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LANGE
PHYSICIAN
ASSISTANT
EXAMINATION
Comprehensive review for the
PANCE and PANRE

1300 + exam-style questions with

detailed answer explanations

Follows the NCCPA examination

blueprint

RACHEL A. CARLSON EDITION

DANIELLE KEMPTON
Me
Graw
Hill
IAN McLEOD
BOB MCMULLEN 8
 EIGHTH EDITION

TM
LANGE Q & A

PHYSICIAN
ASSISTANT
EXAMINATION
Rachel A Orison,EdD, MS &S, PA -C, PFAAPA
- Winchester, Virginia

Danielle Kempton, PlISc, MMS, l'A -C

Reno, Nevada
Ion McLeod, MS, MEd, PA C, ATC -
Phoenix, Arizona
Bob McMullen, EdD, PA C -
Professor, Chair and Director
Central Coast 1JA Program
A ,T, Still University
Santa Maria, California

M
Graw
Hill
-
NL"W Vnrit Ch^TagO SJH FrjndPGQ Alh^ns l.midon. Madrid
Meuco City Milan N w Delhi S poie Sydney TSOPOCIIP
* ^
Copyright © 2022 by McGraw Hill, LLC. All rights reserved. Except as permitted under the United States
Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any
means, or stored in a database or retrieval system, without the prior written permission of the publisher.

ISBN: 978-1-26-047415-2
MHID: 1-26-047415-1

The material in this eBook also appears in the print version of this title: ISBN: 978-1-26-047414-5,
MHID: 1-26-047414-3.

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 Teamwork makes the dream work
To my husband and children,
RAC

To Amy, my greatest supporter

To Bert, Randy, and Richard, my mentors
BM

To two of the best mentors anyone could ask for, AE and BC

DK

To Tamara, I could not have done this without your love and support
IM
 Contents

Contributors
Preface
Introduction
1. Test-Taking Skills: Tips and Techniques
RACHEL A. CARLSON, EDD, MSBS, PA-C, DFAAPA
2. Cardiology
BRITTNEY L. HULSEY, MS, MSPAS, PA-C AND BOB MCMULLEN, EDD, PA-C
3. Dermatologic System
NATALIE R. NYREN, MSPAS, PA-C
4. Endocrine System
TESSA M. TIBBEN, DHSc, MPAS, PA-C AND SARAH WALSH, MS, PA-C
5. Eyes, Ears, Nose, and Throat
LINDA MACCONNELL, DMSC, MAED, PA-C; SARA A. WILSON, MPAS, PA-C; AND BOB MCMULLEN,
EDD, PA-C
6. Gastrointestinal System/Nutrition
JENNIFER HASTINGS, MSHS, PA-C
7. Genitourinary System
RICHARD W. GILBERT, JR., MSPAS, PA-C, ATC; MICHELLE A. GRUVER, DMSC, MSPAS, MSN, PA-
C; JENNIFER R. MILLER, MSPAS, PA-C; AND KATHERINE A. SOLAKLI, MSHS, PA-C
8. Hematologic System
SCOTT LIGHTFOOT, PA-C, MPAS
9. Infectious Diseases
BRENDA L. QUINCY, PHD, MPH, PA-C, DFAAPA AND MARK LUTZ, MPAS, PA-C
10. Musculoskeletal
IAN MCLEOD, MED, MS, PA-C, ATC
11. Neurologic System
ERIC G. JAHN, MSPAS, PA-C; CHRISTINA M. SNYDER, MMSC, PA-C, MBA; AND CRISTINA TIPEI,
MSPAS, PA-C
12. Psychiatry/Behavioral Science
 DANIEL S. CERVONKA, PA-C, MS, CAS, DHSC AND IAN MCLEOD, MED, MS, PA-C, ATC
13. Pulmonary System
SARA A. WILSON, MPAS, PA-C AND DANIELLE KEMPTON, DHSC, MMS, PA-C
14. Renal System
KARA-ANN VALENTINE, MMS, PA-C AND DEBBI HANSON, MCMSC, PA-C
15. Reproductive System
ALEECE FOSNIGHT, MSPAS, PA-C, CSC, CSE
16. Professional Practice
RACHEL A. CARLSON, EDD, MSBS, PA-C, DFAAPA; DANIELLE KEMPTON, DHSc, MMS, PA-C; IAN
MCLEOD, MED, MS, PA-C, ATC; AND BOB MCMULLEN, EDD, PA-C
Index
 Contributors

Rachel A. Carlson, EdD, MSBS, PA-C, DFAAPA

Winchester, Virginia

Daniel S. Cervonka, PA-C, MS, CAS, DHSc

Director of Medical Services,
Recovery Network of Programs:
First Step Inpatient Addictions Unit
Senior Physician Associate
Middlesex Hospital Primary Care:
Urgent Care Department
Bridgeport, Connecticut

Aleece Fosnight, MSPAS, PA-C, CSC, CSE

President, Association of Physician Assistants
Obstetrics and Gynecology
Urology and Sexual Health
Transylvania Regional Hospital
Brevard, North Carolina

Richard W. Gilbert, Jr., MSPAS, PA-C, ATC

Assistant Professor
Shenandoah University
Winchester, Virginia

Michelle A. Gruver, DMSc, MSPAS, MSN, PA-C

Assistant Professor
Shenandoah University
Winchester, Virginia
Debbi Hanson, MCMSc, PA-C Assistant Professor
Physician Assistant Program
Barry University
Miami, Florida

Jennifer Hastings, MSHS, PA-C

Brittney L. Hulsey, MS, MSPAS, PA-C

Assistant Professor
Department of Physician Assistant Studies
A.T. Still University
Mesa, Arizona

Eric G. Jahn, MSPAS, PA-C

Assistant Professor/Principal Faculty
Division of Physician Assistant Studies
Central Coast PA Program
A. T. Still University
Santa Maria, California

Danielle Kempton, DHSc, MMS, PA-C

Reno, Nevada

Scott Lightfoot, PA-C, MPAS

Adjunct Faculty
A.T. Still University
Hematology/Oncology
Ironwood Cancer and Research Centers
Glendale, Arizona

