Download the full version of the textbook now at textbookfull.

com

Neonatal Head and Spine Ultrasonography 1st

Edition Andrea Poretti

https://textbookfull.com/product/neonatal-head-
and-spine-ultrasonography-1st-edition-andrea-
poretti/

Explore and download more textbook at https://textbookfull.com

 Recommended digital products (PDF, EPUB, MOBI) that
you can download immediately if you are interested.

Advanced Myofascial Techniques Neck Head Spine and Ribs

Til Luchau

https://textbookfull.com/product/advanced-myofascial-techniques-neck-
head-spine-and-ribs-til-luchau/

textbookfull.com

Head and Neck Ultrasonography Essential and Extended

Applications 538th Edition Lisa A. Orloff (Editor)

https://textbookfull.com/product/head-and-neck-ultrasonography-
essential-and-extended-applications-538th-edition-lisa-a-orloff-
editor/
textbookfull.com

Atlas of Postsurgical Neuroradiology Imaging of the Brain

Spine Head and Neck 2nd Edition Daniel Thomas Ginat

https://textbookfull.com/product/atlas-of-postsurgical-neuroradiology-
imaging-of-the-brain-spine-head-and-neck-2nd-edition-daniel-thomas-
ginat/
textbookfull.com

Shadow Banking: The Rise, Risks, and Rewards of Non-Bank

Financial Services 1st Edition Roy J. Girasa (Auth.)

https://textbookfull.com/product/shadow-banking-the-rise-risks-and-
rewards-of-non-bank-financial-services-1st-edition-roy-j-girasa-auth/

textbookfull.com
Toward a Science Campus in Milan A Snapshot of Current
Research at the Physics Department Aldo Pontremoli Pier
Francesco Bortignon
https://textbookfull.com/product/toward-a-science-campus-in-milan-a-
snapshot-of-current-research-at-the-physics-department-aldo-
pontremoli-pier-francesco-bortignon/
textbookfull.com

Be My Handy Mechanic Lonely Hearts Club 1 1st Edition

Ally Crew [Crew

https://textbookfull.com/product/be-my-handy-mechanic-lonely-hearts-
club-1-1st-edition-ally-crew-crew/

textbookfull.com

Stochastic Approaches to Electron Transport in Micro and

Nanostructures Mihail Nedjalkov Ivan Dimov Siegfried
Selberherr
https://textbookfull.com/product/stochastic-approaches-to-electron-
transport-in-micro-and-nanostructures-mihail-nedjalkov-ivan-dimov-
siegfried-selberherr/
textbookfull.com

Leadership Lessons for Health Care Providers 1st Edition

Frank James Lexa

https://textbookfull.com/product/leadership-lessons-for-health-care-
providers-1st-edition-frank-james-lexa/

textbookfull.com

Differential Game Theory with Applications to Missiles and

Autonomous Systems Guidance 1st Edition Farhan A. Faruqi

https://textbookfull.com/product/differential-game-theory-with-
applications-to-missiles-and-autonomous-systems-guidance-1st-edition-
farhan-a-faruqi/
textbookfull.com
Learn to Program with Kotlin: From the Basics to Projects
with Text and Image Processing 1st Edition Tim Lavers

https://textbookfull.com/product/learn-to-program-with-kotlin-from-
the-basics-to-projects-with-text-and-image-processing-1st-edition-tim-
lavers-2/
textbookfull.com
Andrea Poretti
Thierry A.G.M. Huisman
Editors

Neonatal Head and

Spine Ultrasonography

123
Neonatal Head and Spine
Ultrasonography
Andrea Poretti
Thierry A.G.M. Huisman
Editors

Neonatal Head and

Spine Ultrasonography
Editors
Andrea Poretti, MD Thierry A.G.M. Huisman, MD,
Assistant Professor of FICIS, EQNR
Radiology Professor of Radiology,
Head of Pediatric Pediatrics, Neurology
Neuroradiology and Neurosurgery
Research Division of Pediatric Chairman, Department
Radiology and Pediatric of Imaging and Imaging Science
Neuroradiology Johns Hopkins Bayview
Department of Radiology Medical Center
and Radiological Sciences Baltimore, MD, USA
The Johns Hopkins Hospital
Baltimore, MD, USA Director, Division of Pediatric
Radiology and Pediatric
Neuroradiology
The Johns Hopkins Hospital
Baltimore, MD, USA

ISBN 978-3-319-14567-9 ISBN 978-3-319-14568-6 (eBook)

