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This page intentionally left blank
Essential Radiological Anatomy for the MRCS
Essential Radiological
Anatomy for the MRCS

Stuart Currie

Steven Kennish

and
Karen Flood
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore,
São Paulo, Delhi, Dubai, Tokyo

Cambridge University Press

The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by Cambridge University Press, New York

www.cambridge.org
Information on this title: www.cambridge.org/9780521728089
© S. Currie, S. Kennish and K. Flood 2009

This publication is in copyright. Subject to statutory exception and to the

provision of relevant collective licensing agreements, no reproduction of any part
may take place without the written permission of Cambridge University Press.
First published in print format 2009

ISBN-13 978-0-511-59552-3 eBook (EBL)

ISBN-13 978-0-521-72808-9 Paperback

Cambridge University Press has no responsibility for the persistence or accuracy

of urls for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
Every effort has been made in preparing this publication to provide accurate and
up-to-date information which is in accord with accepted standards and practice at
the time of publication. Although case histories are drawn from actual cases, every
effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this publication. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
To our loving families
Contents

Preface page ix
How to use this book x

1 Vascular 1

2 General surgery and urology 33

3 Head and neck 70

4 Orthopaedics 120

Index 159

vii
Preface

Nearly all surgical patients undergo some form of radiological imaging as part
of their diagnostic work-up. It is often the role of the surgical trainee to clerk
and examine the patient, and initiate emergent treatment and investigations in
the acute setting. A basic understanding of the role of imaging and its demon-
stration of relevant anatomy is a fundamental prerequisite to the appropriate
utilization of the radiological armamentarium.
Surgical trainees are not expected to interpret imaging to the point of issuing
a report; this is the role of the radiologist. Sound knowledge of radiological
anatomy can prove invaluable however in the initial reviewing of plain films,
and give the surgeon a more informed opinion in the radiological multi-
disciplinary meeting.
Over recent years the Membership of the Royal College of Surgeons (MRCS)
viva examination has increasingly made use of radiological imaging to facilitate
the discussion of anatomy relevant to every day surgical practice. Indeed, the
authors were questioned on sagittal magnetic resonance images of the brain,
male and female pelvis and radiographs of the chest and abdomen.
For many, examinations are stressful. The last thing a candidate needs is to be
faced with unfamiliar radiological images. This review of surgically relevant
radiological imaging aims to prevent initial uncertainties, and should allow the
candidate to rapidly progress to confidently discussing the anatomy and scoring
valuable points.
This book aims to provide you with a number of key advantages before
entering the exam. Firstly, you will become familiar with a range of images of
differing modalities (plain film, fluoroscopy, computed tomography and mag-
netic resonance imaging). Secondly, different planes of imaging are utilized, so
that you will not be fazed by an unusual coronal or sagittal view. You are also
provided with ‘favourite’ anatomy viva questions and concise but detailed
notes. Finally, the anatomical notes are correlated with surgical scenarios
enabling you to read around potential topics for clinical discussion.

ix
 How to use this book

Prerequisites

By convention, radiological images are presented in a way that equates to you

looking at the ‘anatomical man’ face to face. The patient’s right is therefore
found on the left-hand side of the image and vice versa, a so-called mirror image
effect. This applies to cross-sectional imaging such as axial computed tomog-
raphy and magnetic resonance, as well as plain radiographs.
Interpreting the image requires you to recognize the key organs or structures
and orientate yourself with regards to the plane of imaging. Once you have
worked out the plane of imaging, your brain will then help you identify
anatomy you expect to be found based on your 3D anatomical map.

Reminder

Axial or transverse – cross-sectional images. Think of the old magician’s trick of

sawing someone in half. Imagine the patient’s feet nearest to you, and the head
furthest away with a pile of contiguous ‘slices’ available for you to scroll through.
The right-sided structures are on the left-hand side of the image and vice versa.

Axial Image, (L) = left, (P) = posterior

x
 How to use this book xi

Coronal or frontal – the planes run from cephalad to caudad, separating the
patient into front and back portions.

Coronal Image, (L) = left, (F) = frontal

Mid-sagittal – the plane divides the patient from cephalad to caudad but this
time in an anterior to posterior direction through the midline.

Mid-sagittal Image (P) refers to posterior

xii How to use this book

Purpose

This book displays radiological images with labels highlighting various organs
and structures. Your aim is to identify the labelled anatomy and have a sound
anatomical knowledge with respect to surgical practice. You are not expected to
get all the answers correct first time around, so do not get despondent if you
struggle.
Remember that the examiners use radiological imaging as a springboard to
go on to discuss the relevant anatomy, which you should know. Mistakes with
image interpretation are tolerated (you are not expected to be a radiologist) as
long as the morbid and surgical anatomical knowledge is sound.
 1

Vascular

Question 1.1
Name the structures labelled on this chest radiograph.

Figure 1.1

Answer
A: Right 1st rib.
B: Trachea.
C: Right main bronchus.
D: Posterior rib.
E: Left main bronchus.
F: Right costophrenic angle.

1
2 Chapter 1: Vascular

Anatomical notes

The thorax is divided into two lateral compartments each containing a lung and
associated pleura, and a central compartment, the mediastinum, which con-
tains the other thoracic structures. Each lung is surrounded by a pleural sac,
created by two pleural membranes in close apposition. Pleural membranes:
* Visceral: lies in contact with the lung.

* Parietal: lies in contact with the diaphragm (innervated by vagus nerve),

pericardium and chest wall (innervated by intercostals nerves).

The pleural cavities are potential spaces between the pleura and contain a layer
of serous fluid that allows the layers to glide over each other during respiration.
The parietal pleura produces pleural reflections as it changes direction.
Reflections occur where the costal pleura becomes continuous with the media-
stinal pleura anteriorly and posteriorly, and with the diaphragmatic pleura
inferiorly. The visceral and parietal layers of pleura are continuous at the root
of the lung. The pulmonary ligament, a double layer of parietal pleura, suspends
from this region.
The lung root contains:
* Main bronchus.

* Pulmonary artery.
* Pulmonary vein.

* Bronchial arteries.

* Lymph nodes.

The vagus nerve runs anterior to the lung root, whereas the phrenic nerve runs
posterior to this structure.
During expiration the lung does not completely occupy the thoracic cavity,
creating potential pleural cavities.
* Costodiaphragmatic recess (diaphragmatic pleura in contact with costal

pleura).
* Costomediastinal recess (posterior to the sternum).
 Chapter 1: Vascular 3

Question 1.2
What type of image is shown below?
What thoracic level is it showing?
Name the labelled lobe/structure.

Figure 1.2

Answer
This is an axial lung CT (computed tomography) scan taken at the level of the
carina (T4/5).
A: Left upper lobe.
B: Left main bronchus.
C: Left oblique fissure.
D: Left lower lobe.
E: Right lower lobe.

Anatomical notes

The trachea begins at the level of C6 and continues inferiorly from the cricoid
cartilage to the carina (bifurcation) at the vertebral level of T4/5 (angle of
4 Chapter 1: Vascular

Louis). The right and left main bronchi pass inferolaterally from this level and
branch within the lungs to form the bronchial tree, consisting of secondary
(lobar) and tertiary (segmental) bronchi. Each bronchopulmonary segment has
an apex that faces the root of the lung and a base at the pleural surface.
The right main bronchus is shorter, wider and leaves the main bronchus at a
more vertical angle than the left main bronchus. The left main bronchus passes
inferolaterally, inferior to the arch of aorta and anterior to the oesophagus and
thoracic aorta to reach the root of the lung. C-shaped cartilage rings support the
bronchi.
The right lung is divided into three lobes by the oblique and horizontal
fissures. The left lung has two lobes, divided by the oblique fissure. Each lung
has the following surfaces:
* Costal surface.

* Mediastinal.

* Diaphragmatic.

The lung borders are as follows:

* Anterior.

* Inferior.

* Posterior.

Clinical notes
Due to the vertical course and greater width of the right main bronchus
there is a greater tendency for foreign bodies and aspirated material to pass
into it.

Antoine Louis (1723–1792) – French surgeon and physiologist.

 Chapter 1: Vascular 5

Question 1.3
Name the vascular structures identified on the chest radiograph.

Figure 1.3

Answer
A: Aortic knuckle.
B: Superior vena cava (SVC).
C: Left pulmonary artery.
D: Right pulmonary artery.
E: Left heart border: left ventricle.
F: Right heart border: right atrium.
G: Inferior heart border: right ventricle.

Anatomical notes

The mediastinum is the central part of the thoracic cavity which lies between the
pleural sacs. It extends from the superior thoracic aperture to the diaphragm and from
the sternum and costal cartilages to the thoracic vertebrae. An arbitrary line formed
between the sternal angle to the inferior border of T4 divides the mediastinum
into superior and inferior parts. The inferior mediastinum is subdivided by the
6 Chapter 1: Vascular

pericardium into anterior, middle and posterior parts. The heart and great vessels lie
within the middle mediastinum.
The heart has a base, apex, three surfaces and four borders. The base of the
heart is located posteriorly and formed mainly by the left atrium. The apex is
normally located in the left fifth intercostal space, mid-clavicular line in adults
and is formed by the left ventricle.
The three surfaces are:
* Sternocostal (right ventricle).

* Diaphragmatic (left ventricle and part of right ventricle).

* Pulmonary (left ventricle).

The borders comprise:

* Right heart border: formed by the right atrium and located between the

superior and inferior vena cavae.

* Left heart border: formed by the left ventricle and partly by the left auricle.

* Superior border: formed by the right and left auricles.

* Inferior border: formed mainly by right ventricle, partly by left ventricle.

 Chapter 1: Vascular 7

Question 1.4
What does the image below show?
Name the labelled structures.

Figure 1.4

Answer
The image shows a CT axial slice through the thorax, demonstrating the
chambers of the heart.
A: Right ventricle.
B: Interventricular septum.
C: Left ventricle.
D: Left atrium.
E: Descending aorta.

