, and
was certainly sorry that it had not brought her to more seeming prosperity.

"You sure didn't take that like you vasn't used vith it," he said.

"I'll take another just to show you how," she answered, and pressed the
nearest button.

This time his eyes were on her and she had to drink. But she did not
scruple: so long as she retained her head and Max lost his, the effect of the
alcohol on her system concerned her but little.
 They had a third drink, for "old time's sake," as Mary suggested, and
this she succeeded in pouring down her dress-front. At the fourth, Max
began to show signs of fear that he would have a drunken woman on his
hands, but Mary's patent sobriety soon reassured him, and overcame his
protests against a fifth by recalling his promise of liberality.

His cold eyes sparkled into a faint light. Little spots of red appeared in
the olive of his cheeks. He felt the advance of the enemy in his veins and
tried to go; but Mary began an imaginative narrative of her recent
experiences and insisted on his listening. When he at last successfully
interrupted that, she twitted him with being able to drink less than his
pupils, and Max was once more forced to order. He was not drunk, or nearly
drunk, but the fine edge of his discretion was dulled: he saw in the woman,
who had now moved to his side, nothing that, whatever motives might be at
work, could possibly harm him; he found something ludicrous in the
situation. Her looks seemed better than they had appeared an hour earlier,
and her tentative advances flattered him.

Mary, though she had drunk more than was good for her, had managed
to spill enough liquor to retain all the sobriety she needed; but, when they at
last rose, she swayed a little unsteadily.

"Now," she said, "you'll just buy me a half-pint for my head in the
mornin', an' then you'll walk as far as my door."

Still enjoying the piquancy of the affair, he obeyed her. He even

consented to come to her hall-bedroom with her—a room the exact
reproduction of that which she had formerly rented farther uptown—and
there, forgetful of the provision against the morning, they finished the half-
pint.

At last he stood up from the bed on which he had been sitting while she,
opposite, used the single chair.

"Vell," he said, grinning; "it's been good to see you again, und maybe I'll
gome back some efenin'."
 She rose before him. The light was at her back and her face resumed, as
she stood there, some furtive traces of its earlier grace. The eyes seemed to
soften, the cheeks were a natural pink beneath their coating of rouge, and
her russet hair, curling about her face, relieved the harder outlines and cast a
gentle shadow around the neck. She spread out her arms.

"Kiss me," she said.

He smiled and leaned condescendingly toward her.

"What's your hurry?" she murmured.

He looked at her, and the weak light and the strong liquor stood her in
good stead.

"I ain't in no hurry," he smiled.

She met him smile for smile—and then, in a sudden sense of triumph,
she flung back her head and laughed.

It was not until three hours later that he finally left her, but he left
hurriedly, for the remorseless gray light of morning was coming in at the
window, and it fell upon her as she wrapped a soiled pink kimona around
her shivering figure and slipped her feet into a pair of rundown Turkish
slippers.

"Good-by," he said, looking away from her.

"Wait a minute," said Mary. "I'll go with you to the door."

She did go. She followed him down the dark stairway, creaking noisily
under their shamed feet, and she stood for a moment in the black hall,
holding the brass knob of the door, as he passed to the step outside. Mary
slipped the dead-latch, ready to bolt the door.

"Max," she said.

He turned quickly, nearly knocking over, as he did so, the milk-bottles

that were lined, in a white row, upon the step.
 "Yes?" he returned, and grinned sheepishly.

She thrust out her towsled head and looked up and down the gray
morning street. The block was empty. She drew her head clear of the door.
She was still trembling, but from neither cold nor fear.

"You ain't goin' without kissin' me?" she asked.

But a reaction of disgust had seized him.

"Yes, I am," he said.

Mary's one hand tightened on the knob; the other flattened itself against
the nearest panel of the door, ready to push hard.

"All right," she replied, with a sudden change in her voice that, still low,
became tense and metallic. "You think I'm—I'm done for, Max. Well—
you're done for, too!"

The man's jaw dropped. His olive face was ashen. His eyes stared.

"What do you mean?" he asked.

Mary's mouth was wreathed in a smile.

"You know," she answered.

Max retreated so suddenly that he nearly fell down the stone steps.

"You've—you've——" he gasped.

"Yes," said Mary.