DOI 10.1007/978-3-319-14568-6

Library of Congress Control Number: 2015947271

Springer Cham Heidelberg New York Dordrecht London

© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of
translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service
marks, etc. in this publication does not imply, even in the absence of a specific
statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and
information in this book are believed to be true and accurate at the date of
publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer

Science+Business Media (www.springer.com)
Preface

Head and spine ultrasonography is an important tool in the

initial evaluation of intracranial and intraspinal abnormali-
ties in newborns. Ultrasonography is an incredibly versatile
bedside imaging tool in detecting brain and spine abnor-
malities in neonates, following the course of these lesions,
and evaluating the maturation of the neonatal brain and
spine. We believe it is a safe and cost-efficient alternative to
magnetic resonance imaging and computed tomography in
many cases.
This book allows readers to explore and advance their
knowledge with neonatal head and spine ultrasonography
and its application to a variety of common and rare neonatal
neurologic disorders. Organized to correspond to daily rou-
tine bedside practice, it presents a symptom-based approach
and classifies neonatal neurologic disorders at presentation.
For each symptom or finding, we present exemplary clinical
cases from our routine practice and illustrate how head and
spine ultrasonography may help in making the correct
diagnosis.
For the creation of the valuable collection of cases, we are
grateful to our coauthors, Drs. Frances J. Northington, Güneş
Orman, and Jacqueline Salas, who helped us with their inter-
est and expertise in this field to select the most interesting and
didactic cases and prepare succinct clinical vignettes as well as
illustrative, high-quality images. To be able to complete this
book, we were supported and intellectually challenged by a

v
vi Preface

number of brilliant physicians who are members of the

Neurosciences Intensive Care Nursery Program at the Johns
Hopkins Hospital, with their professional requests and stimu-
lating discussions at our weekly joint neonatal neurology
conference. This interdisciplinary culture has its roots in Johns
Hopkins’ four core values: excellence and discovery, leader-
ship and integrity, diversity and inclusion, and respect and
collegiality. These are as valid today as they were at the found-
ing of our hospital and our school of medicine in the late
nineteenth century.
We are thankful to Springer International Publishing AG,
who gave us the opportunity to publish our experiences with
neonatal head ultrasonography. We are particularly grateful
to Janet Foltin, Senior Editor, and Patrick Carr, Project
Coordinator, for their support in the conceptualization,
preparation, and realization of this book.
We hope that this book and case collection is as enjoyable
and helpful for readers as its preparation was for us.

Baltimore, MD, USA Andrea Poretti, MD

Thierry A.G.M. Huisman,
MD, FICIS, EQNR
Contents

1 Introduction.................................................................. 1
References ............................................................................. 3

2 How to Perform a Neonatal Head

Ultrasonography Study ............................................... 5
References ............................................................................. 18

3 Normal Head Ultrasound in the Preterm

and Term Newborn ...................................................... 19
References ............................................................................. 27

4 Seizures ......................................................................... 29
Differential Diagnosis of Brain Abnormalities
Associated with Neonatal Seizures That May Be
Detected by Neonatal Head Ultrasonography ............ 30
Arterial Ischemic Stroke (Figs. 4.1 and 4.2).................. 31
Herpes Encephalitis (Figs. 4.3, 4.4, and 4.5) .................. 34
Congenital Cytomegalovirus Infection
(Figs. 4.6, 4.7, 4.8, and 4.9) ........................................... 38
Intraventricular Hemorrhage with Periventricular
Venous Infarction (Figs. 4.10 and 4.11) ..................... 43
Periventricular Subependymal Heterotopia
(Figs. 4.12 and 4.13) ..................................................... 46
References ............................................................................. 49

5 Encephalopathy ........................................................... 51
Differential Diagnosis of Brain Abnormalities
Associated with Neonatal Encephalopathy That May
Be Detected by Neonatal Head Ultrasonography ...... 52
Hypoxic-ischemic Injury (Figs. 5.1, 5.2, and 5.3) .......... 53

vii
viii Contents

Intraventricular Hemorrhage (Figs. 5.4 and 5.5) .......... 57

Subdural Hematoma (Figs. 5.6, 5.7, and 5.8)................. 60
Bacterial Meningitis (Figs. 5.9 and 5.10) ....................... 64
Herpes Encephalitis (Figs. 5.11, 5.12, and 5.13) ............ 67
Maple Syrup Urine Disease (Figs. 5.14 and 5.15) ........ 71
References ............................................................................. 74