Anatomical notes

The heart has four chambers: two atria and two ventricles. The right atrium
receives blood from the superior and inferior vena cavae, the coronary sinus
and anterior cardiac vein. The crista terminalis is a muscular ridge which runs
vertically downwards between the vena cavae and separates the smooth-walled
posterior part of the atrium (derived from the sinus venosus) from the
8 Chapter 1: Vascular

rough-walled anterior portion (derived from true fetal atrium). It is also the site
of the sino-atrial node (SAN), the pacemaker of the heart.
The right ventricle is separated from the right atrium by the tricuspid valve
and from the pulmonary trunk by the pulmonary valve. The inflow and outflow
tracts of the ventricle are separated by a muscular ridge, the infundibuloven-
tricular crest. The inner aspect of the inflow tract has a number of irregular
muscular elevations (trabeculae carneae), whereas the outflow is smooth-
walled. A muscular bundle, termed the moderator band, crosses the ventricular
cavity from the interventricular septum to the anterior wall and conveys the
right branch of the atrioventricular bundle.
The left atrium has thicker walls, but is smaller than the right. The pulmo-
nary vein openings lie on its posterior wall, whereas the depression correspond-
ing to the fossa ovalis of the right ventricle lies on the septal surface. The atrium
communicates with the left ventricle via the mitral valve. The left ventricular
wall is marked by thick trabeculae carnae, with the exception of the fibrous
vestibule which lies immediately below the aortic orifice.
 Chapter 1: Vascular 9

Question 1.5
What does the image show and can you name the labelled structures?

Figure 1.5

Answer
This is a coronal magnetic resonance angiographic image demonstrating the
mediastinal aorta and its branches.
A: Left vertebral artery.
B: Common carotid artery bifurcation.
C: Left common carotid artery.
D: Left subclavian artery.
E: Arch of aorta.
F: Ascending aorta.
G: Descending aorta.

Anatomical notes

The arch of the aorta lies at approximately the level of T4. It gives rise to three
main branches: the right brachiocephalic (inominate), the left common carotid
10 Chapter 1: Vascular

and the left subclavian arteries. The right brachiocephalic artery divides into the
right subclavian and the right common carotid arteries.
The common carotid artery ascends the neck in the carotid sheath lying
medial to the internal jugular vein and anterior-medial to the vagus nerve. It
terminates by division into the internal and external carotid arteries at approx-
imately the level of C4. The internal carotid artery has no branches in the neck.
The vertebral arteries originate from the subclavian arteries. They ascend in
the neck through the upper six foramina transversaria of the cervical spine.
They converge at the junction between the medulla oblongata and the pons to
form the basilar artery. (Refer to the neurosurgery chapter for a more detailed
description of the cerebral circulation.)

Clinical notes
Occlusion of the subclavian artery proximal to the origin of the vertebral
artery may result in compensatory retrograde blood flow in that vertebral
artery. This has been termed the subclavian steal phenomenon.
Exercising the arm on the affected side results in a need for increased
blood delivery. Since the subclavian artery is occluded the exercising arm
achieves this requirement by ‘stealing’ the blood from the ipsilateral
vertebral artery. This leaves the brain momentarily deficient of blood
leading to transient neurological symptoms such as dizziness, unsteadiness,
vertigo and visual disturbances. The combination of retrograde vertebral
artery blood flow and neurological symptoms is termed subclavian steal
syndrome.
 Chapter 1: Vascular 11

Question 1.6
What does this image show and can you name the labelled structures?

Figure 1.6

Answer
This is an angiogram of the left arm, demonstrating the brachial artery and its
branches.
A: Brachial artery.
B: Medial epicondyle.
C: Radial head.
D: Ulnar artery.
E: Radial artery.
F: Anterior interosseous artery.
12 Chapter 1: Vascular

Anatomical notes

The brachial artery provides the arterial supply to the arm. It is a continuation of
the axillary artery and begins at the lower border of teres major, and terminates by
dividing into the ulnar and radial arteries at the level of the neck of the radius in
the cubital fossa, under the cover of the bicipital aponeurosis.
It is a superficial structure that can be palpated throughout its course, lying
anterior to triceps and brachialis, initially medial and then anterior to the
humerus. As it passes inferolaterally the artery accompanies the median
nerve, which crosses it from lateral to medial at the midpoint of the humerus.
In addition to the nutrient artery to the humerus, the brachial artery gives off
three collateral branches:
* Profunda brachii.

* Superior and inferior ulnar collateral arteries.

The profunda brachii is given off high up in the arm to the extensor compart-
ment where it runs with the radial nerve in the spiral groove of the humerus,
before dividing into two terminal branches. These terminal branches, together
with the ulnar collaterals, form an important anastomosis around the elbow
joint with recurrent branches of the radial and ulnar arteries. The brachial
artery is accompanied by paired venae commitantes.
 Chapter 1: Vascular 13

Question 1.7
What radiological technique is being used here?
Name the labelled structures and the boundaries of the cubital fossa.

Figure 1.7

Answer
This is a venogram of the left arm.
A: Cephalic vein.
B: Humeral shaft.
C: Basilic vein.
D: Median cubital vein.
E: Median vein of forearm.
14 Chapter 1: Vascular

Anatomical notes

The cubital fossa is the hollow triangular space on the anterior surface of the
elbow. Its boundaries are:
* Superiorly: an imaginary line connecting the medial and lateral epicondyles.
* Medially: pronator teres.
* Laterally: brachioradialis.
* Floor: brachialis and supinator.
* Roof: deep fascia that blends with the bicipital aponeurosis, superficial
fascia and skin.
The contents of the cubital fossa are: the brachial artery and terminal branches,
median cubital vein, median, radial and lateral antebrachial cutaneous nerves.
In the forearm the superficial veins (cephalic, median, basilic, and their
connecting veins) make a variable, M-shaped pattern. The cephalic and basilic
veins occupy the bicipital grooves, one on each side of biceps brachii.

Clinical notes
The cubital fossa is an important anatomical landmark for venepuncture.
The bicipital aponeurosis separates the brachial artery from the median
cubital vein. This was thought to be important when a patient underwent
phlebotomy from the median cubital vein in former days as the bicipital
aponeurosis protected the artery from the surgeon’s knife and therefore
gained the term: ‘grâce à Dieu’ (praise be to God).
Anatomy of the venous drainage of the arm and forearm is important,
especially in fistula formation for haemodialysis: radio-cephalic, brachio-
cephalic or basilic vein transposition.
 Chapter 1: Vascular 15

Question 1.8
What anatomy does this angiogram demonstrate?
Name the labelled structures.

Figure 1.8

Answer
The angiogram demonstrates the branches of the radial and ulnar arteries
A: Ulnar artery.
B: Radial artery.
C: Common interosseous artery.
D: Posterior interosseous artery.
E: Anterior interosseous artery.
F: Ulnar.
G: Radius.
16 Chapter 1: Vascular

Anatomical notes

The ulnar and radial branches are terminal branches of the brachial artery and
are formed opposite the neck of radius in the inferior part of the cubital fossa.
The larger of the two branches is the ulnar artery which leaves the fossa deep to
pronator teres and flexor digitorum superficialis, just lateral to the median
nerve. It lies on flexor digitorum profundis and lateral to flexor carpi ulnaris
before passing superficially to the flexor retinaculum.
At the level of pronator teres the ulnar artery gives off the common inteross-
eous artery which divides into anterior and posterior interosseous arteries.
The radial artery arises in the cubital fossa and descends inferolaterally deep
to brachioradialis, crossing anterior to the biceps tendon to lie on suprinator. It
then passes down the radial side of the forearm; lying on pronator teres, flexor
digitorum superficialis, flexor pollicis longus and pronator quadrates before
passing onto the lower end of the radius where its pulse is palpable lateral to the
tendon of flexor carpi radialis.
 Chapter 1: Vascular 17

Question 1.9
Name the vascular and bony labelled structures.
What is the clinical significance of the palmar arches?
What clinical test is performed to determine patency of the ulnar artery and
how is it performed?

Figure 1.9

Answer
A: Radial artery.
B: Ulnar artery.
C: Deep palmar arch.
D: Superficial palmar arch.
E: Index metacarpal.
F: Digital artery.
18 Chapter 1: Vascular

Anatomical notes

The ulnar artery gives rise to the superficial palmar arch (most distal) which lies
deep to the palmar aponeurosis. The deep palmar arch is derived from the
radial artery after it pierces the first interosseous muscle. The superficial and
deep arches are completed by communicating branches from the radial and
ulnar arteries, respectively.
The superficial arch gives rise to palmar digital arteries to the little, ring and
middle fingers, and the ulnar half of the index finger, whereas the deep arch
gives rise to the palmar digital branches to the thumb and remaining half of the
index finger (princeps pollicis and radialis indicis arteries). The dorsal arch also
gives rise to three palmar metacarpal arteries which, after supplying the small
muscles of the hand and the metacarpal bones, anastomose with the dorsal
metacarpal arteries (these give rise to the dorsal digital arteries) which arise
from the dorsal carpal arch.

Clinical notes
Allen’s test is performed to test the patency of the radial and ulnar arteries.
This is achieved by occluding the radial and ulnar arteries at the wrist, by
direct pressure. The patient is then asked to open their hand which should
be white. The pressure over the ulnar artery is released, whilst continuing to
occlude the radial artery and the palm should become pink. The test is
repeated again; this time releasing the radial artery and occluding the ulnar.
If the palm does not become pink this signifies an occlusion of the released
artery.
This is clinically important when planning surgical arteriovenous fistulae
and radial artery donation for coronary artery bypass grafting.
 Chapter 1: Vascular 19

Question 1.10
Name the labelled structures A–E.
At what vertebral level does letter B lie at?
Name the unpaired branches of the abdominal aorta and the vertebral levels
they leave the aorta.

Figure 1.10a

Answer
A: Abdominal aorta.
B: Bifurcation of abdominal aorta (L4).
C: Left common iliac artery.
D: Left external iliac artery.
E: Left internal iliac artery.

Anatomical notes

The abdominal aorta is a continuation of the descending thoracic aorta, as it

passes through the diaphragm at the level of T12. It ends at L4 where it
bifurcates into the common iliac arteries. The branches of the abdominal
aorta are described as visceral or parietal and paired or unpaired:
20 Chapter 1: Vascular

Unpaired branches:
* Coeliac trunk (T12).
* Superior mesenteric artery (L1).
* Inferior mesenteric artery (L3).
Paired visceral:
* Suprarenal.
* Renal.
* Gonadal.
Paired parietal:
* Subcostal.
* Inferior phrenic.
* Lumbar.
Unpaired parietal:
* Median sacral.