Mark Lutz, MPAS, PA-C

Assistant Professor
Department of Physician Assistant Studies
Butler University
Indianapolis, Indiana

Linda MacConnell, DMSc, MAEd, PA-C

Associate Professor
Department of Physician Assistant Studies
A.T. Still University
Mesa, Arizona

Ian McLeod, MEd, MS, PA-C, ATC

Phoenix, Arizona

Bob McMullen, EdD, PA-C

Professor, Chair and Director
Central Coast PA Program
A.T. Still University
Santa Maria, California

Jennifer R. Miller, MS-PAS, PA-C

Assistant Professor
Shenandoah University
Winchester, Virginia
Natalie R. Nyren, MSPAS, PA-C
University Hospital
San Antonio, Texas

Brenda L. Quincy, PhD, MPH, PA-C, DFAAPA

Professor—DMS Bridge Program
Department of Physician Assistant Studies
Butler University
Indianapolis, Indiana

Christina M. Snyder, MMSc, PA-C, MBA

Assistant Professor
Central Coast PA Program
A.T. Still University
Santa Maria, California

Katherine A. Solakli, MSHS, PA-C

Tessa M. Tibben, DHSc, MPAS, PA-C

Assistant Professor
Department of Physician Assistant Studies
A.T. Still University—Arizona School of Health Sciences
Mesa, Arizona

Cristina Tipei, MSPAS, PA-C

Assistant Professor
Central Coast PA Program
A.T. Still University
Santa Maria, California

Kara-Ann Valentine, MMS, PA-C

Assistant Professor
Physician Assistant Program
Barry University
Miami Shores, Florida

Sarah Walsh, MS, PA-C

Assistant Professor
Department of Physician Assistant Studies
A.T. Still University
Mesa, Arizona

Sara A. Wilson, MPAS, PA-C

Preclinical Coordinator and Assistant Faculty
Central Coast PA Program
Visit https://testbankfan.com
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A.T. Still University
Santa Maria, California
 Preface

In this eighth edition of Lange Q&A™: Physician Assistant Examination, we have responded to the
changing aspects of healthcare by including many of the new treatments and diagnostic tests from modern
medical practice in extensively updated questions, while maintaining the basic format and quality our
readers have grown to expect. With this edition, overall 40% of the questions are new or substantially
revised. We have adjusted the chapters to align with the NCCPA content areas. This includes a new
professional practice chapter and expanded color page supplements for images and ECGs.
We believe that you will find this review book a helpful and useful resource as you prepare for your
initial or recertification examination.
We would like to thank our families, friends, and coworkers for their support, encouragement, and
patience during the long hours spent working on this project. We also wish to thank Sydney Keen, Kim
Davis, Michael Weitz from McGraw Hill, Susan Oldenburg who encouraged us to do another edition, and
Tasneem Kauser at KnowledgeWorks Global Ltd. for their editorial assistance and our contributors for
their hard work and dedication. Finally, we thank you, the readers, for choosing this book as one of your
resources. We wish you success on the examination.
Your comments and constructive criticisms are welcome and will be considered in future editions.
Please send your comments to [email protected]. Note the title of the book
in the subject line.
Rachel A. Carlson, EdD, PA-C
Danielle Kempton, DHSc, PA-C
Ian A. McLeod, MS, PA-C
Bob McMullen, EdD, PA-C
 Introduction

This book has been designed as a study aid to review for the PA National Certification and
Recertification Examination. Here, in one package, is a comprehensive review resource with 1,300
questions presented in the format seen in the national examinations. Each question is answered with a
referenced, paragraph-length answer. The entire book has been organized by specialty area to help
evaluate your areas of relative strength and weakness and to further direct your study effort with the
available references.

ORGANIZATION
This book is divided into specialty chapters preceded by an Introduction and a chapter on test-taking tips
and techniques. Chapter 1 provides helpful hints on how to prepare for and take certification
examinations. The remaining chapters cover the different NCCPA blueprint specialties, including a new
professional practice chapter. The Introduction provides information on question types, methods for using
this book, and specific information on the national certifying and recertifying examinations. The reader is
also urged to consult the National Commission on Certification of PAs’ website for up-to-date information
on the examination procedures and content. The website is www.nccpa.net.

QUESTIONS
The National Certifying Examination is made up of “one best answer–single item” questions. In addition,
some questions have illustrative materials (graphs, x-rays, and tables) that require understanding and
interpretation on your part. Finally, some of the items are stated in the negative. However, these items are
discouraged and not included. Many examinees will not encounter a negative question when they take the
certifying examinations.

ONE BEST ANSWER–SINGLE ITEM QUESTION

This type of question presents a problem or asks a question and is followed by four to five choices, only
one of which is entirely correct. The directions preceding this type of question will generally appear as
below:

DIRECTIONS: Each of the numbered items or incomplete statements in this section is followed by
answers or by completion of the statement. Select the ONE lettered answer or completion that is
BEST in each case.

An example for this item type follows:

1. An obese 21-year-old woman complains of increased growth of coarse hair on her lip, chin, chest,
and abdomen. She also notes menstrual irregularity with periods of amenorrhea. Which of the
 following is the most likely cause?
(A) Polycystic ovary disease
(B) An ovarian tumor
(C) An adrenal tumor
(D) Cushing disease
(E) Familial hirsutism

In this type of question, choices other than the correct answer may be partially correct, but there can be
only one best answer. In the question above, the key word is “most.” Although ovarian tumors, adrenal
tumors, and Cushing disease are causes of hirsutism (described in the stem of the question), polycystic
ovary disease is a much more common cause. Familial hirsutism is not associated with the menstrual
irregularities mentioned. Thus, the most likely cause of the manifestations described can only be “(A)
Polycystic ovary disease.”