6 Muscular Hypotonia.................................................... 75
Differential Diagnosis of Brain Abnormalities
Associated with Muscular Hypotonia That May Be
Detected by Neonatal Head Ultrasonography ............ 76
Joubert Syndrome (Figs. 6.1, 6.2, and 6.3) ..................... 77
References ............................................................................. 81

7 Hemiparesis .................................................................. 83
Differential Diagnosis of Brain Abnormalities
Associated with Hemiparesis/Hemiplegia That May
Be Detected by Neonatal Head Ultrasonography ...... 84
Arterial Ischemic Stroke (Figs. 7.1 and 7.2).................. 85
Intraventricular Hemorrhage (Figs. 7.3, 7.4,
and 7.5).......................................................................... 88
Unilateral Periventricular Venous Infarction
(Fig. 7.6) ........................................................................ 92
References ............................................................................. 94

8 Apnea ............................................................................ 95
Differential Diagnosis of Brain Abnormalities
Associated with Apnea That May Be Detected
by Neonatal Head Ultrasonography.............................. 96
Cerebellar Hemorrhage (Figs. 8.1 and 8.2) ................... 97
Intraventricular Hemorrhage (Figs. 8.3 and 8.4) .......... 100
References ............................................................................. 103

9 Microcephaly ................................................................ 105

Differential Diagnosis of Brain Abnormalities
Associated with Microcephaly That May Be
Detected by Neonatal Head Ultrasonography ............ 106
Lissencephaly (Figs. 9.1, 9.2, and 9.3)............................. 107
Schizencephaly (Figs. 9.4 and 9.5) .................................. 111
Congential Rubella Infection (Figs. 9.6, 9.7,
and 9.8).......................................................................... 114
References ............................................................................. 118
 Contents ix

10 Macrocephaly ............................................................... 119

Differential Diagnosis of Brain Abnormalities
Associated with Macrocephaly That May Be
Detected by Neonatal Head Ultrasonography ............ 120
Post-hemorrhagic Hydrocephalus
(Figs. 10.1, 10.2, and 10.3) ............................................ 121
Chiari 2 Malformation (Figs. 10.4, 10.5, and 10.6) ........ 125
Dandy–Walker Malformation (Figs. 10.7, 10.8,
and 10.9)........................................................................ 129
Vein of Galen Malformation (Figs. 10.10, 10.11,
and 10.12)...................................................................... 133
References ............................................................................. 137

11 Craniofacial Dysmorphic Features ............................ 139

Differential Diagnosis of Brain Malformation
Associated with Craniofacial Dysmorphic
Features That May Be Detected by Neonatal
Head Ultrasonography .................................................... 139
Holoprosencephaly (Figs. 11.1, 11.2, 11.3,
and 11.4)........................................................................ 140
Agenesis of the Corpus Callosum
(Figs. 11.5 and 11.6) ..................................................... 145
References ............................................................................. 148

12 How to Perform a Neonatal Spine

Ultrasonography Study and Normal Spine
Ultrasound in the Neonate ......................................... 149
References ............................................................................. 155

13 Neonatal Spine Abnormalities ................................... 157

Types of Spinal Dysraphia That May Be Detected
by Neonatal Spine Ultrasonography ............................. 157
Myelomeningocele (Figs. 13.1 and 13.2)........................ 158
Diastematomyelia (Fig. 13.3) .......................................... 161
Dorsal Dermal Sinus (Fig. 13.4) ..................................... 163
Caudal Regression Syndrome (Fig. 13.5) ...................... 165
References ............................................................................. 167

Index...................................................................................... 169
Visit https://textbookfull.com
now to explore a rich
collection of eBooks, textbook
and enjoy exciting offers!
Contributors