Clinical notes
Seventy-five per cent of abdominal aortic aneurysms are asymptomatic and
often an incidental finding. The common presenting symptom is pain
radiating into the back and flanks. Their complications are:
* Rupture: Intraperitoneal rupture causing exsanguination and
shock, whereas a retroperitoneal bleed can be
tamponaded by the surrounding tissues.
* Fistulation: Into bowel, IVC or left renal vein.
* Thrombosis: Leads to lower limb ischaemia.
* Distal embolism: May give rise to the clinical spectrum of acute
ischaemia to trash foot.
* Distal obliteration: Patients may present with symptoms of distal
occlusive disease such as claudication, rest pain or
gangrene.
The risk of rupture increases with the size of the aneurysm. Surgeons or
interventional radiologists would offer an elective repair or stent-grafting for
aneurysms > 5.5 cm in diameter.
See figure opposite: this is a T2-weighted sagittal MR which shows an
aortic aneurysm (white arrow).
 Chapter 1: Vascular 21

Figure 1.10b
22 Chapter 1: Vascular

Question 1.11
Name the arteries labelled on this angiogram.

Figure 1.11

Answer
This is an iliac angiogram.
A: Abdominal aorta.
B: Left common iliac artery.
C: Left internal iliac artery.
D: Left external iliac artery.

Anatomical notes

The common iliac arteries commence at the bifurcation of the aorta, just to the
left of the midline at L4. They pass inferolaterally and bifurcate anterior to the
sacroiliac joint to give the external and internal iliac arteries.
The external iliac artery descends laterally from the common iliac artery to
pass under the inguinal ligament at the mid-inguinal point where it becomes
 Chapter 1: Vascular 23

the femoral artery. The medial border of psoas major lies posterolaterally,
whilst the femoral vein lies medially. Anteromedially, it is covered by perito-
neum on which lies small bowel and sigmoid colon. It is crossed at its origin by
the ureter and then by gonadal vessels, genital branch of the genitiofemoral
nerve, deep circumflex iliac vein and vas deferens or round ligament.
24 Chapter 1: Vascular

Question 1.12
Name the labelled branches on this coeliac angiogram.
At which vertebral level does the coeliac axis leave the abdominal aorta?

Figure 1.12a

Answer
A: Coeliac trunk.
B: Left gastric artery.
C: Common hepatic artery.
D: Splenic artery.
E: Common hepatic artery.
F: Gastroduodenal artery.
The coeliac axis leaves the aorta at the vertebral level of T12.
 Chapter 1: Vascular 25

Anatomical notes

The coeliac axis supplies the embryological foregut and arises from the anterior
aspect of the abdominal aorta at the level of the lower border of T12 and after
1 cm divides into its terminal branches:
* Left gastric artery.

* Splenic artery.

* Common hepatic artery.

Left gastric artery

This passes superolaterally on the posterior wall of the lesser sac to reach the
gastro-oesophageal junction, where it divides into oesophageal branches. The
terminal gastric branches anastomose with the right gastric artery.

Splenic artery
This passes laterally, to the left, and runs in the posterior wall of the lesser sac. It
has a tortuous course which takes it along the superior border of the pancreas,
anterior to left crus of diaphragm, upper pole of left kidney and adrenal gland
before entering the lienorenal ligament to reach the splenic hilum.

Common hepatic artery

It passes inferolaterally to the right in the posterior wall of the lesser sac. It runs
towards the first part of the duodenum and gives off the gastroduodenal and
right gastric arteries. It then moves anteriorly as the hepatic artery to pass into
the inferior margin of the opening of the lesser sac. It lies anterior to the portal
vein, with the bile duct on its right as it ascends to terminate at the porta hepatis
as the right and left hepatic branches (see Figure 1.12b).
26 Chapter 1: Vascular

Figure 1.12b Hepatic angiogram. A, left hepatic artery; B, right hepatic artery; C, common
hepatic artery.
 Chapter 1: Vascular 27

Question 1.13
What radiological investigation does this image show?
Name the labelled anatomical structures.

Figure 1.13

Answer
A lower limb angiogram has been performed, demonstrating branches of the
left femoral artery.
A: Femoral head.
B: Common femoral artery.
C: Lateral circumflex femoral artery.
D: Descending branch.
E: Superficial femoral artery.
F: Profunda femoris.
28 Chapter 1: Vascular

Anatomical notes

The femoral artery is a direct continuation of the external iliac artery. It

commences posterior to the inguinal ligament at the mid-inguinal point (half
way between the anterior-superior iliac spine and the symphysis pubis) and
ends as it passes through the adductor hiatus in adductor magnus to become the
popliteal artery.
It has the following branches:
* Superficial epigastric.

* Superficial circumflex iliac.

* Superficial external pudendal.

* Deep external pudendal.

* Lateral circumflex femoral.

* Medial circumflex femoral.

* Profunda femoris.

* Descending genicular.

* Perforating branches.

Proximally it lies in the femoral sheath with the femoral vein medial to it.
Lateral to it and outside the femoral sheath lies the femoral nerve. The artery
lies on the tendon of psoas major and is separated from pectineus and adductor
longus by the femoral vein which comes to lie progressively more posterior to
the artery within the femoral triangle.
As the femoral artery enters the adductor canal it lies on adductor longus and
then on adductor magnus, with vastus medialis lying anteriorly. Initially it is
covered only by deep fascia then by sartorius.
The main branch of the femoral artery is the profunda femoris which is given
off posterolaterally just below the femoral sheath, 3.5 cm below the inguinal
ligament. It runs posteriorly between pectineus and adductor longus and passes
deep into the thigh where it supplies the deep structures and posterior and
medial compartments. The perforating and descending branches anastomose
with the genicular branches of the popliteal artery.
 Chapter 1: Vascular 29

Question 1.14
Label the anatomical structures demonstrated on this lower limb angiogram.
List the branches of structure C.

Figure 1.14

Answer
A: Superficial femoral artery.
B: Femoral shaft.
C: Popliteal artery.
D: Patella.
E: Medial tibial condyle.
30 Chapter 1: Vascular

Anatomical notes

The popliteal artery commences as the continuation of the femoral artery as it

passes through the adductor hiatus and ends as it passes under the fibrous arch
of soleus, immediately dividing into anterior and posterior tibial arteries. The
popliteal artery extends from a hand’s breadth above the knee and to the same
distance below it.
On entering the popliteal fossa it lies medial to the femur and becomes the
deepest structure, with only fat between it and the popliteal surface of the
femur. More distally it lies on the capsule of the knee joint and then on
popliteus. Initially biceps femoris is lateral to it and semimembranosus is
medial. It then lies between the two heads of gastrocneumius. It is crossed
laterally to medially by the tibial nerve and the popliteal vein with the vein
always between the artery and nerve.
The branches of the popliteal artery are:
* Superior medial and lateral geniculate arteries.

* Middle genicular artery.

* Inferior medial and lateral geniculate arteries.

* Anterior and posterior tibial arteries.

* Muscular branches.

Clinical notes
The popliteal artery is a site of aneurysms. They are commonest in men and
those over the age of 50. Atherosclerosis is the commonest cause, but others
include: collagen disorders, fibromuscular dysplasia, infection, or blunt and
penetrating trauma.
Complications of popliteal artery aneurysms are:
* Rupture.
* Acute occlusion and lower limb ischaemia.

* Tibial nerve compression.

* Popliteal vein thrombosis.

 Chapter 1: Vascular 31

Question 1.15
Below is an angiogram demonstrating the leg vessels.
Name the structures labelled A-F.

Figure 1.15

Answer
A: Popliteal artery.
B: Anterior tibial artery.
C: Peroneal artery.
D: Posterior tibial artery.
E: Shaft of fibula.
F: Shaft of tibia.
32 Chapter 1: Vascular

Anatomical notes

The anterior tibial artery commences at the bifurcation of the popliteal artery
just under the fibrous arch of soleus and supplies the structures in the extensor
compartment of the leg. It passes anteriorly between the heads of tibialis
posterior and descends on the interosseous membrane to cross the lower tibia
at the ankle joint, midway between the malleoli. Here it continues over the
dorsum of the foot as the dorsalis pedis artery, gives off the arcuate artery, and
runs between the 1st and 2nd metatarsals to join the lateral plantar artery in the
formation of the plantar arch.
The posterior tibial artery is the largest terminal branch of the popliteal
artery and supplies the structures of the posterior compartment of the leg. It
descends deep to soleus, lying on tibialis posterior, flexor digitorum longus, the
tibia and ankle joint. It passes behind the medial malleolus between the tendons
of flexor digitorum longus and flexor hallucis longus, accompanied by the
posterior tibial vein and tibial nerve. Below the ankle it divides into the medial
and lateral plantar arteries, which supply the foot.
 2

General surgery and urology

Question 2.1
Can you identify the labelled anatomy on this supine abdominal radiograph?
A B C D

E
Figure 2.1

33
34 Chapter 2: General surgery and urology

Answer
A: Tip of right lobe of liver.
B: Right kidney.
C: Left psoas shadow.
D: Tip of spleen.
E: Rectum.

Anatomical notes

The liver occupies the right hypochondrium. Traditionally it is divided into left
and right lobes by the falciform ligament antero-superiorly and the fissures of
ligamentum teres and ligamentum venosum posteriorly. The liver can be
further subdivided into eight segments, each with a separate blood supply
and biliary drainage. The left and right branches of the hepatic portal vein
and the three hepatic veins form useful landmarks and boundaries for describ-
ing segmental liver anatomy on imaging.
The spleen typically occupies the left hypochondrium and measures up
to 12 cm in cranio-caudal length. It is often not identified on a plain abdominal
radiograph but surrounding fat, as in this example, may outline its inferior tip.
The lateral aspect of the left psoas muscle is also well demonstrated due
to adjacent fat. The right psoas border is not as clear in this example, because of
overlying bowel gas.