Answers, Explanations, and References

In each of the sections of this book, the question sections are followed by a section containing the
answers, explanations, and references for the questions. This section (1) tells you the answer to each
question; (2) gives you an explanation, reviews the reason the answer is correct, and supplies background
information on the subject matter (and in most cases, the reason the other answers are incorrect); and (3)
tells you where you can find more in-depth information on the subject matter in other books and journals.
We encourage you to use this section as a basis for further study and understanding. If you choose the
correct answer to a question, you can read the explanation for reinforcement and to add to your
knowledge of the subject matter. If you choose the wrong answer to a question, you can read the
explanation for an instructional review of the material in the question. Furthermore, you can note the
reference cited, look up the complete source in the references at the end of the chapter (e.g., McPhee SJ,
Papadakis MA. Current Medical Diagnosis and Treatment, 2021, 60th ed. New York, NY: McGraw
Hill; 2020), and refer to the pages or chapter cited for a more in-depth discussion. With this edition, most
authors have used UpToDate to ensure we have referenced, at the time of publication, the most recent
information and is readily accessible.

Practice Test
Users are provided access to the online question bank at PAeasy.com. This question bank and program aid
the user in preparing for online test-taking to simulate the PANCE and PANRE.

HOW TO USE THIS BOOK

There are two logical ways to get the most value from this book. We will call them Plan A and Plan B.
In Plan A, you go straight to PAeasy.com and take the comprehensive test and complete it according to
the instructions provided. This will be a good indicator of your initial knowledge of the subject and will
help to identify specific areas for preparation and review. You can then use the earlier chapters of the
book to help you improve your relative weak points.
In Plan B, you go through each section checking off your answers and then comparing your choices
with the answers and discussions in the book. It is best to complete a series of questions prior to checking
off your answers and reading the explanations, as some of the explanations provide answers to following
questions and therefore would not provide you with an accurate representation of your knowledge base.
Once you have completed this process, you can take the Test on PAeasy.com and see how well prepared
you are. If you still have a major weakness, it should be apparent in time for you to take remedial action.
In Plan A, by taking the Practice Test first, you get quick feedback regarding your initial areas of
strength and weakness. You may find that you have a good command of the material, indicating that
perhaps only a cursory review of each section is necessary. This, of course, would be good to know early
in your examination preparation. On the other hand, you may find that you have many areas of weakness.
In this case, you could then focus on these areas in your review—not just with this book but also with
appropriate textbooks. (It is, however, unlikely that you will not study before taking the national boards,
especially because you have this book.) Therefore, it may be more realistic to take the Practice Test after
you have reviewed the chapters (as in Plan B). This is likely to provide you with a more realistic type of
testing situation, as very few of us merely sit down to a test without studying. In this case, you will have
done some reviewing (from superficial to in-depth) and your Practice Test will reflect this study time. If,
after reviewing the question chapters and taking the Practice Test, you still have some weaknesses, you
can then go back to the end of the chapters and supplement your review with the reference texts.
We hope that through careful use of this book, whether through Plan A or Plan B, you find this text a
useful and beneficial study guide.