"It's a lie! You're tryin' to scare me!" His jaw worked spasmodically.
"It's a damned lie!" he repeated.

"You don't believe me?" the girl inquired.

 If she had looked for heroics, if she had feared melodrama, she was as
yet disappointed. The knees of Max shook under him; he was in abject
terror.

"It's a lie," he muttered over and over. "It's a damn' lie!"

"Think what you please," said Mary. She was still smiling, still serene.
"You believed I'd forgot, didn't you? Well, I didn't forget, Max Grossman,
an' now you'll remember. If you don't yet think I'm givin' you a straight
story, all you have to do is just one thing: wait."

Max uttered an inarticulate cry and threw himself at her, but he only
bashed his head against the closed door.

Mary had shut it, and in time. Behind it, in the dark hallway, she lay half
fainting.

"It's the last of you, Max," she laughed.

And it was.

XXVIII

HUSKS OF THE SWINE

Mary was too ill to go to work that night, and on the night following she
was no better. The shock, the spasm of success, the recoil, not moral but
physical, after the satisfaction of a supreme desire—these things were, of
themselves, enough to leave her prostrate. But, in addition to these, she had,
while standing at that open door, contracted one of those heavy colds to
which she was now rendered especially susceptible. Through long hours of
the day and the darkness she tossed among the hot sheets of her bed,
sometimes with her teeth clicking in a chill, again with her body burning in
a fever, but always revolving in her seething brain the details of the
vengeance that she had wrought.

Her physical sufferings mattered little to her. There were hours when
she was wholly incapable of feeling them. When the inertia of the state of
reaction began at last to wear away, it left her with a glow of recollection so
great that there seemed no place for lesser sensation. She had accomplished
her great work, she had achieved her mission. What she had done had been
done solely for her own heart's sake; there had been no delusion of a
celestial command, no distorted thought of a social duty; yet, the impulse,
however utilitarian, had been supreme, and its end filled her with a sense of
triumph that, for want of the proper title, she was sure was happiness.

A wiser head and an unwounded heart would have known enough of

life to see that even Max Grossman was not entirely to blame. A better
brain could have looked back into the past. It could have seen Max as the
type of all his kind, the symbol of every one of the great company of
slavers, the inevitable result of a system blind both to its own interests and
to the interests of the race. It could have seen the child, one of half a dozen
born to a woman that could not, properly, have cared for three. It could have
seen that child neglected, dirty, forgotten, locked, by day, in the bedroom
where the whole family tried vainly to sleep by night, learning the highest
facts of life from the worst of teachers: the cramped childish brain—and
going out, at last, upon the street, with passions prematurely developed and
perverted. It could have seen the social order shape that child into society's
enemy: the starved boy-pickpocket sent to the monstrously misnamed
"reformatory"; the same child branded as a criminal, with none to shelter or
to trust him, and with a knowledge, gained in the state's own institution,
which fitted him to be only a crafty gorilla to harass the state. It could have
seen the fatal line of least resistance as clearly in the resultant man as it is
seen in the life of him that does no more than wreck a bank or steal a
corporation, and, hideous as its course is in the one instance, it would have
seen that the line was the same in all.

But Mary never doubted her justice, and never regretted it. One only
thought troubled her: she was afraid that, by telling Max, she might have
given him a warning sufficiently early to defeat her own ultimate purpose.
It was a large part of her plan that he should know whose hand had struck
him, and, for a man in his business, the only way in which she could make
that knowledge certain was the way that she had followed. Yet what if he
were in time to profit by her information? What if, even were he too late, he
should guard and doctor himself with proper caution? She turned the
questions over and over in her mind, but she had always to end in the faith
that the worst had happened.

Sometimes, in the moments of exhaustion from the mad round of these

inquiries, she reverted for relief to matters that touched her less nearly, and
endeavored to occupy herself with the affairs of others. She thought of
Dyker, and without resentment. She knew that he would use her written
retraction to regain Marian's confidence, and she hoped that he would be
successful. Again she fell to speculating upon the fate of Carrie Berkowicz
and to wondering what had become of Katie. But upon her own past and
present she did not permit herself to dwell, and always, with the certainty of
a machine, her brain recurred to Max and her vengeance on him.

On the third evening, however, her landlady, entering with supper,

reminded her, without mincing matters, that the rent was due, and Mary
recalled that her little stock of money was exhausted.