Clinical notes
Plain film radiography of the abdomen is particularly useful as initial imaging
if bowel obstruction is being considered. Distended gas-filled bowel is usually
well demonstrated. However, if the obstructed bowel is fluid filled it may not
be clearly identified on plain film. Computed tomography is the investigation
of choice if there is ongoing clinical concern.
The jejunum is typically found to the left of the midline and towards the
hypochondrium; a transverse lumen diameter over 3.5 cm is considered
abnormal. The ileum is typically found to the right of the midline and
towards the iliac fossa; a diameter over 2.5 cm is abnormal. The jejunum
typically has a higher concentration of valvulae conniventes than the ileum.
This increase in mucosal surface area befits the jejunum’s role as the
predominant absorbing portion of the small bowel.
Gas-filled colon can usually be differentiated from small bowel on a plain
radiograph by the presence of haustra. These projections into the lumen can
be seen as linear areas perpendicular to the length of the colon wall, but only
partially traverse the width of the lumen. Valvulae conniventes in small
bowel on the other hand are seen to pass all the way across the lumen.
 Chapter 2: General surgery and urology 35

Question 2.2
This is a CT axial section of the upper abdomen. Can you name the labelled
structures?

A B C D E
Figure 2.2

Answer
A: Right hepatic vein.
B: Inferior vena cava.
C: Descending aorta.
D: Stomach.
E: Splenic flexure of colon.

Anatomical notes

There are three hepatic veins (right, middle and left), which drain blood away
from the liver, into the inferior vena cava (IVC).
The diaphragmatic foramen of the IVC is located at the level of the 8th
thoracic vertebral body. The IVC is accompanied by terminal branches of the
right phrenic nerve.
The oesophageal hiatus is located at the level of the 10th thoracic vertebral
body. The oesophagus is accompanied by the vagus nerves, oesophageal lym-
phatics and oesophageal branches of the left gastric vessels.
36 Chapter 2: General surgery and urology

The diaphragmatic foramen of the aorta is located at the level of the 12th
thoracic vertebral level. The aorta is accompanied by the azygos vein and
thoracic duct.

Clinical notes
A hiatus hernia is generally considered to be a protrusion of any portion of
the stomach into the thoracic cavity through the oesophageal hiatus. Sliding
hiatus hernias are by far the most common and the gastro-oesophageal
junction is typically displaced at least a centimetre above the level of the
diaphragmatic hiatus. The hiatus itself may be abnormally widened. There
is a somewhat complex relationship with lower oesophageal sphincter
incompetence and gastro-oesophageal reflux disease. Many patients with
large hernias are asymptomatic. Those who are symptomatic, however, may
benefit from a fundoplication procedure, which can usually be performed
laparoscopically.
Para-oesophageal hiatus hernias occur when the gastro-oesophageal
junction remains below the hiatus, but a portion of stomach rolls up
alongside it into the thoracic cavity. Mixed hiatal hernias consist of a gastro-
oesophageal junction within the thorax and an associated para-oesophageal
hernia. Large para-oesophageal hernias with abnormally rotated stomach are
at risk of volvulus with obstruction and ischaemia.
Other documents randomly have
different content
Countess Dolores, for example, is still very backward in that
respect."
Johannes understood next to nothing of this harangue, but he was
afraid of being taken for a fool if he let it be evident. So he ventured
the remark:
"I will do my best."
Van Lieverlee burst out laughing, and Johannes laughed with him,
pleased that he appeared to have said something smart. Thereupon
he took his leave, and went to look up Marjon, that they might go to
the city of the miners.

III
The walls of the little house were much thicker than those of the
houses of Dutch laborers. The small sashes, curtained with white
muslin, lay deep in the window-openings, and upon each broad sill
stood a flowering plant and a begonia.
When Johannes and Marjon looked in through the window, Markus
was sitting at the table. The housewife stood beside him, sleeves
tucked up, carrying on her left arm a half-sleeping child, while with
her right hand she was putting food upon his plate. A somewhat
older child stood by his knee watching the steaming: food.
The mother's cheeks were pale and sunken, from sorrow, and her
eyes were still full of tears.
"Nothing will come of it, after all," she said with a sigh. "If only he
had been wiser! Those miserable roysterers have talked him into it.
That's what comes of those meetings. If only he had stayed at
home! The husband belongs at home.
"Do not be afraid, mother," said Markus. "He did what he sincerely
thought was right. Who does that can always be at peace."
"Although he should starve?" asked the wife, bitterly.
"Yes, although he should starve. It is better to starve with a good
conscience, than to live in comfort by fraud."
This silenced the woman for a time. Then she said, "If it were not
for the children...." and the tears flowed faster.
"It is exactly on account of the children, mother. If the children are
good, they will thank the father who is struggling for their sakes,
even though he struggle in vain. And there is something for them
still, else you would not have been able to give to me—the stranger."
Markus looked at her smilingly, and she smiled in return.
"You—you should have our last mouthful!" said she, heartily. Then,
glancing toward the window, she added: "Who are those young
scamps looking in? And a monkey with them!"
Then Markus turned around. As soon as the two standing outside
recognized his face, they shouted "Hurrah!" and rushed in without
knocking.
Marjon flew to Markus, threw her arms about his neck, and kissed
him. Johannes, rather more shy, clung to his hand. Keesje, being
distrustful of the children, peered around the place with careful
scrutiny.
Then there followed in Dutch a brisk, confused interchange of
information. All the adventures had to be narrated, and Marjon was
very happy and communicative. The mother kept still, looking on
with a discontented air, full of her own troubles. The noise awakened
the half-slumbering child, and it began to cry.
Then the husband came home, morose and irritable.
"What confounded business is this?" he cried; and the two were
silent, slowly comprehending that they were in a dwelling full of
care. Johannes looked earnestly at the weary, care-seamed face of
the man, and the pale, anxious features of the mother, wondering if
there was any news.
"Hollanders?" asked the miner, seating himself at the table, and
holding up a plate.
"Yes, friends of Markus," replied the wife. Then, in assumed
calmness, she asked: "Is there any news?"
"We have the best of it!" said the husband, with forced cheerfulness.
"We win—we surely win. It can't be otherwise. What have you to say
about it, Markus?"
But Markus was silent, and gazing out-of-doors. Swearing because
the food was not to his taste, the man then began to eat. Marjon's
merriment subsided. The wife shook her head sadly, and kissed her
child.
"You need to look out, you young rascals," said the man, all at once.
"They are searching for you. Have you been pilfering? Which of you
is the girl in disguise?"
"Iam!" said Marjon. "What do they want of me? Now what if I have
no other duds?"
"Are you a girl?" asked the wife. "Shame on you!"
"Has not Vrouw Huber a spare garment for her?" asked Markus.
"She has so many daughters!"
"We may need to pawn them all," replied the wife. But Johannes,
with a manly bearing, cried: "We can pay for them. I have some
money!"
"O-o-oh!" said the others doubtfully, while Markus simply smiled.
Thus Marjon was soon back again in her girl's apparel—an ugly red-
checked little frock. Keesje alone was satisfied with the change.
"Have you been singing much?" asked Markus.
"Yes, we sing every day," said Marjon, "and Johannes has made
some nice new songs."
"That is good," said Markus. Then, turning to husband and wife:
"May they sing here a little?"
"Sing! A pretty time for singing!" said the wife, scornfully.
"Why not?" asked the husband. "A nice song is never out of place."
"You are right," said Markus. "It is not well to hear nothing but
sighs."
Marjon softly tuned her guitar; and while the husband sat beside the
brick stove, smoking his pipe, and the wife laid her little one in bed,
the two children began to sing a song—the last of those they had
made together. It was a melancholy little song, as were all those
they had sung during the last weeks. These were the words:
"If I should say what makes me sad,
My effort would be all in vain;
But nightingales and roses glad
They whisper it in sweet refrain.

"The evening zephyr softly sighs

In strains one clearly understands;
I see it traced high o'er the skies
In writing made by mystic hands.

"I know a land where every grief

Is changed into a mellow song;
Where roses heal with blushing lips
All wounds and every aching wrong.

"That land, though not so far away,

 I may not, cannot enter there;
It is not here where now I stay
And no one saves me from despair."
"Is that Dutch, now?" asked the miner. "I can't understand a bit of
it? Can you, wife?"
Weeping, the wife shook her head.
"Then what are you snivelling for, if you don't understand?"
"I don't understand it at all; but it makes me cry, and that does me
good," said the wife.
"All right, then! If it does you good we'll have it once more." And the
children sang it over again.