SPECIFIC INFORMATION ON THE EXAMINATIONS

The official source for all information on the certification or recertification process is the National
Commission on Certification of PAs, Inc. (NCCPA). This organization comprises representatives from the
major organizations of medicine, including the American Academy of PAs and the PA Education
Association. Their function is to formulate and administer the annual certification examination and to
provide the means for recertification. Eligibility requires graduation from a PA program that is accredited
by the Accreditation Review Commission on Education for the PA (ARC-PA). Details regarding
registration are available from the NCCPA. The entry-level examination (PANCE) consists of 300
questions addressing all aspects of PA education, including basic science concepts, history taking,
physical examination, laboratory and radiographic interpretation, as well as treatment modalities. Tips for
improving your score on the examination are provided in Chapter 1. Currently, the recertification
examination, PANRE, consists of 240 questions constructed in a similar format as the entry-level
examination.
Exploring the Variety of Random
Documents with Different Content
wasps, whining for this, sticking their fingers into that, and thinking
they were helping with the jam-making. And suddenly my stepmother
turned round and caught little Polly with her mouth all black with
mulberry juice. And oh, the taking she was in! She caught her and
shook her, and ordered her to spit out anything she might have in her
mouth; and then, when she found out it was mulberries, she cooled
down all of a sudden and told Polly she must be a good girl and
never put anything in her mouth without asking first.
"Now, the jam was boiled in great copper cauldrons, and I noticed a
little pipkin simmering on the hearth, and I asked my stepmother
what it was. And she answered carelessly, 'Oh, it's some mulberry
jelly, sweetened with honey instead of sugar, for my old grandfather
at home.' And at the time I didn't give the matter another thought. But
the evening before my father died ... and I've never mentioned this to
a soul except my poor Peppercorn ... after supper he went and sat
out in the porch to smoke his pipe, leaving her and him to their own
doings in the kitchen; for she'd been brazen-faced enough, and my
father weak enough, actually to have the fellow living there in the
house. And my father was a queer man in that way—too proud to sit
where he wasn't wanted, even in his own kitchen. And I'd come out,
too, but I was hid from him by the corner of the house, for I had been
waiting for the sun to go down to pick flowers, to take to a sick
neighbour the next day. But I could hear him talking to his spaniel,
Ginger, who was like his shadow and followed him wherever he
went. I remember his words as clearly as if it had been yesterday:
'Poor old Ginger!' he said, 'I thought it would be me who would dig
your grave. But it seems not, Ginger, it seems not. Poor old lady, by
this time tomorrow I'll be as dumb as you are ... and you'll miss our
talks, poor Ginger.' And then Ginger gave a howl that made my
blood curdle, and I came running round the corner of the house and
asked father if he was ailing, and if I could fetch him anything. And
he laughed, but it was as different as chalk from cheese from the
way he laughed as a rule. For poor father was a frank-hearted, open-
handed man, and not one to hoard up bitterness any more than he
would hoard up money; but that laugh—the last I heard him give—
was as bitter as gall. And he said, 'Well, Ivy, my girl, would you like to
fetch me some peonies and marigolds and shepherd's thyme from a
hill where the Silent People have danced, and make me a salad from
them?' And seeing me looking surprised, he laughed again, and
said, 'No, no. I doubt there are no flowers growing this side of the
hills that could help your poor father. Come, give me a kiss—you've
always been a good girl.' Now, these are flowers that old wives use
in love potions, as I knew from my granny, who was very wise about
herbs and charms, but father had always laughed at her for it, and I
supposed he was fretting over my stepmother and Pugwalker, and
wondering if he could win her heart back to him.
"But that night he died, and it was then that I started wondering
about that jelly in the pipkin, for him, liking scum as he did, and
always having a saucer of it set aside for him, it wouldn't have been
difficult to have boiled up some poison for him without any danger of
other folks touching it. And Pugwalker knew all about herbs and such
like, and could have told her what to use. For it was as plain as print
that poor father knew he was going to die, and peonies make a good
purge; and I've often wondered since if it was as a purge that he
wanted these flowers. And that's all I know, and perhaps it isn't
much, but it's been enough to keep me awake many a night of my
life wondering what I should have done if I'd been older. For I was
only a little maid of ten at the time, with no one I could talk to, and as
frightened of my stepmother as a bird of a snake. If I'd been one of
the witnesses, I dare say it would have come out in court, but I was
too young for that."
"Perhaps we could get hold of Diggory Carp?"
"Diggory Carp?" she repeated in surprise. "But surely you heard
what happened to him? Ah, that was a sad story! You see, after he
was sent to gaol, there came three or four terrible lean years, one
after the other. And food was so dear, no one, of course, had any
money for buying fancy goods like baskets ... and the long and the
short of it was that when Diggory came out of gaol he found that his
wife and children had died of starvation. And it seemed to turn his
wits, and he came up to our farm, raging against my stepmother, and
vowing that someday he'd get his own back on her. And that night he
hanged himself from one of the trees in our orchard, and he was
found there dead the next morning."
"A sad story," said Master Nathaniel. "Well, we must leave him out of
our calculations. All you've told me is very interesting—very
interesting indeed. But there's still a great deal to be unravelled
before we get to the rope I'm looking for. One thing I don't
understand is Diggory Carp's story about the osiers. Was it a pure
fabrication of his?"
"Poor Diggory! He wasn't, of course, the sort of man whose word
one would be very ready to take, for he did deserve his ten years—
he was a born thief. But I don't think he would have had the wits to
invent all that. I expect the story he told was true enough about his
daughter selling the osiers, but that it was only for basket-making
that she wanted them. Guilt's a funny thing—like a smell, and one
often doesn't quite know where it comes from. I think Diggory's nose
was not mistaken when it smelt out guilt, but it led him to the wrong
clue. My father wasn't poisoned by osiers."
"Can you think what it was, then?"
She shook her head. "I've told you everything I know."
"I wish you knew something more definite," said Master Nathaniel a
little fretfully. "The Law dearly loves something it can touch—a blood-
stained knife and that sort of thing. And there's another matter that
puzzles me. Your father seems, on your showing, to have been a
very indulgent sort of husband, and to have kept his jealousy to
himself. What cause was there for the murder?"
"Ah! that I think I can explain to you," she cried. "You see, our farm
was very conveniently situated for ... well, for smuggling a certain
thing that we don't mention. It stands in a sort of hollow between the
marches and the west road, and smugglers like a friendly, quiet
place where they can run their goods. And my poor father, though he
may have sat like a dumb animal in pain when his young wife was
gallivanting with her lover, all the same, if he had found out what was
being stored in the granary, Pugwalker would have been kicked out
of the house, and she could have whistled for him till she was black
in the face. My father was easy-going enough in some ways, but
there were places in him as hard as nails, and no woman, be she
never so much of a fool (and, fair play to my stepmother, she was no
fool), can live with a man without finding out where these places
are."
"Oh, ho! So what Diggory Carp said about the contents of that sack
was true, was it?" And Master Nathaniel inwardly thanked his stars
that no harm had come to Ranulph during his stay in such a
dangerous place.
"Oh, it was true, and no mistake; and, child though I was at the time,
I cried through half one night with rage when they told me what the
hussy had said in court about my father using the stuff as manure
and her begging him not to! Begging him not to, indeed! I could have
told them a very different story. And it was Pugwalker that was at the
back of that business, and got the granary key from her, so they
could run their goods there. And shortly before my father died he got
wind of it—I know that from something I overheard. The room I
shared with my little brother Robin opened into theirs, and we always
kept the door ajar, because Robin was a timid child, and fancied he
couldn't go to sleep unless he heard my father snoring. Well, about a
week before my father died I heard him talking to her in a voice I'd
never known him to use to her before. He said he'd warned her twice
already that year, and that this was the last time. Up to that time he'd