"Can you wait till to-morrow morning, Mrs. Foote?" she asked.

Mrs. Foote was an ample woman, with round cheeks and robust frame,
whose only dissipations were an over-indulgence in ritualism, babies, and
the hospital. She had a high-church cleric to whom she confessed the sins of
her neighbors; a wraithlike husband whose sole occupation appeared to be
that indispensable to the regular increase of her family—and whom she
would otherwise have failed altogether to tolerate—and such a passion for
being ill that she could never quite believe in the illnesses of others.

"I can wait just that long, Miss Morton," she said; "but I'm sufferin' so
from rheumatism in my fingers that I just know my old gastric trouble is
comin' on ag'in, an' that'll mean another of them hospital-bills."

Mary raised her aching head.

 "You won't have to wait any longer," she answered.

"I'm glad of it, Miss Morton," responded Mrs. Foote, "for there was a
young lady lookin' at this room to-day an' she offered me a dollar more a
week for it, an' I wouldn't like to lose you."

"You won't lose me," said Mary, to whom even sustained conversation
was physical pain. "I'm goin' out to-night, an' I'll have plenty for you by the
mornin'."

"You're sure?" asked the landlady.

"Of course I am. It'd be a pity if I couldn't earn that much."

Mrs. Foote looked at Mary's face and seemed to doubt the foundation
for her assurance.

"Well," she sighed, "I certainly hope you can."

For some minutes after the door closed, Mary lay still. She had again
been brought face to face with the most poignant of tragedies, the tragedy
of living.

An hour earlier, had she questioned herself, she would have said that
she was careless of life, that neither this earth nor the quitting of it
interested her, that continued existence was a matter of indifference. Then
she was in that state of exultation above things mundane which is produced
only by great sorrow, great joy, or the great revenges that are both grief and
triumph. But now the words of the landlady had brought her back from the
indulgence of contemplation to the necessity of action. Mary's insidious,
implacable disease had completed what her business had begun, and what
her business alone would have completed far more slowly. The few
emotions that she was now capable of feeling were the more intense
because of their rarity, but their intensity was equaled by their brevity and,
when the moment had gone, it left her even more of a moral weakling than
it had found her.
 She knew Mrs. Foote and her tribe too well to deceive herself as to what
must happen should the morning dawn upon an empty stocking. Life held
nothing for which Mary greatly cared, but the instant of death contained all
of which she was afraid. She did not greatly want to harm others by plying
her trade in her present condition, but she could not think of others. Each
step would be a separate wound to her tortured body and her throbbing
head, but she understood that the landlady had to wring out the rents by the
means that conditions had forced upon her; and so the worst of fears, the
fear of poverty, which is the fear of death, took this sick woman from her
bed, dressed her in her best frock, and sent her out into the street.

Along Sixth Avenue, where fortune had often, theretofore, been kind to
her, she met no significant glances. A passing girl or two, having missed her
for the last few evenings, proffered a casual sympathy; but that was all.
Through the open doors of the Haymarket, she turned in, but there even the
women at first disregarded her. Several men that she recognized in the
boxes of the gallery around the little hall nodded, but immediately looked
away. The one man that she happened to know better than any of the others
did not appear at all to remember her, and his neighbor, who had frequently
accompanied her, signaled elsewhere.

She was lonely. She approached two women who were circling the
floor, arm in arm. She addressed them with the familiarity of the craft.

"Hello," she said.

The one woman smiled, but her companion, a formidable, tailor-made

personage, swelled with dignity.

"You better beat it," she declared.

Mary flushed.

"What's eatin' you?" she demanded.

"You don't belong here," the woman answered. She made a lofty survey
of Mary's finery, and then added: "Goin'?"
 Mary's heart sickened, but she stood her ground.

"No," she said, "I ain't."

The floor-manager was passing. The social arbiter turned to him.

"Will," she asked, and her shrill voice seemed to carry over all the
room; "what's this place comin' to? Throw that Fourteenth Street woman
out o' here!"

This was enough. Mary left the place, and, still aching in every limb,
turned through a narrow cross-street to Broadway. Her eyes swam as she
lingered before shop-windows in the hope that someone she passed would
accost her. Her throat was dry and it hurt her when she hummed into the
ears of careless pedestrians. Nobody seemed to heed her. The night was
cold, and she shook like a recovering drunkard. She mastered all her
strength to speak plainly to a complacent man in a great ulster.