When they went away, they left the family in a more peaceful mood.
Markus took his place in the middle, between the two children,
Keesje sitting upon his shoulder, with one little hand resting
confidingly on his cap, attentively studying the thick, dark hair at his
temples.
"Markus!" said Johannes. "I do not understand it. Really, what has
my grief to do with theirs? And yet, it did seem as if they were
crying over my verses. But my little griefs are of so little account,
while they are anxious about things so much more important."
"I understand, perfectly," said Marjon. "Awhile ago, they might beat
me as hard as they pleased, and I wouldn't utter a sound. But once,
when they had given me a hard whipping, I saw a forlorn little kitten
that looked quite as unhappy as I was, and then I began to cry with
all my might, and it made me feel better."
"Then you think, children, that all sorrow suffered is one single
sorrow? But so is all happiness one happiness. The Father suffers
with everything, and whoever comforts a poor little kitten, comforts
the Father."
These sayings made things more plain to Johannes, and gave him
much to ponder over. He forgot everything else, until they were
again in their lodgings—two little rooms in an old, unoccupied mill.
Here they were given some bed-clothes, by a girl from a near-by
lodging-house. Marjon now slept apart, while Johannes and Markus
stayed together, in one room.
The next morning, while they were drinking coffee in the dark little
bar-room of the lodging-house, Johannes felt he must speak of what
lay on his heart. He brought out the fragrant, violet-colored note,
also the one adorned with the crown and the blue sealing-wax; but
in his diffidence even his hope of an understanding with Markus
drooped again.
"I smell it already!" cried Marjon. "That's the hair-dresser scent of
that fop, with his tufted top-piece."
That angered Johannes. "Don't you wish you could make such
poems as that 'fop' can?"
And, nettled by this disrespect of his new friend, he sprang to his
feet, and began excitedly repeating the verses. He had his trouble
for his pains. Markus listened with unmoved countenance, and
Marjon, somewhat taken aback, looked at Markus. But the latter said
not a word.
"I'll tell you what," she exclaimed at last, "I don't believe a bit of it!
Not a darn bit."
"Then I'll tell you," retorted Johannes, sharply, "that you are too
rude and coarse to understand things that are elevated."
"Maybe I am," said Marjon in her coolest, most indifferent manner.
Then Johannes spoke to Markus alone, hoping for an understanding
from him. What he said came out passionately, as if it had long been
repressed, and his voice trembled with ready tears.
"I have thought for a long, long time, Markus, that there was no use
in trying. I cannot bear anything rude and rough, and everything I
have yet seen in people is rude and rough—neither good nor
beautiful. It cannot be that the Father meant it to be so. And now
that I have found something fine, and exquisite, and noble, ought I
not to follow it? I had not thought that there were anywhere such
beautiful human beings. Markus, they are the most beautiful of all I
have ever seen. Their hair is like gold, Markus. Not even the elves
have more beautiful hair. And their little feet are so slim, and their
throats so slender! I cannot help thinking of them all the time—of
the pretty, proud way they raise their heads, of their sensitive lips, of
the beautiful, upturned curves at the corners of their mouths, and of
the music in their voices when they ask me anything. They danced
together to the music, hand in hand, and then their nice smooth
stockings peeped out, together, from under their little velvet dresses.
It made me dizzy. One of them has blue eyes, and fuller, redder lips.
She is the gentler and more innocent. The other has greyer, more
mischievous eyes, and a smaller mouth. She is more knowing and
roguish. She is the fairer, and she has little fine freckles just under
her eyes. And you ought to see them when they run up to their
mother, one on each side, when all their hair tumbles down over her,
in two shades of gold—brown gold and light gold—that ripples
together like a flowing river! And I saw the diamonds in their
mother's neck, sparkling through it all! You ought to hear them
speak English—so smoothly and purely. But they speak Dutch, too,
and I would much rather hear that. One of them—the innocent one
—lisps a little. She has the darkest hair, with the most beautiful
waves in it. But I could talk more easily with the other one. She is
more intelligent. And the mother, also, is so attractive in every way.
Everything she says is fine and noble, and every movement is
charming. You have a feeling that she stands far, far above you, and
yet she acts in everything as if she were the least of all. Isn't that
lovely, Markus? Is it not the way it should be?"
Markus made no reply, but looked straight at him, very seriously, and
with a puzzling expression. It was kind, but wholly incomprehensible
to Johannes.
In his excitement Johannes kept on: "I have just come into a
consciousness now of something in the world of people, of which I
knew nothing whatever before. My friend Walter, the one who made
that poem, lives in that world. She—" pointing to Marjon—"has no
idea of it. That is not her fault. I had no idea of it before. But I am
not surly, like her; I do not scoff at it just because I do not belong
there yet. It is a world of beauty and refinement—a sublime world of
poetry and art. Walter wishes to lead me into it, and I think it silly in
her now to jeer about it. Do you not think it silly, Markus?"
Markus' eyes remained as serious and puzzling as ever, and his
mouth uttered not a word. Johannes looked first at one, then at the
other, for an answer to his question.
At last Markus said: "What does Marjon say?"
Marjon, who had been leaning forward as she sat, lifted up her
head. She no longer looked indifferent. Her cheeks were glowing,
and her eyes, with their dry, red rims, seemed to be afire. She
stared with the fixed, glittering look of one in a fever, and said:
"What do I say? I have nothing to say. He thinks me too rude and
rough. Possibly I am. I swear sometimes, and Keesje smells. I can't
endure those people, and they don't want anything to do with me—
certainly not with Kees. As Jo has need of finer companionship now,
he must choose for himself."
"No, Marjon, you do not understand me; or do you not wish to
understand?" said Johannes, sadly. "It is not because I have need of
it, but because it is good. It is good to enter a finer life—into a more
elevated world. Is it not so, Markus? You understand me, do you
not?"
"I understand," said Markus.
"Tell her, then, that she must come too—that it would be better so."
"I don't think it would be better," said Marjon, "and I'm certainly not
going with you."
"Tell us, then, Markus, while we have you with us—tell us what we
ought to do. We will do as you say."
"I don't know yet whether I will or not," said Marjon.
Then Markus smiled, and nodding toward Marjon, he said: "Look!
She knows already we must not promise obedience to any one. Let
him who promises obedience promise it to the Father."
"But you are so much wiser than we are, Markus."
"Is it enough that I am wiser, Johannes? Do you not wish to become
wiser yourself? Because I can run better, ought you to let me carry
you? How will you ever learn to run, yourself?"
Marjon stared at him fixedly, with her flashing, flaming eyes, while
two red spots burned upon her pale cheeks. She stepped up to
Markus and pressed her hand upon his mouth, exclaiming
passionately:
"Do not say it! I know what you are going to say. Don't say it; for
then he will do it, and he must not! he must not!"
Then she hid her face on Markus' arm. Markus laid his hand upon
her head and spoke to her tenderly:
"Are you not willing, then, to grant him what you yourself demand—
that he should be doing what he himself, not some one else, thinks
right?"
Marjon looked up. Her eyes were tearless. Johannes listened quietly,
and Markus continued:
"There are frightful events, children, but most of them are not so
bad as they seem to be. The fear of them, only, is bad. But the only
events that you should dread come through not doing what you
yourself think right—yourself, children—yourself alone, with the
Father. The Father speaks to us also through men, and through their
wise words. But they are indirect vehicles; we have Him within
ourselves—directly—just as you, Marjon, are now resting upon my
bosom. He wills it to be so, and there we must seek him—more and
more.
"Now there is a great deal of self-deception. Self is a long while blind
and deaf, and we often mistake the Devil's voice for the voice of
God, and take the Enemy to be the Father. But whoever is too fearful
of straying never leaves his place, and fails to find the right way. A
swimmer who dares not release his hold upon another—will drown
when in peril. Dare then, children, to release your hold upon others
—all—all —to follow the Father's voice as it speaks within yourselves.
Let all who will, call evil what seems to yourselves good. Do this,
and the Father will not be ashamed of you."
"But understand me well; close your ears to no one, for the truth
comes from all sides, and God speaks everywhere. Ask the opinion
of others, but ask no one else to judge for you."
They were all silent for awhile. At last Marjon stood up, slowly, with
averted face, and flinging back her short, ash-blonde hair from her
forehead, she stepped up to Keesje, who, fastened to a chain, sat
shelling nuts. She loosened his chain, and said gently and
affectionately: "Coming with me, Kees? I know very well what is
going to happen now." Then she had him leap to her shoulder, and,
without once looking round, she went out into the street.
"Do you also know, Johannes?" asked Markus.
"Yes!" said Johannes, resolutely, "I am going!"
 IV
And so Little Johannes took leave again of his Guide and of his
friend, and went forth to seek a finer and a nobler sphere of life.
He did not do this now in a heedless way, as when first he left his
father, and, afterward, Windekind; nor partly by compulsion, as
when he chose Vrede-best rather than the gypsy-wagon.
He was acting now quite voluntarily, according to his own ideas—not
recklessly, but in harmony with his convictions. Ought we not to
admit that he was making good progress? Indeed, he thought so
himself.
How well he recollected his first talk with Markus, during the storm,
about remembering and forgetting! What he was now doing,
however, did not seem to him disloyal. True, he was turning away
from friends, but he was following that which he took to be the mind
of his dearest friend, even as Markus had taught him.
He was resolved to combat the sorrows of humanity. But first of all,
he most become a good man himself, and he agreed with Van
Lieverlee that it was the proper thing for a good man to be also a
clever one, and to live a fine life.
Hitherto, there had been too little of that which was beautiful around
him. With regard to his face, he had a vague idea that it was plain.
But that he could not very well help. All the more, it behooved him
to have a care for his clothes. Every flower and every bird presented
a more comely appearance than did he. His cap and jacket were
formless, ragged, and rain-spotted. His shoes were worn and out of
shape. And while so attired, the thought of becoming the guest of a
countess, and of appearing beside Van Lieverlee, was not a little
distressing.
Happily, he now possessed a little money—not much, to be sure, for
he had his traveling expenses to meet, but yet he could spare a little
for a few purchases. And that was a serious question for Johannes,
involving much thought—how he could array himself the most finely,
at the least cost.
He first bought a white, starched "dicky," and with it a ready-made
tie—black—not venturing, when he thought of Van Lieverlee's
gorgeous cravats, to select a colored one. Then for his dicky he
selected studs with little green stones in them. They looked like
emeralds, but they were only green glass. The studs were not a
necessity, for the dicky fastened at the back. But their modest
twinkling simply attested his toleration of outward adornment. He
bought also a stiff, round hat, a cloak, and a pair of new shoes. That
the shoes pinched and pained him was a small matter. He was
pleased at the odor of new leather which they spread around, and
liked their loud squeaking still better.
They did not squeak at first, to his distinct disappointment; but after
an hour or two—there it was! They began to creak and squeak, as if
proclaiming to everybody that from this day forward he became part
of the higher life, and one of the finer sort of human beings.
Finally—a pair of kid gloves! But these he dared not put on after he
had them. As little did he dare leave them off, for they had cost a
good deal, and the money must not be thrown away. So he settled
the question by wearing one and carrying the other. He seemed,
indeed, to remember that this was the mode.
And a traveling-bag now seemed to him the ideal—the acme—of
dignity. But he had nothing to put into it. To buy more for the mere
sake of filling it was not to be thought of, and to carry it for the
mere sake of appearances ran counter to his ideas of sincerity and
honesty. Aunt Seréna's old satchel he left behind with Marjon.
The leave-taking was not hard for him. No, indeed! He was too full
of the new life which awaited him. Never had he felt more fully
convinced that he was taking the right path—that he was going to
do the right thing.
Markus had said that we must seek for happiness and prosperity, as
well as for goodness. Johannes felt happier than he ever had felt
since leaving Windekind. Did not that prove that he was in the right
way?
And what was the Father's voice of which Markus had spoken, if not
this inner joy? It was not, however, the audible, usual voice,
sounding in Dutch, or some other tongue. The Bible, indeed, said so;
but that was not now the way. Surely, then, it must be this feeling of
joy and of glad anticipation that he now experienced.
Does it not seem to you that Johannes had advanced? I do not
believe that you would have reasoned better than he did. And if you
were not taken in as he was, it would have been more from good
luck than from wisdom.
At first Van Lieverlee had promised to accompany him; but at the
last moment, without giving a reason, he wrote to recall his promise,
and let Johannes go alone.
In the corner of a third-class railway coach, among a strange people,
he sped through a foreign country. He was at rest and contented,
because he was going to the two children. It was as great a pleasure
to him as if he had been traveling to the home of his parents. Where
those dear, beautiful little beings were, there was his home. He
looked at the foreigners with interest. They seemed less coarse and
clownish, less ugly and unmannerly, than his own people. They were
much more merry and agreeable, also more obliging to one another.
Johannes was on the alert for an occasion to do the polite thing.
However, as he did not speak the language very fluently, he sat in
his corner wrapped in his cloak, listening quietly, and in a friendly
mood, to the scraps of conversation that came to him. This was
carried on in the rattling, jolting car, with loud laughter and
vehement gesticulations.
At night he slept once more on the leather-covered benches of a
boat. This time it was not on the smooth Rhine, but on the mighty,
swelling ocean. All around him were people to whom he had nothing
to say. Only, his neighbor on the leather bench requested him not to
kick his head. Then he made himself as small as possible, and lay
farther away, and quite still.
About midnight he took a peep around the cabin, hardly knowing
whether or not he had been asleep.
The people lay at rest. Most of them appeared to be asleep—some
making queer noises. The light was dim, and, in the semi-darkness,
the lamps swung mysteriously to and fro, and the plants that stood
upon the table were all of them quivering. One could hear, above the
soft jingling and creaking everywhere, the quaking and dull
throbbing of the engines. Outside, the water was hissing and
rushing, and dashing along the sides of the vessel.
Beside the table sat a lone passenger—a tall, dark figure. He was
motionless, his head resting upon his hand.
Johannes gave him a good look. He seemed to have on an
amazingly big, spacious cloak, full of folds; on his head was a broad-
brimmed hat. The one hand which Johannes could distinguish looked
very thin and white.
How familiar the man looked, though! Johannes expected
immediately to hear the sound of a well-known voice. He thought of
Markus, then of his father....
Suddenly, the emaciated hand was removed, and the face turned
slowly round toward Johannes. Only the white beard came into view.
The rest remained in the shadow of the hat. Then Johannes
recognized him.
"Friend Hein!" said he. And he was much more at his ease than the
first time he had seen him—in fact, not at all afraid.
"How do you do?" said Death, nodding. How very kind he looked,
and how much more human! Not a bundle of bones with a scythe!
He looked instead more like a kind, old—very, very old, uncle.
"What are you doing here?" asked Johannes.
"Things!" replied Death, drily.
"Are we going to be shipwrecked?"
Johannes had come to this conclusion without any special alarm. It
even seemed to him just now that a shipwreck would be a rather
interesting incident.
"No, no!" said Death. "Would you really like that?"
"I would not want it, but neither would I be afraid of it."
"The last time we met, Johannes, you asked me to take you with
me."
"I would not ask you that now," said Johannes; "life is too pleasant
now."
"Then you are not afraid of me this time, Johannes?"
"No; for now you look so much more friendly."
"And I am friendly, Johannes. The more you try your best to live a
fine life, the more friendly I become."
"But what do you mean, friend Hein? I should think the finer life
became, the harder it would be to leave it."
"It must be the right sort of fineness, Johannes—the right sort."
"Then it must certainly be that I am seeking the right kind now, or
you would not look so much more friendly."
"You are indeed seeking it, Johannes; but look well to it that you
also find it. Take care! Take care! I should like when I come again to
look most friendly, dear Johannes, and you must be careful to have
it so."
"What shall I do, friend Hein? How can I be certain of the right way
to live? How can I make you look friendly when you come again?"
But Death turned away his pale face, gave a slight shake of the
head, and continued to sit immovable and silent. Once again
Johannes asked him a question, but it was of no avail. Then his head
grew heavy, his eyelids drooped, and everything vanished under the
veil of slumber, while his resting-place quivered and shivered above
the heaving waters.