held his head high, he said, because his hands were clean and all
his doings straight and fair, and now he warned her for the last time
that unless this business was put a stop to once and for all, he'd
have Pugwalker tarred and feathered, and make the neighbourhood
too hot for him to stay in it. And, I remember, I heard him hawking
and spitting, as if he'd rid himself of something foul. And he said that
the Gibbertys had always been respected, and that the farm, ever
since they had owned it, had helped to make the people of Dorimare
straight-limbed and clean-blooded, for it had sent fresh meat and
milk to market, and good grain to the miller, and sweet grapes to the
vintner, and that he would rather sell the farm than that poison and
filth should be sent out of his granary, to turn honest lads into idiots
gibbering at the moon. And then she started coaxing him, but she
spoke too low for me to catch the words. But she must have been
making him some promise, for he said gruffly, 'Well, see that it's
done, then, for I'm a man of my word.'
"And in not much more than a week after that he was dead—poor
father. And I count it a miracle that I ever grew up and am sitting here
now telling you all this. And a still greater one that little Robin grew
up to be a man, for he inherited the farm. But it was her own little girl
that died, and Robin grew up and married, and though he died in his
prime it was through a quinsy in his throat, and he always got on with
our stepmother, and wouldn't hear a word against her. And she has
brought up his little girl, for her mother died when she was born. But
I've never seen the lass, for there was never any love lost between
me and my stepmother, and I never went back to the old house after
I married."
She paused, and in her eyes was that wistful, tranced look that
always comes when one has been gazing at things that happened to
one long ago.
"I see, I see," said Master Nathaniel meditatively. "And Pugwalker?
Did you ever see him again till you recognized him in the streets of
Lud the other day?"
She shook her head. "No, he disappeared, as I told you, just before
the trial. Though I don't doubt that she knew his whereabouts and
heard from him—met him even; for she was always going out by
herself after nightfall. Well, well, I've told you everything I know—
though perhaps I'd have better held my tongue, for little good comes
of digging up the past."
Master Nathaniel said nothing; he was evidently pondering her story.
"Well," he said finally, "everything you have told me has been very
interesting—very interesting indeed. But whether it will lead to
anything definite is another matter. All the evidence is purely
circumstantial. However, I'm very grateful to you for having spoken to
me as freely as you've done. And if I find out anything further I'll let
you know. I shall be leaving Lud shortly, but I shall keep in touch with
you. And, under the circumstances, perhaps it would be prudent to
agree on some word or token by which you would recognize a
messenger as really coming from me, for the fellow you knew as
Pugwalker has not grown less cunning with advancing years—he's
full of guile, and let him once get wind of what we're after, he'd be up
to all sorts of tricks to make our plans miscarry. What shall the token
be?"
Then his eyes began to twinkle: "I've got it!" he cried. "Just to give
you a little lesson in swearing, which you say you dislike so much,
we'll make it a good round oath. You'll know a messenger comes
from me if he greets you with the words, By the Sun, Moon and Stars
and the Golden Apples of the West!"
And he rubbed his hands in delight, and shouted with laughter.
Master Nathaniel was a born tease.
"For shame, you saucy fellow!" dimpled Mistress Ivy. "You're as bad
as my poor Peppercorn. He used always...."
But even Master Nathaniel had had his fill of reminiscences. So he
cut her short with a hearty good-bye, and renewed thanks for all she
had told him.
But he turned back from the door to hold up his finger and say with
mock solemnity, "Remember, it's to be By the Sun, Moon and Stars
and the Golden Apples of the West!"
 CHAPTER XIX
THE BERRIES OF MERCIFUL DEATH
Late into that night Master Nathaniel paced the floor of his pipe-
room, trying to pierce through the intervening medium of the dry
words of the Law and the vivider though less reliable one of Mistress
Ivy's memory, and reach that old rustic tragedy, as it had been before
the vultures of Time had left nothing of it but dry bones.
He felt convinced that Mistress Ivy's reconstruction was correct—as
far as it went. The farmer had been poisoned, though not by osiers.
But by what? And what had been the part played by Pugwalker, alias
Endymion Leer? It was, of course, gratifying to his vanity that his
instinctive identification of the two had been correct. But how
tantalizing it would be if this dead man's tale was to remain but a
vague whisper, too low to be heard by the ear of the Law!
On his table was the slipper that Master Ambrose had facetiously
suggested might be of use to him. He picked it up, and stared at it
absently. Ambrose had said the sight of it had made Endymion Leer
jump out of his skin, and that the reason was obvious. And yet those
purple strawberries did not look like fairy fruit. Master Nathaniel had
recently become but too familiar with the aspect of that fruit not to
recognize it instantly, whatever its variety. Though he had never seen
berries exactly like these, he was certain that they did not grow in
Fairyland.
He walked across to his bookcase and took out a big volume bound
in vellum. It was a very ancient illustrated herbal of the plants of
Dorimare.
At first he turned its pages somewhat listlessly, as if he did not really
expect to find anything of interest. Then suddenly he came on an
illustration, underneath which was written THE BERRIES OF
MERCIFUL DEATH. He gave a low whistle, and fetching the slipper
laid it beside the picture. The painted berries and the embroidered
ones were identical.
On the opposite page the berries were described in a style that a
literary expert would have recognized as belonging to the Duke
Aubrey period. The passage ran thus:—
THE BERRIES OF MERCIFUL DEATH
These berries are wine-coloured, and crawl along the
ground, and have the leaves of wild strawberries. They
ripen during the first quarter of the harvest moon, and are
only to be found in certain valleys of the West, and even
there they grow but sparsely; and, for the sake of birds
and children and other indiscreet lovers of fruit, it is well
that such is the case, for they are a deadly and insidious
poison, though very tardy in their action, often lying
dormant in the blood for many days. Then the poison
begins to speak in itchings of the skin, while the tongue,
as though in punishment for the lies it may have told,
becomes covered with black spots, so that it has the
appearance of the shards of a ladybird, and this is the only
warning to the victim that his end is approaching. For, if
evil things ever partake of the blessed virtues, then we
may say that this malign berry is mercifully cruel, in that it
spares its victims belchings and retchings and fiery
humours and racking colics. And, shortly before his end,
he is overtaken by a pleasant drowsiness, yielding to
which he falls into a peaceful sleep, which is his last. And
now I will give you a receipt, which, if you have no sin
upon your conscience, and are at peace with the living
and the dead, and have never killed a robin, nor robbed
an orphan, nor destroyed the nest of a dream, it may be
will prove an antidote to that poison—and may be it will
not. This, then, is the receipt: Take one pint of salad oil
and put it into a vial glass, but first wash it with rose-water,
and marygold flower water, the flowers being gathered
 towards the West. Wash it till the oil comes white; then put
it into the glass, and then put thereto the buds of Peonies,
the flowers of Marygold and the flowers and tops of
Shepherd's Thyme. The Thyme must be gathered near
the side of a hill where the Fairies are said to dance.
Master Nathaniel laid down the book, and his eyes were more
frightened than triumphant. There was something sinister in the
silent language in which dead men told their tales—with sly malice
embroidering them on old maids' canvas work, hiding them away in
ancient books, written long before they were born; and why were his
ears so attuned to this dumb speech?
For him the old herbalist had been describing a murderer, subtle,
sinister, mitigating dark deeds with mercy—a murderer, the touch of
whose bloody hands was balm to the sick in body, and whose voice
could rock haunted minds to sleep. And, as well, in the light of what
he already knew, the old herbalist had told a story. A violent, cruel,
reckless woman had wished to rid herself of her enemy by the first
means that came to her hand—osiers, the sap of which produced an
agonizing, cruel death. But her discreet though murderous lover took
the osiers from her, and gave her instead the berries of merciful
death.
The herbalist had proved beyond the shadow of a doubt that the
villain of the story was Endymion Leer.
Yes, but how should he make the dead tell their tale loud enough to
reach the ear of the Law?
In any case, he must leave Lud, and that quickly.
Why should he not visit the scene of this old drama, the widow
Gibberty's farm? Perhaps he might there find witnesses who spoke a
language understood by all.