"Hello!" she said, trying to smile. "What's your hurry?"

The man looked at her and swore.

"You must think I'm blind," he ended.

She knew that she looked ill, but she knew that she must find money.
She pleaded with age, because she knew it to be æsthetically tolerant; she
ogled youth, because she knew it to be inexperienced; and she stationed
herself at last near a saloon in a poorly lighted quarter, because she
concluded that the men leaving such places were the only men to whom she
was just then fitted successfully to appeal. It was one o'clock in the morning
before she could induce even one of these to give way to her, and he,
staggering with drink so that she had to support him with all her ebbing
powers, insisted on stopping in an alleyway when, for the first time, she
picked a pocket. A dollar and a half was all that she had as she left him, and
the next dark figure that she stopped—she did not look at his face or care
what sort of face it was—answered her with sharp laughter.
 "A two-spot?" he cackled. "You have a few more thinks comin', old
girl!"

"A dollar?" suggested Mary, tremulously.

"I got just a half—an' you ain't worth a cent more."

She took it—what would she not have taken?—and she worked on into
the dawn, on with a mounting fever and a sick determination, knowing now
that her chances grew with the approach of morning and finding herself,
when at last the morning came, with scarcely a dollar beyond the sum due
for rent.

During all the months that followed she skirted the dire edge of
starvation, more than half the time too ill to rise from her bed and aware
that she was at no moment fit to rise. As her cold grew steadily better her
deeper illness steadily increased. It thrived on every exertion and seemed to
gain each atom of strength that she lost. Things might thus continue for
almost any period, but she knew that her manner of life forbade absolute
cure, and that, at the end, there waited a slow and loathsome death.
Anticipation made her faint; the melancholia and terror, which are
symptomatic, sometimes nearly maddened her. The last vestiges of the
moral sense, so early injured by previous experience, were almost wholly
destroyed; there was no social consciousness; the appeal of the individual
widened until it occupied her entire horizon; there was room for nothing but
the craven passion for life.

Fat Dr. Helwig, when she went to see him, blinked at her out of his
deep-set eyes, and told her that she was not taking sufficient rest.

Mary twisted her helpless hands.

"How can I afford to take it?" she asked.

"Save your money," said he, patting her thin shoulders, and chuckling
prosperously. "You girls never put aside a cent."

"We don't earn enough."

 "Poof! That's what you all say. I know—I know. We men aren't such
fools as you take us for."

But Mary, as each evening she made up before her little mirror, noted
the gradual depreciation of her wares; each week she found it harder to pay
rent and retain enough money for food. Mrs. Foote seemed to come every
day, instead of every seventh, and yet each night business grew more
difficult. Whenever Mary missed a few evenings, or whenever she changed
her hunting-grounds, the police needed fresh payments. She surrendered
one uptown cross-street after another. At last she deserted Broadway and
patrolled only that Fourteenth Street which the woman at the Haymarket
had so scornfully referred to and which had so wonderfully burst upon
Mary's sight when she first stepped from the Hudson Tunnel upon the
surface of Manhattan.

Spring, summer, and autumn passed, and a lean winter followed them.
Mary caught another cold and was ill for a week. She went to work too
soon and had to go back to bed for several days and remain idle for several
nights. At last, with the ancient fear of the white race—the fear of that
poverty which is death—gnawing at her vitals, she struggled to her feet and
tramped once more along Fourteenth Street from Sixth Avenue to Third.

But now the sword descended. Even the Fourteenth Street saloon best
known for her purposes gave no fish to her net, and Eighth Street was little
better. She was too tired to go farther; she had, the next morning, to offer
Mrs. Foote only a third of what was due.

The landlady, whose bulk seemed to crowd the hall-bedroom, leaned

heavily against its frail door. Mary thought the woman's slow, brown eyes
more than commonly suspicious and her round face implacably hard. The
tenant, with all explanation frozen upon her lips, handed over the clinking
bits of money. They fell into the big, extended palm as a few drops of water
might fall into a basin. Mrs. Foote began slowly to count the coins.