When on deck, the next morning, the world looked again most
bright and cheerful. The sun was shining warmly, the fresh, blue sea
was sparkling in the light, and there, in front of him—there lay the
foreign land—a long line of grey-white coast, basking in the October
sunshine. On the hills Johannes saw little houses standing out in full
sight; and he thought of the pettiness of life in those houses—of
dressing, of bread and butter, and of little children going to school;—
everything so trite and trivial, in what for him was so strange and
great.
They coursed up a large river, much broader than the Rhine. The
sea-gulls circled over the yellow water, and rested on the sand-banks
and the muddy shores. The fishing-boats tacked in zig-zags all
about, and throngs of ships and steamboats came to meet them. At
last there loomed in the distance, enshrouded with a grey fog, a
giant city—a dark maze of masts and chimneys and towers. It was
sombre, awful, incomprehensible.
If Johannes had not been so absorbed in thinking of the two
children, he would have paid more attention to the city. As it was, he
only accepted it for a fact—the unforeseen shadow of a mysterious
substance—an ominous premonition, like the rumbling of the ground
preceding an earthquake: an instant later all fear is over, and one
thinks no further about it.
So it was with Johannes; the great city, the miners—everything was
forgotten, when he heard the loved voices of the two little girls.

They lived in a country-seat which to Johannes seemed a small

palace. It was built of red brick and grey limestone, and stood on
the summit of a hill, close by the shore. In the garden were dark
cedar-trees and holm-oaks, and large plots of rhododendrons. The
grass was short and even—quite like green velvet; and through it led
neat, trim paths of yellow gravel.
The day was far from being so pleasant as Johannes had expected.
In fact, it was very unpleasant. To be waited upon by a lackey, as
one conies without a trunk, from a third-class carriage, is far from
funny. Johannes had not heretofore had such a trying experience.
Indoors, it was very still and stately. The children were at their
lessons, and for the first hour were invisible. Johannes received an
unfavorable impression of fashionable life. He wished that he had
not come. His hopefulness and confidence suddenly took flight. He
tripped over a rug of white bearskin, and ran against a glass door,
thinking it was open—just as if he were a bumblebee behind a
window-pane. He wondered which was the quickest way out, and
wished he were with Markus again, in the small tavern. He was not
very far from crying.
On a couch in the quiet reception-room, beside a softly crackling
coal fire, sat the countess. Johannes strode up to her, and made an
awkward bow. A number of dogs, as many as seven, snapped and
yapped about his shin-bones. He thought of his dicky and the green
glass studs, and felt that they could be making next to no
impression. The countess looked as if she did not quite remember
who he was, nor what could have been his object in coming.
"Sit down," she said, in English, with a formal smile, and a weary
tone of voice; "I hope you have had a pleasant journey."
Johannes took a seat and, as he did so, observed that some one else
was in the room. He tried again to bow, but his attempt was
unnoticed.
That other indeed was a most impressive personage. She lay back in
an armchair, so enswathed in white lace, swan's down, gauze, and
tulle as to look still larger than she really was. Upon her head was a
huge hat, bearing natural-sized plums and peaches, artificial blue
flowers—forget-me-nots and corn-flowers—besides a blue gauze
veil. Her face was amazingly big, and highly colored by nature, but
toned down with powder to a rosy flush. It was somewhat pimply,
and more or less moustached. Her fat, red, shiny hands were rigid
with jeweled rings; and, although it was not at all warm, she waved
incessantly a large fan of white ostrich-feathers, in the midst of
which glittered purple and green precious stones. Most wonderful
bangles of gold and silver—little pigs, crosses, hearts, and coins—
hung in a great bunch upon her bosom, from a long, many-stranded
necklace. A slender crutch with a gold handle stood beside her chair,
and on the table at hand, a small green parrot was eating grapes.
The seven little dogs—all of them white, with pale-blue ribbons
around their necks—probably belonged to her. They sat in a
threatening circle, as if awaiting the word, and sharply eyed
Johannes' ankles.
"What does that boy want?" she asked, in a deep, heavy voice,
without even looking at Johannes. And before and answer could
come, she called, "Alice!"
Instantly, there appeared from behind a curtain, just as in a comedy,
a trim, spruce lady's-maid. She was dressed in black, with cap and
cuffs of dazzling whiteness. With quiet little steps and mincing
manners, she glided up to the large lady, and offered a smelling-
bottle, at which that person began to sniff industriously.
Johannes sat there in extreme embarrassment. He felt that the
costly cut-glass smelling-bottle concerned himself. It cried out, in the
keen language of its hundreds of cut facets, "You smell of the third
class!"
He sat like one rooted to the spot, and all unnerved, looking at the
smelling-bottle as if he wished it was a dynamite bomb which would
promptly send himself, the fine house, and all his beautiful illusions,
flying into space.
Then Countess Dolores came to his rescue.
"Dear Lady Crimmetart," said she, in a coaxing voice, "this is a very
interesting youth—really, very interesting. He is a young poet who
sings his own compositions. Is it not so, Johannes? They are so
charmingly melancholy—really, charmingly so! Indeed, you must
hear them, dear friend. I am sure they will please you."
"Really?" said the deep voice; and the blue goggle-eyes in the
frightfully big face glared at Johannes.
"Oh, yes, Lady Crimmetart," continued the countess; "but that is not
all. Johannes is also a medium—a sensitive—who can see all kinds of
elementals—sometimes even in broad daylight. Is it not so,
Johannes?"
Johannes was too much distressed and confounded to do more than
give a nod of stupefied acquiescence.
"Really?" said Lady Crimmetart, in a voice like that of a ship's
commander in heavy weather. "Then he must come to my party next
Saturday evening."
"Do you hear, Johannes? That is a great honor," said Countess
Dolores. "Lady Crimmetart is one of the cleverest women in the
world, and the elect of intellectual England attend her parties."
"Young man," said Lady Crimmetart, "I will let you talk with Ranji-
Banji-Singh, of the University of Benares, the great Theosophist, and
with Professor von Pennewitz, from Moscow."
One can well fancy what a fine prospect that opened out for poor
little Johannes! But Lady Crimmetart did not request; she
commanded. It did not seem possible to decline.
Then came another housemaid—just as trim and still and swift as
the first one—to offer tea, little slices of bread and butter, and hot
cake. Johannes watched nervously, to see how the others partook of
them, and then tried to do as they did. But, under the cool, keen
regard of the trig maid, of course he upset the milk.
"The bishop is coming, too! The angel!" burst forth Lady Crimmetart.
Johannes had before his mind's eye the mitre and crozier at the
evening party. It made him think of Santa Claus. Thereupon the
ladies began chatting about church affairs, the altar and the Lord's
Supper, elections, and corn-laws, until he could follow them no
further. At last Alice was again summoned, the carriage ordered, the
smelling-bottle stored away in a big reticule, the seven small dogs
were arranged upon a long, blue-silk cord—like a string of beads;
and thus, with the parrot upon the hand of the lady's maid, the
procession passed out. At the door, the great lady, who limped a
little with gout, turned round once again, while still fanning herself,
and thundered: "Come on time, mind! And do not forget your
instrument!"