The next morning he ordered a horse to be saddled, packed a few

necessaries in a knapsack, and then he told Dame Marigold that, for
the present, he could not stay in Lud. "As for you," he said, "you had
better move to Polydore's. For the moment I'm the most unpopular
man in town, and it would be just as well that they should think of
you as Vigil's sister rather than as Chanticleer's wife."
Dame Marigold's face was very pale that morning and her eyes were
very bright. "Nothing would induce me," she said in a low voice,
"ever again to cross the threshold of Polydore's house. I shall never
forgive him for the way he has treated you. No, I shall stay here—in
your house. And," she added, with a little scornful laugh, "you
needn't be anxious about me. I've never yet met a member of the
lower classes that was a match for one of ourselves—they fall to
heel as readily as a dog. I'm not a bit afraid of the mob, or anything
they could do to me."
Master Nathaniel chuckled. "By the Sun, Moon and Stars!" he cried
proudly, "you're a chip off the old block, Marigold!"
"Well, don't stay too long away, Nat," she said, "or else when you
come back you'll find that I've gone mad like everybody else, and am
dancing as wildly as Mother Tibbs, and singing songs about Duke
Aubrey!" and she smiled her charming crooked smile.
Then he went up to say good-bye to old Hempie.
"Well, Hempie," he cried gaily. "Lud's getting too hot for me. So I'm
off with a knapsack on my back to seek my fortune, like the youngest
son in your old stories. Will you wish me luck?"
There were tears in the old woman's eyes as she looked at him, and
then she smiled.
"Why, Master Nat," she cried, "I don't believe you've felt so light-
hearted since you were a boy! But these are strange times when a
Chanticleer is chased out of Lud-in-the-Mist! And wouldn't I just like
to give those Vigils and the rest of them a bit of my mind!" and her
old eyes flashed. "But don't you ever get downhearted, Master Nat,
and don't ever forget that there have always been Chanticleers in
Lud-in-the-Mist, and that there always will be! But it beats me how
you're to manage with only three pairs of stockings, and no one to
mend them."
"Well, Hempie," he laughed, "they say the Fairies are wonderfully
neat-fingered, and, who knows, perhaps in my wanderings I may fall
in with a fairy housewife who will darn my stockings for me," and he
brought out the forbidden word as lightly and easily as if it had been
one in daily use.
About an hour after Master Nathaniel had ridden away Luke Hempen
arrived at the house, wild-eyed, dishevelled, and with very startling
news. But it was impossible to communicate it to Master Nathaniel,
as he had left without telling anyone his destination.
 CHAPTER XX
WATCHING THE COWS
In the interval between his two letters—the one to Hempie, and the
one to Master Nathaniel—Luke decided that his suspicions had been
groundless, for the days at the farm were buzzing by with a soothing
hum like that of summer insects, and Ranulph was growing gay and
sunburned.
Then towards autumn Ranulph had begun to wilt, and finally Luke
overheard the strange conversation he had reported in his letter to
Master Nathaniel, and once again the farm grew hateful to him, and
he followed Ranulph as if he were his shadow and counted the hours
for the order to come from Master Nathaniel bidding them return to
Lud.
Perhaps you may remember that on his first evening at the farm
Ranulph had wanted to join the children who watched the widow's
cows at night, but it had evidently been nothing but a passing whim,
for he did not express the wish again.
And then at the end of June—as a matter of fact it was Midsummer
day—the widow had asked him if he would not like that night to join
the little herdsmen. But towards evening had come a steady downfall
of rain, and the plan had fallen through.
It was not alluded to again till the end of October, three or four days
before Master Nathaniel left Lud-in-the-Mist. It had been a very mild
autumn in the West and the nights were fresh rather than cold, and
when, that evening, the little boys came knocking at the door for their
bread and cheese, the widow began to jeer at Ranulph, in a hearty
jovial way, for being town-bred and never having spent a night under
the sky.
"Why don't you go tonight with the little herdsmen? You wanted to
when you first came here, and the Doctor said it would do you no
harm."
Now Luke was feeling particularly downcast that night; no answer
had come from Master Nathaniel to his letter, though it was well over
a week since he had written. He felt forlorn and abandoned, with a
weight of responsibility too heavy for his shoulders, and he was
certainly not going to add to that weight by allowing Ranulph to run
the risk of catching a bad chill. And as well, any suggestion that
came from the widow was greeted by him with suspicion.
"Master Ranulph," he cried excitedly, "I can't let you go. His Worship
and my old auntie wouldn't like it, what with the nights getting damp
and all. No, Master Ranulph, be a good little chap and go to your bed
as usual."
As he was speaking he caught Hazel's eye, and she gave him an
almost imperceptible nod of approval.
But the widow cried, with a loud scornful laugh, in which Ranulph
shrilly joined: "Too damp, indeed! When we haven't had so much as
a drop of rain these four weeks! Don't let yourself be coddled, Master
Ranulph. Young Hempen's nothing but an old maid in breeches. He's
as bad as my Hazel. I've always said that if she doesn't die an old
maid, it isn't that she wasn't born one!"
Hazel said nothing, but she fixed her eyes beseechingly on Luke.
But Ranulph, I fear, was a very spoiled little boy, and, into the
bargain, he dearly loved annoying Luke; so he jumped up and down,
shouting, "Old maid Hempen! Old maid Hempen! I'm going—so
there!"
"That's right, little master!" laughed the widow. "You'll be a man
before I am."
And the three little herdsmen, who had been watching this scene
with shy amusement, grinned from ear to ear.
"Do as you like, then," said Luke sullenly, "but I'm coming too. And,
anyway, you must wrap up as warmly as you can."
So they went upstairs to put on their boots and mufflers.
When they came down Hazel, with compressed lips and a little frown
knitting her brows, gave them their rations of cheese and bread and
honey, and then, with a furtive glance in the direction of the widow,
who was standing with her back turned, talking to the little herdsmen,