Mary watched, in fascinated silence, the counting of those few pieces of

silver, each one of which seemed stained with her blood. She saw the
landlady's expression change to one of incredulity. She saw the counting
repeated.
 Mrs. Foote again thrust out her grimy fingers.

"What's this?" she demanded.

"It's——" Mary looked at the floor. "It's the rent," she concluded, in a
whisper.

"What's the rent?"

"That's all I have—just now. I thought—I thought, considerin' how long

I've been here, you might wait a day for the rest, Mrs. Foote."

The landlady opened her hand, and Mary's little store of coin dropped to
the bed.

"I can't take this," she said.

"You mean," asked Mary, with a quick gasp of hope, "that you'll let me
keep it till I get the rest?"

"No, I don't mean nothin' of the sort," said Mrs. Foote. "I mean I've got
to have the whole bill—right now."

Mary's heart sank.

"That's all I have," she said.

She had sunk to a seat on the tumbled bed, beside her scattered coins.
Her thin hands were locked across her knees; the dirty pink kimona slipped
lower from her shoulders at every frequent cough, and her eyes sought
those of Mrs. Foote in dumb appeal. Her russet hair fell dully disordered
about her hollow cheeks, and the rouge on her lips was purple.

"I'm sorry," pursued Mrs. Foote, who was too used to such incidents
greatly to concern herself; "but I've got to make my living like anybody else
does."

"I was expectin' some money this evenin'," said Mary.

 "Hump!" sniffed the landlady.

"You don't believe that?"

"I don't care, Miss Morton; I can't care."

"But I"—Mary's fingers knotted tighter about her knees—"I was

promised it," she lied, "an' I'm dead sure to get it then."

"I've heard that so many times," said Mrs. Foote, "that I knowed it by
heart three year' ago."

"I could pawn somethin'," suggested Mary.

The landlady swept the bare room with a critical glance.

"What?" she asked.

There was no adequate answer to be made. Mary had tried to pledge her
coat a few days before, and had been offered only an inadequate twenty-
five cents for it.

"Then you won't—you can't wait?"

"No, I can't. I'm a sick woman myself; my rent's due, Miss Mary, an' the
honest truth is that there's such a lot of women wantin' rooms that I'd only
be doin' a injustice to my children not to take in a lady that could pay
prompt—for a while."

Mary said nothing more. She packed her few belongings into her trunk,
left it in the hall to be called for, and, as the chill evening fell, went away
from the house with no idea where she was to find a lodging for the night.
For an hour, though she was still weak, and the time was as yet so early, she
walked up Broadway and, in the Forties, turned eastward for a few blocks,
and so south again. Not far from the Grand Central Station she saw a little
crowd gathered at a corner, and she stopped, rather for the luxury of
standing still than from any curiosity.
 The place was a church. Colored lights streamed from its rich stained-
glass windows. Through its swinging doors there stole the scent of flowers
and the sound of delicate music. A long row of carriages, the coachmen
walking up and down to keep warm, stretched far around the corner.

Mary, shivering, worked her way quietly through the group of men and
women on the sidewalk. In order to avoid a particularly entangled portion
of the press, she started to walk along the steps by the tower-entrance, and
then, seeing a side-door open, she listlessly turned toward it and looked in.

Far away up the vaulted nave the altar stood, white with damask and
yellow with candles. The chancel was a garden, the whole building heavy
with scent. Acolytes in scarlet were grouped about the robed priests. The
choir had risen and, preceded by a lad that bore aloft a great brass cross,
were forming into a singing procession, which slowly filed down the center
aisle.

With a subdued scuffle and swish, the congregation also rose as the
double line of choristers moved between them. Women craned their necks
and men, pretending to look stolidly ahead of them, looked really out of the
corners of their eyes. The choir, at the main door, divided and stood still.
High overhead a deep-toned organ was playing the wedding-march from
Lohengrin, and through the respectful line of white-clad boys there moved a
man of regular features with lowered lids that hid his eyes, and a crisp
brown mustache, which concealed his lips, and, on his arm, in the costume
of a bride, a tall, graceful, pure woman, whose face was like a Greek cameo
and in whose hand was a huge bunch of orchids and lilies-of-the-valley.

The fingers of a policeman touched Mary's arm.

"You'll have to get back," he said. "The people'll be comin' out in a

minute."

But Mary did not wish to move.

"I've got a right here," she answered.