"A woman in a million," said Countess Dolores after she had gone.
"Is she not a wonderful woman, Johannes? So good! So clever!"
"Yes!" replied Johannes, meekly, his thoughts occupied anxiously
with that instrument he was expected to take to the party.
At last he heard the chattering of high-pitched little voices, and the
pattering of light little feet through the quiet house.
His heart began to thump. Then the door opened, and in two
seconds the dear, soft little hands put him into a tumultuous state,
and the lively, high little voices quite overwhelmed him.
He was consoled; and when they led him away, out-of-doors, and he
walked with them, one on each side, over the green cliffs, beside the
broad ocean—then he felt something of the new happiness for which
he had hoped.
But at night he could not sleep, and when it grew light he still lay in
a state of excitement, gazing at the handsome ceiling of dark-brown
wood whereon he could see little gilt stars.
He—Little Johannes—was being entertained by a countess, ushered
into a sphere of refinement, and living with the dearest little
creatures to be found among human beings. He was with his child
friends now, but yet he was not happy. He was much too poor and
too dull, and would be pitifully mortified here. When he thought of
that glittering smelling-bottle, and of the upset milk-pitcher, he
buried his face, in shame and bitterness, deep in the pillows.
Toward morning, when he fell asleep for a little while, he dreamed of
a big shop where swimming trousers only were for sale in a hundred
varieties of color and material, and bordered with fur, cloth, leather,
ermine, and velvet, and decked with bows and monograms. And
when Johannes went in to select a pair for the party, an immense
man, with a long beard and a high fur cap, stood up behind the
counter. It was Professor von Pennewitz, and he gave Johannes an
examination; but Johannes knew nothing—absolutely nothing. He
failed. Then he was given a stringless violin, and forced to play upon
it. The professor was not pleased with the performance; and taking
off his fur cap, he completely extinguished Johannes. Suffocated
with the heat and closeness, the boy found himself awake, and
clammy with distress, having been aroused by a vigorous tap, tap,
tap!
 V
Even before his "ya" (instead of the "yes" he had firmly intended to
say, but was surprised out of saying), the door flew open, and the
chambermaid came in bearing a big, silver tea-tray. She looked still
more trig and trim than the day before, as if all this time she had
been standing under a bell-glass. Without the least embarrassment,
she went up to Johannes and presented the tea.
Oh, woe! That was a distressing situation! Nothing of the kind had
befallen him since the whooping-cough period while his mother was
still living, and when she had brought him, abed, tea and toast.
Daatje had, indeed, come just once to call him, and it had made him
angry because it seemed as if he were still a child. In Daatje's case,
too, it was quite different. She looked more like a nurse-maid.
But this utterly strange and stylish little lady, with arranged hair, and
a cap with snow-white strings, who surprised him in his nightgown,
sound and well, in bed, while his dicky was still hanging by itself
over the back of a chair, and the green glass studs were looking in a
frightened way at the rest of the shabby clothes lying scattered over
the table—this housemaid put him out of countenance. Blushing
deeply, he declined the tea. As each of his poor garments came
under the eye or hand of this pert chambermaid, he could feel her
scornful, unuttered thoughts, and he lay dead still while his room
was being put in order. He shrank under the sheets up to his nose,
and grew wet with perspiration. When the door closed behind her,
he took breath again, and regarded, in astonishment, the pitcher of
hot water and the snowy towels that she had left him, uncertain
exactly what it was he was expected to do with them all.
Really, it was no trifling matter for Johannes—that entrance into a
higher and finer station.
Things went rather better during the forenoon, for he stayed with
the two children and their German governess. With this kind, every-
day sort of person, Johannes felt more at his ease; and he ventured
to consult her about his clothes, and what he might, and might not,
do in such a grand house.
The countess herself he did not see until afternoon. Then, through
the medium of a housemaid, he received an invitation to go to her.
She wished to talk with him.
She was again resting on the sofa, and beckoned him to a seat
beside her. Johannes thought that she wished to ask him about
something. But no! She simply wanted a little conversation—he must
know what about. Then, very naturally, Johannes could not think at
all; and after a painful quarter of an hour, during which he uttered
scarcely anything more than "Yes, Mevrouw!" or "No, Mevrouw!" he
was dismissed, still more unhappy than before.
The principal meal, at half-past eight in the evening, was no less
distressingly formal, and full of trials. It was as quiet as a funeral,
voices were low and whispering, and the servants moved noiselessly
to and fro. The governess had told Johannes that he must "dress"
for dinner. But alas! poor fellow! What had he to do it with?
As he stood behind his chair, in his shabby jacket and dicky, while
the rose-shaded candles lighted up the flowers and the glittering
table-furnishings, and the countess came into the great dim dining-
room in her rustling, silk attire—then again he felt really wretched.
Besides, it was very awkward trying to talk English here, and Dutch
seemed not to be in favor. He was conscious during each course of
doing something wrong or clumsy; and the lackeys, as they bent
over him in offering the dishes, breathed slightingly on his neck.
The second night, being tired from lack of sleep, he soon lost
consciousness. But during the small hours he had a thrilling and
stirring time. Surely I do not need to tell you what rude occurrences
there may be in one's dreams. Raging bulls tore after him as he tried
to escape, meeting him again and again at the turning of a lane.
There were lonely rooms whose doors flew open of their own accord
—a footstep, and a shadow around the corner—of it! There were
railway tracks with an oncoming train, and, suddenly—paralysis!
Then loud hangings at the door, and a call of "Johannes! Johannes!"
and, waking up, a deathly stillness. After that he noticed some very
queer and most astonishing things in the room—a pair of pantaloons
that walked away of itself, and in the corner a blood-curdling
phantom. And then he was conscious of not being awake, and of
making a desperate effort to shake off sleep. Such was the frightful
time which befell Johannes that night.
At last, when he actually woke himself up with a scream that he
heard resounding in the stillness, and while he lay listening to the
beating of his heart, he also heard, like a soft echo of his cry, a
fearful, smothered moaning and lamenting that lingered in the silent
hallways of the darkened house When all was still, he thought it had
been a part of his dreams. But even while he was lying wide awake,
it began again, and it was such a dismal sound he could feel the
goose-flesh forming. Then silence. "It must have been a dog," he
thought. But there it was! A dog does not groan like that! It was a
human voice. Could Olga or Frieda be ill?
The next time it came, he knew it was not the voice either of Olga or
of Frieda. It was that of a much older person—not an invalid, but
some one in mortal anguish—some one being menaced, who was
imploring pity. He heard something like "Oh! Oh!—O God, have
mercy!" But he could not understand the words, for the sounds
came faintly.
He thought a murder was being committed, and he recalled that
Death had been his fellow traveler. He sprang out of bed and
stepped into the dark hall. Everything was quiet there. The sound
came from upstairs, and now he heard, replying to the groans, a
calm, soothing, hushing voice—sometimes commanding, sometimes
coaxing. A door opened, and a faint light shone out. Another door
was opened and then closed. All this seemed to prove that
Johannes' intervention was not at all necessary, and that he would
perhaps cut a ridiculous figure by attempting to step in as a rescuer.
Then, unnerved and miserable, he went to sleep again.
In the morning, both little girls and the governess partook of their
breakfast of tea, malted milk, toasted bread, and ham and eggs, just
as if nothing had happened. The mother was to be away again until
afternoon. Frieda and Olga sat peacefully and quietly eating, like
well bred little girls.
At last Johannes could keep silence no longer, and said to the
governess:
"Did anything bad happen in the night?"
"No," said the young German lady, looking at her plate. "There is an
invalid in the house."
"Did you hear Heléne?" asked Olga, looking at Johannes earnestly. "I
never hear her now. At first I used to very plainly, but now I sleep
through it. Poor Heléne!"
"Poor Heléne!" lisped Frieda dutifully after her, resuming her busy
spooning of the malted milk.