she slipped two sprigs of fennel into Luke's button-hole. "Try and get
Master Ranulph to wear one of them," she whispered.
This was not reassuring. But how is an undergardener, not yet
turned eighteen, to curb the spoiled son of his master—especially
when a strong-willed, elderly woman throws her weight into the other
scale?
"Well, well," said the widow, bustling up, "it's high time you were off.
You have a full three miles walk before you."
"Yes, yes, let's be off!" cried Ranulph excitedly; Luke felt it would be
useless to protest further, so the little cavalcade dived into the
moonlit night.
The world was looking very beautiful. At one end of the scale of
darkness stood the pines, like rich black shadows; at the other end
of the scale were the farm buildings, like white glimmering human
masks. And in between these two extremes were all the various
degrees of greyness—the shimmer of the Dapple that was more
white than grey, and all the different trees—plane-trees, liege-oaks,
olives—and one could almost recognize their foliage by their lesser
or greater degree of density.
On they trudged in silence, up the course of the Dapple—Luke too
anxious and aggrieved to talk, Ranulph buried too deep in dreams,
and the little herdsmen far too shy. There were nothing but rough
cattle paths in the valley—heavy enough going by day, and doubly
so by night, and before they had yet gone half the way Ranulph's
feet began to lag.
"Would you like to rest a bit and then go back?" said Luke eagerly.
But Ranulph shook his head scornfully and mended his pace.
Nor did he allow himself to lag again till they reached their
destination—a little oasis of rich pasturage, already on rising ground
though still a mile or two away from the hills.
Once here—in their own kingdom, as it were—the little herdsmen
became lively and natural; laughing and chatting with Ranulph, as
they set about repairing such breaches as had been made in the
huts by the rough and tumble of twelve odd hours. Then there was
wood to be collected, and a fire to be lit—and into these tasks
Ranulph threw himself with a gay, though rather feverish, vigour.
At last they settled down to their long watch—squatting round the
fire, and laughing for sheer love of adventure as good campaigners
should; for were there not marching towards them some eight dark
hours equipped with who could say what curious weapons from the
rich arsenal of night and day?
The cattle crouched round them in soft shadowy clumps, placidly
munching, and dreaming with wide-open eyes. The narrow zone of
colour created by the fire-light was like the planet Earth—a little freak
of brightness in a universe of impenetrable shadows.
Suddenly Luke noticed that each of the three little herdsmen was,
like himself, wearing a sprig of fennel.
"I say! why are all you little chaps wearing fennel?" he blurted out.
They stared at him in amazement.
"But you be wearing a bit yourself, Master Hempen," said Toby, the
eldest.
"I know"—and he could not resist adding in an offhand tone—"it was
a present from a young lady. But do you always wear a bit in these
parts?" he added.
"Always on this night of the year," said the children. And as Luke
looked puzzled, Toby cried in surprise, "Don't you wear fennel in Lud
on the last night of October?"
"No, we don't," answered Luke, a little crossly, "and why should we, I
should like to know?"
"Why," cried Toby in a shocked voice, "because this is the night
when the Silent People—the dead, you know—come back to
Dorimare."
Ranulph looked up quickly. But Luke scowled; he was sick to death
of western superstitions, and into the bargain he was feeling
frightened. He removed the second sprig of fennel given him by
Hazel from his button-hole, and holding it out to Ranulph, said,
"Here, Master Ranulph! Stick that in your hatband or somewhere."
But Ranulph shook his head. "I don't want any fennel, thank you,
Luke," he said. "I'm not frightened."
The children gazed at him in half-shocked admiration, and Luke
sighed gloomily.
"Not frightened of ... the Silent People?" queried Toby.
"No," answered Ranulph curtly. And then he added, "At least not
tonight."
"I'll wager the widow Gibberty, at any rate, isn't wearing any fennel,"
said Luke, with a harsh laugh.
The children exchanged queer little glances and began to snigger.
This aroused Luke's curiosity: "Now then, out with it, youngsters!
Why doesn't the widow Gibberty wear fennel?"
But their only answer was to nudge each other, and snigger behind
their fingers.
This put Luke on his mettle. "Look here, you bantams," he cried,
"don't you forget that you've got the High Seneschal's son here, and
if you know anything about the widow that's ... well, that's a bit fishy,
it's your duty to let me know. If you don't, you may find yourselves in
gaol some day. So you just spit it out!" and he glared at them as
fiercely as his kindly china-blue eyes would allow.
They began to look scared. "But the widow doesn't know we've seen
anything ... and if she found out, and that we'd been blabbing, oh
my! wouldn't we catch it!" cried Toby, and his eyes grew round with
terror at the mere thought.
"No, you won't catch it. I'll give you my word," said Luke. "And if
you've really anything worth telling, the Seneschal will be very
grateful, and each of you may find yourselves with more money in
your pockets than your three fathers put together have ever had in
all their lives. And, anyhow, to begin with, if you'll tell me what you
know, you can toss up for this knife, and there's not a finer one to be
found in all Lud," and he waved before their dazzled eyes his
greatest treasure, a magnificent six-bladed knife, given him one
Yule-tide by Master Nathaniel, with whom he had always been a
favourite. At the sight of this marvel of cutlery, the little boys proved
venal, and in voices scarcely above a whisper and with frequent
frightened glances over their shoulders, as if the widow might be
lurking in the shadows listening to them, they told their story.
One night, just before dawn, a cow called Cornflower, from the
unusually blue colour of her hide, who had recently been added to
the herd, suddenly grew restless and began to moo, the strange moo
of blue cows that was like the cooing of doves, and then rose to her
feet and trotted away into the darkness. Now Cornflower was a very
valuable cow and the widow had given them special injunctions to
look after her, so Toby, leaving the other two to mind the rest of the
herd, dashed after her into the thinning darkness and though she