 "You?" The policeman looked at her, and then laughed. "What right?"
he asked.

"Isn't that Miss Lennox?"

"It was."

"And Judge Dyker?"

"Sure."

"Well, I gave him his marriage-license."

The policeman's good-nature was amused, but he forced her back to the
street.

"No use," he said.

"An' I guess," said Mary bitterly—"I guess I paid for the bride's
bouquet."

He did not reply, nor would she have heard him had he spoken, for in
the stream of lesser guests now flowing from the rear of the church, which
had been assigned to them, she was met by Katie Flanagan.

Not the piquant Katie of that photograph which used to adorn the
bureau in the shabby tenement of bachelor Hermann Hoffmann, or the
saucy girl of the second-hand clothing-store, or yet the frightened clerk that
had at first evaded and at last defied the whiskered Mr. Porter. Those days
were patently passed; Katie, like many another strong soul, had faced
temptation and conquered it; and in the stead of the old days had come new
days that brought a maturity and a dignity with which Katie was
consciously satisfied. Her blue eyes were as glad as Mary remembered
them, but their happiness was calm; her black hair was gathered in a formal
knot, and her gown, though a better gown than that she used to wear, was of
a simplicity almost severe.

Nevertheless, when she saw Mary, who sought evasion, Katie came
frankly forward with outstretched hand. She recognized with regret, the
change in her former acquaintance, but, knowing, as she must have known,
its cause, she decided to ask no questions concerning it, and, if she offered
no assistance, she at least proffered no advice.

"I just come to see the last o' Miss Marian," she explained. "Near the
half of old Rivington Street's been tucked in here among th' swells to give
the good word to her—Jews an' Irish—an' if the rabbis won't mind for the
sheenies to come to such a heathen church, I thought Father Kelly might
manage to forgive me."

Mary's brain was just then too dull to make any but a commonplace
answer.

"You're lookin' well," she said.

"I ought to be, though there's a youngster expected. I tell Hermann—we

was married a few weeks after last election—I don't know how we'll keep a
family; but he just whistles an' says we'll make out some way, an' I guess
we will."

"I'm glad," said Mary, "that you're married."

"Well, so am I—most of the time. Of course, the man has some queer
ideas, but I'm doin' me best, with Father Kelly's help, to get 'em out of the
head of him, an' nowadays, when he goes to one of them Socialist meetin's
by night, I make him make up by goin' with me to early mass next mornin'."

She paused and surveyed again the pale woman before her. Essentially
Katie had not changed. She had still, and would always have, the big, kind
heart and the ready hand of her earlier days. But her condition had altered,
and Mary's had evidently again fallen; she looked through an alien
atmosphere, and her gaze was distant: the responsibilities and adjustment of
young married life shackled her, and must continue to shackle her until they
were no longer new. She did not know how to suggest any assistance, did
not even believe that it was desired; but, though she still felt that she must
refrain from intimate inquiry, one effort she tried to make.

"An' you," she asked—"how're you gettin' on, Mary?"

 Mary bit her lip.

"Fine," she answered, huskily.

"Are you——? There ain't——?" Katie floundered in a maze that she

would, a few months previously or a few months in the future, have cut her
way through with a strong directness. "There ain't nothin' I could——?"

Mary's head shook, almost mechanically. It was not entirely that she felt
unable to accept assistance from her former protector; it was rather that she
felt only that she must run away.

"Oh, no," she said, forcing a smile. "I'm doin' grand."

The gala crowd was sweeping about them. It jostled both girls and
threatened momentarily to separate them. After all, there was nothing more
to be said.

"I—I got to go," murmured Mary. "I got an appointment——"

"But you'll come to see us sometime, won't you Mary?" asked Katie,
and she gave her address. "We'll have a fine party at the christening an' I'll
want you to see the baby."

"Oh, yes," said Mary; "yes, of course."

But Katie was hesitant.

"You're sure I can't do nothin'?" she asked.

"No, no. I——" Mary caught and pressed with what warmth there was
left in her fingers, the Irish girl's hand. "Good-by," she concluded, and then,
in order to keep up the farce of an appointment, she got upon a passing car.

Even if panic had not possessed her, she could not have accepted
anything that Katie might offer. The most that could have been given her
would have been but temporary, and what she must have was a means of
earning a living.