At noon Johannes was again summoned to the drawing-room. He

had had a long walk, alone, beside the sea, and felt more at his
ease. He had resolved to ask if he might not go away, since he was
out of place here, and felt unhappy. And the party the next evening,
at Lady Crimmetart's, where he was expected with an instrument—
that was too much for him. He must get away before that.
But ere he had a chance to speak about it, his hostess began thus:
"Were you alarmed in the night, Johannes? Did you hear anything?"
Johannes nodded.
"Well, now that I trust you, fully, I will confide to you my sorrowful
secret. Listen."
And the estimable and attractive woman beckoned him, with her
loveliest smile, to sit beside the sofa, on a low stool.
It made Johannes feel as if he had been brought, nearly benumbed,
into a warm room. Pleasant tinglings coursed down his back, and a
fine feeling of contentment and security came over him. The
countess rested her soft, delicate hand upon his own, and looked
into his eyes, kindly. How beautiful she was! And what a sweet,
caressing voice she had! All the distress of those recent days was
more than amended.
"I am going to speak to you, my dear Johannes, as if you were
much older than you are. You really do seem to me older and wiser
than your years would lead one to expect."
Johannes was charmed.
"You must know, then, that my life has been full of suffering. Sorrow
has been, so to speak, my constant companion, from earliest youth."
Johannes' heart was aglow with compassion. In well-chosen words,
and in the flowing English that Johannes more admired than
comprehended, the lady continued:
"My marriage was very unhappy. Constrained by my parents I
married a rich man whom I did not love. He is dead now. I will not
speak any evil of him."
Johannes that instant made up his mind to a certainty that the man
had been a wretch.
"Neither will I trouble you with the story of all our misery. It suffices
to say that we did not belong to each other, and each embittered the
other's life. After six years of torture—it was nothing else—
something happened ... what usually happens in such cases.... Do
you understand?"
Johannes, greatly to his vexation, did not understand, and he felt
himself to be very stupid.
"I became fond of another.... Do you think less of me for that?"
"No! No!" said Johannes' head, as he shook it emphatically.
"Fortunately, my dear boy, I can say that I have nothing to reproach
myself with, and can look into the faces of my children without
shame. The man for whom I cared was unhappily married—just as I
was. We have never seen each other again—not even...."
There was a pause in which the voice of the beautiful speaker broke,
while her eyes were veiled in the tears that she was making an
effort to repress. Johannes' heart was melting with sympathy.
"Not even," she resumed, "when I was free. My husband made this
the opportunity for taking away from me my two children. For years
I lived separated from them, even in poverty and privation, with only
one old servant who, notwithstanding his low wages, would not
desert me.
"During that time, my boy,—you may be surprised to know it,—I
longed not only for my children, but even for him who had caused
me so much suffering. The mutual parentage of dearly loved
children is a wonderful bond that is never completely severed. I
would have forgiven him all if he had only called me back."
A silence, in which Johannes' heart, already so inclined to
admiration, surrendered itself wholly. The lady continued:
"I was recalled, but alas! too late. They telegraphed me that he was
ill, and wished to speak with me. When I arrived, he lay raving, and
never recovered his reason. For three days and nights I sat beside
him, almost without sleep, to catch anything he might have to say to
me. But he raved and raved, incessantly, uttering nothing but
nonsense and inarticulate sounds. He certainly knew me; but just
the same, he remained hard and cold—sometimes taunting,
sometimes angry and abusive. Never shall I forget that night...."
"With my own two children I found an older girl whom I had never
seen. They told me she was a child of a former union. I had never
even heard of her. Where the mother was, no one could say. It was
thought she was not living. The girl was then about fifteen years of
age, beautiful, with a brilliant color, a fine profile, and flowing black
hair."
"More beautiful than Frieda or Olga?" asked Johannes.
The countess smiled.
"Quite another kind of beauty. Much more gloomy and melancholy.
When I went to her, she sat crying, and would pay no attention to
me. 'Every one dislikes me,' she kept saying. And she repeated this
all day long. She did nothing but walk back and forth, crying and
lamenting. Only with the greatest trouble could she be induced to
rise in the morning, and be dressed, and in the evening, to go to
sleep. Her mind was diseased, and little by little it has grown worse.
My husband died, and I remained with the three daughters, caring
for them as well as I could."
Countess Dolores studied for a while her beautiful, gem-adorned
hands, and then went on, with frequent pauses.
"Heléne knew very little concerning her mother; but she steadfastly
maintained that she was living, and would return, and also ... that
her father and mother had been married...."
Another prolonged silence, the countess regarding Johannes with
her lightly half-closed eyes, to see if he understood. Apparently he
did not understand; for he sat, in unsuspecting patience, waiting for
whatever else was to be said.
"Can you fancy, Johannes, what that would signify to me to my
children ... if it were true?"
Johannes fancied only that he was looking at the speaker in a
somewhat confounded and sheepish manner.
"Bigamy, Johannes, is a terrible crime!"
Wait!—A light broke in upon him, albeit a feeble one. His dearly
loved children, then, were not legal—were illegitimate—natural, or
whatever it was called. Yes, indeed! That was terrible, even though
no one, to look at them, would ever think it. But the countess
enlightened him still further.
"The idea of living upon the property of another, Johannes, is, to a
woman of honor, insufferable!"
What more? The property of another? Then all this sumptuousness,
belonged, perhaps, to poor, crazed Heléne; and his dear, pretty
children and their beautiful mother were only illegal intruders—
usurpers of another's possessions!
Johannes faithfully tried his best to feel as the speaker did about all
these curious and confusing things. But he did not succeed. Then, in
his desire to comfort her, he gallantly uttered in broken English
whatever came into his head.
"No, Mevrouw; you must not think that. You are beautiful and your
children are beautiful, and therefore everything that is beautiful
belongs to you. I do not believe you have cause to be ashamed, for
I have seen no sign of it. If there were any disgrace, I should have
detected it. And how is any one to suppose that such evidence exists
either on paper or in some secret closet or other—who knows
where? Are you and Frieda and Olga any less beautiful, less lovely,
less good? I do not care a bit about it. Absolutely nothing."
The countess laughed so heartily, and pressed his hand so warmly,
that Johannes was embarrassed.
"Oh, you lovely boy!" she laughingly cried. "Oh, you queer, funny,
darling of a boy! How you cheer me up! I have not been so light-
hearted in a long time."
Johannes was very glad, and proud of his success. Countess Dolores
dried her tears of laughter upon her lace handkerchief, and
resumed:
"But now we must be in earnest. It will be clearer to you now why I
am so interested in all that pertains to spiritualism and theosophy—
why I listen so eagerly to the wisdom of Mijnheer van Lieverlee, and
of Lady Crimmetart—why I attend the circle of the Pleiades, at the
Hague—and, too, why it made me so happy to meet you, when I
heard that you also were a medium, and could see the elementals,
in full daylight."
"But why, Mevrouw?" asked Johannes, in some distress.
"How can you ask that, my dear boy! Nothing can ever bring back
my peace of mind, except one word from him, from the other side of
the grave!"
Ah! but that was a hard blow for Johannes. He was not so troubled
at having been invited as a guest, for a side purpose—he was not so
overweening as that—but because he was surely going to be a
disappointment to his beloved countess. With a sigh he looked down
at the carpet.
"Shall we not make a call upon the invalid?" asked the lady, rising.
Johannes nodded, and followed her.

The door of the sick-room was barely open, when a pitiable scream
rang out from the corner. The poor girl sat on the floor, huddled up
in her nightgown, her long black hair disheveled, and hanging down
over face and back. Her beautiful dark eyes were widely distended,
and her features wore an expression of mortal anguish.
"Oh, God!—It is coming!" she shrieked, trembling. "Now it will
happen! Oh, God! It surely will! I know it will! There it comes! Did I
not say so? Now it comes!—Oh! Oh! Oh!"
The nurse hushed and commanded, but the poor, tormented
creature trembled and wept, and seemed so desperately afraid, that
Johannes, greatly moved, begged leave to go away again. It seemed
as if she were afraid of him.
"No, my boy!" said the countess. "It is not on account of you. She
does that way whoever comes in. She is afraid of everybody and
everything she sees or hears."

That whole day, and a good deal of the night, Johannes mused over
this one query: "Why—why is that poor girl so afraid?"

VI
Johannes did not leave, and at last came the day of the dreaded
party. Having grown more confident, he had spoken of his needs.
The carriage put in an appearance, and in the neighboring town, he
was soon provided with suitable clothing.
Still, his mind was not quite at rest.
"Will you also say, dear lady," said Johannes that afternoon, when
with the children and their mother, "that I truly cannot play upon
any instrument? Please don't ask me to do anything!"
"But, Johannes," urged the countess, "that would really be very
disagreeable in me. After what I have said, something will be
expected of you."
"I cannot do anything!" said Johannes, in distress.
"He is joking, Mama," said Olga; "he can play the castanets and can
imitate animals."
"Oh, yes! all kinds of animals! Awfully nice!" cried Frieda.
"Is that so, Johannes? Well, then?"

It was true that Johannes had amused his two little friends while
they were taking walks together—mimicking all sorts of animal
sounds, like those of the horse, donkey, cow, dog, cat, pig, sheep,
and goat. He had whistled like the birds so cleverly that the two little
girls had been enraptured. And one single instrument he did indeed
play admirably—the genuine boys' castanets that every schoolboy
and street urchin in Holland carries in his pocket certain months of
the year. Many an autumn day, sauntering home from school, he had
shortened the way for himself with the sharp, clear, uninterrupted
"a-rick-a-ty, tick-a-ty tick!—a-rick-a-ty, tick-a-ty tick!—a-rick-a-ty, tick-
a-ty tick!—tack! tack!"
The little girls now begged him to let their mama hear. So he took
out his castanets, which he himself had made while there, and
clicked away with them lustily.
"Delightful!" cried the countess. "Now you must sing and dance at
the same time, like the Spaniards."
Johannes shied at the dancing. But indeed he would sing. And he
sang all kinds of street ditties, such as "Oh, Mother, the Sailor!" and
"Sara, you're losing your Petticoat," to the merry music of the
castanets. The children thought it splendid.
Their enthusiasm excited him, and he began improvising all sorts of
nonsense. The little girls clapped their hands, and the longer he
played the more merry they grew. Johannes struck an attitude, and
announced his selections just as if he were before an audience. The
countess and her daughters went and sat in a row—the little girls
wild with delight.
"Sketches from Animal Life," announced Johannes, beginning, to the
time-keeping accompaniment of the castanets, the well-known air
from The Carnival of Venice,
"A hen that came from Japan
Assured a crippled toad
She'd never have him for her man.
That was a sorry load."
The little girls shouted and stamped, with glee.
"More, Jo!—More, more, Johannes! Do!"
"Splendid!" cried the countess, speaking in Dutch, now, herself.
"A rhinoceros said to a louse,
'I'll stamp you flat on the ground!'
The louse made tracks for his house,
And there he is now to be found.

"A grasshopper sat in the grass,

And said to a chimpanzee:
'Your coat I will thank you to pass,
That I may attend a partie.'

"A snoop who stood on the stoop

Asked of his fellow boarder
If hairs he found in the soup.
The hostess?—'Twas malice toward her!

"A crab who enjoyed a joke,

Gave his mama a kick.
And when she dropped at his poke,
He laughed till the tears fell thick."
"Hey, there!" the little girls shouted boisterously. "Jolly! More, more!
Jo!"
"A stock-fish, deaf-and-dumb born,
Once said to a billy-goat:
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