had got a good start of him was able to keep in her track by the
tinkling of her bell. Finally he came on her standing at the brink of the
Dapple and nozzling the water. He went close up to her and found
that she had got her teeth into something beneath the surface of the
stream and was tearing at it in intense excitement. Just then who
should drive up in a cart but the widow and Doctor Endymion Leer.
They appeared much annoyed at finding Toby, but they helped him
get Cornflower away from the water. Bits of straw were hanging from
her mouth and it was stained with juices of a colour he had never
seen before. The widow then told him to go back to his companions,
and said she would herself take Cornflower back to the herd in the
morning. And, to account for her sudden appearance on the scene,
she said she had come with the doctor to try and catch a very rare
fish that only rose to the surface an hour before sunrise. "But you
see," went on Toby, "my dad's a great fisherman, and often takes me
out with him, but he never told me about this fish in the Dapple that
can only be caught before sunrise, and I thought I'd just like to have
a peep at it. So instead of going back to the others right away, I hid, I
did, behind some trees. And they took some nets, they did, out of the
cart, but it wasn't fish they drew up in them ... no it wasn't." He was
suddenly seized with embarrassment, and he and his two little
friends again began to snigger.
"Out with it!" cried Luke impatiently. "What was in their nets? You'll
not get the knife for only half a story, you know."
"You say, Dorian," said Toby bashfully, nudging the second eldest
boy; but Dorian, too, would only giggle and hang his head.
"I don't mind saying!" cried Peter, the youngest, valiantly. "It was fairy
fruit—that's what it was!"
Luke sprang to his feet. "Busty Bridget!" he exclaimed in a horrified
voice. Ranulph began to chuckle. "Didn't you guess right away what
it was, Luke?" he asked.
"Yes," went on Peter, much elated by the effect his words had
produced, "it was wicker baskets all full of fairy fruit, I know, because
Cornflower had torn off the top of one of them."
"Yes," interrupted Toby, beginning to think that little Peter had stolen
enough of his thunder, "she had torn off the top of one of the
baskets, and I've never seen fruit like it; it was as if coloured stars
had fallen from the sky into the grass, and were making all of the
valley bright, and Cornflower, she was eating as if she would never
stop ... more like a bee among flowers, she was, than a common
cow. And the widow and the doctor, though of course they were put
out, they couldn't help laughing to see her. And her milk the next
morning—oh my! It tasted of roses and shepherd's thyme, but she
never came back to the herd, for the widow sold her to a farmer who
lived twenty miles away, and...."
But Luke could contain himself no longer. "You little rascals!" he
cried, "to think of all the trouble there is in Lud just now, and the
magistrates and the town guard racking their brains to find out how
the stuff gets across the border, and three little bantams like you
knowing all about it, and not telling a soul! Why did you keep it to
yourselves like that?"
"We were frightened of the widow," said Toby sheepishly. "You won't
tell that we've blabbed," he added in an imploring voice.
"No, I'll see that you don't get into trouble," said Luke. "Here's the
knife, and a coin to toss up for it with ... toasted Cheese! A nice
place this, we've come to! Are you sure, young Toby, it was Dr. Leer
you saw?" Toby nodded his head emphatically. "Aye, it was Dr. Leer
and no mistake—here's my hand on it." And he stuck out a brown
little paw.
"Well, I'm blessed! Dr. Leer!" exclaimed Luke; and Ranulph gave a
little mocking laugh.
Luke fell into a brown study; surprise, indignation, and pleasant
visions of himself swaggering in Lud, praised and flattered by all as
the man who had run the smugglers to earth, chasing each other
across the surface of his brain. And, in the light of Toby's story, could
it be that the stranger whose mysterious conversation with the widow
he had overheard was none other than the popular, kindly doctor,
Endymion Leer? It seemed almost incredible.
But on one thing he was resolved—for once he would assert himself,
and Ranulph should not spend another night at the widow Gibberty's
farm.
Toby won the toss and pocketed the knife with a grin of satisfaction,
and by degrees the talk became as flickering and intermittent as the
light of the dying fire, which they were too idle to feed with sticks;
and finally it was quenched to silence, and they yielded to the
curious drugged sensation that comes from being out of doors and
wide awake at night.
It was as if the earth had been transported to the sky, and they had
been left behind in chaos, and were gazing up at its towns and
beasts and heroes flattened out in constellations and looking like the
stippled pictures in a neolithic cave. And the Milky Way was the only
road visible in the universe.
Now and then a toad harped on its one silvery note, and from time to
time a little breeze would spring up and then die down.
Suddenly Ranulph broke the silence with the startling question, "How
far is it from here to Fairyland?"
The little boys nudged one another and again began to snigger
behind their hands.
"For shame, Master Ranulph!" cried Luke indignantly, "talking like
that before youngsters!"
"But I want to know!" said Ranulph petulantly.
"Tell what your old granny used to say, Dorian," giggled Toby.
And Dorian was finally persuaded to repeat the old saying: "A
thousand leagues by the great West Road and ten by the Milky
Way."
Ranulph sprang to his feet, and with rather a wild laugh, he cried,
"Let's have a race to Fairyland. I bet it will be me that gets there first.
One, two, three—and away!"
And he would actually have plunged off into the darkness, had not
the little boys, half shocked, half admiring, flung themselves on him
and dragged him back.
"There's an imp of mischief got into you tonight, Master Ranulph,"
growled Luke.
"You shouldn't joke about things like that ... specially tonight, Master
Chanticleer," said Toby gravely.
"You're right there, young Toby," said Luke, "I only wish he had half
your sense."
"It was just a bit of fun, wasn't it, Master Chanticleer? You didn't
really want us to race to ... yonder?" asked little Peter, peering
through the darkness at Ranulph with scared eyes.
"Of course it was only fun," said Luke.
But Ranulph said nothing.