Thierry A.G.M. Huisman, MD, FICIS, EQNR Professor of

Radiology, Pediatrics, Neurology and Neurosurgery, Chairman,
Department of Imaging and Imaging Science, Johns Hopkins
Bayview Medical Center, Baltimore, MD, USA
Director, Division of Pediatric Radiology and Pediatric
Neuroradiology, The Johns Hopkins Hospital, Baltimore,
MD, USA
Section of Pediatric Neuroradiology, Division of Pediatric
Radiology, Russell H. Morgan
Frances J. Northington, MD Division of Neonatology,
Department of Pediatrics, The Johns Hopkins Hospital,
Baltimore, MD, USA
Güneş Orman, MD Section of Pediatric Neuroradiology,
Division of Pediatric Radiology, Russell H. Morgan
Department of Radiology, The Johns Hopkins Hospital,
Baltimore, MD, USA
Andrea Poretti, MD Research Division of Pediatric
Radiology and Pediatric Neuroradiology, Department of
Radiology and Radiological Sciences, The Johns Hopkins
Hospital, Baltimore, MD, USA
Jacqueline Salas, MD Division of Neonatology, Department
of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD,
USA

xi
Chapter 1
Introduction

Ultrasonography (US) is a safe imaging modality that does

not require sedation and can be performed bedside. It can be
repeated as often as necessary because of the lack of ionizing
radiation. Modern “high-end” (i.e., technologically advanced,
up-to-date) US units can obtain two- and three-dimensional
(3-D) images of the neonatal brain in high resolution
(Daneman et al. 2006; Govaert and de Vries 2010; Maalouf
et al. 2001; Orman et al. 2015; van Wezel-Meijler et al. 2010).
Neonatal US requires a well-trained sonographer or radiolo-
gist familiar with neonatal pathology who is able to perform
an optimized, personalized study and knows how to take full
advantage of new technical developments (Benson et al. 2002;
Daneman et al. 2006; Di Salvo 2001; Leijser et al. 2006;
Nwafor-Anene et al. 2003; Steggerda et al. 2009; van Wezel-
Meijler et al. 2010; Ladino Torres and DiPietro 2014).
In the past, US has often been considered inferior to the
competing cross-sectional imaging modalities of computed
tomography (CT) and magnetic resonance imaging (MRI).
However, many of the studies that compared US with CT
and/or MRI used only limited “low-end” US studies with
“high-end” CT/MRI studies or compared an acute US with a
follow-up CT/MRI study done at a time when the findings
were more apparent or better demarcated due to ongoing
tissue injury or lesion evolution (Daneman et al. 2006;
Leijser et al. 2006; Maalouf et al. 2001). It is our experience

© Springer International Publishing Switzerland 2016 1

A. Poretti, T.A.G.M. Huisman (eds.), Neonatal Head and
Spine Ultrasonography, DOI 10.1007/978-3-319-14568-6_1
2 1. Introduction

that a “high-end” US, utilizing modern equipment that

includes gray-scale anatomical and color-coded duplex
Doppler techniques, performed by a skilled sonographer, can
be a very valuable and cost-efficient alternative to CT and
MRI in both the acute and chronic phases of neonatal brain
and spine pathology.
In this short book, we will discuss the standard, up-to-date
US techniques available, how to perform the study, and what
to look for on the images. We will present a variety of brain
and spine findings that may be encountered including com-
plications of prematurity, hypoxic ischemic brain injury, neo-
natal stroke, infections, malformations, neoplasms, and several
rare neonatal pathologies. There are textbooks that provide
an invaluable overview of the US findings in several neonatal
neurologic diseases (Govaert and de Vries 2010). The new-
borns, however, do not present with a diagnosis, but with
symptoms and findings, which typically guide clinicians to
finally determine the diagnosis and start the therapy.
Therefore, we have prioritized a symptom/finding-based
approach for our book and classified the neonatal neurology
diseases based on the symptoms/findings at presentation.
 References 3

References
Benson JE, Bischop MR, Cohen HL. Intracranial neonatal neuro-
sonography: an update. Ultrasound Q. 2002;18:89–114.
Daneman A, Epelman M, Blaser S, Jarrin JR. Imaging of the brain in
full-term neonates: does sonography still play a role? Pediatr
Radiol. 2006;36:636–46.
Di Salvo DN. A new view of the neonatal brain: clinical utility of
supplemental neurologic US imaging windows. Radiographics.
2001;21:943–55.
Govaert P, de Vries LS. An atlas of neonatal brain sonography.
London: Mac Keith Press; 2010.
Ladino Torres MF, DiPietro MA. Spine ultrasound imaging in the
newborn. Semin Ultrasound CT MR. 2014;35:652–61.
Leijser LM, de Vries LS, Cowan FM. Using cerebral ultrasound
effectively in the newborn infant. Early Hum Dev. 2006;82:
827–35.
Maalouf EF, Duggan PJ, Counsell SJ, Rutherford MA, Cowan F,
Azzopardi D, Edwards AD. Comparison of findings on cranial
ultrasound and magnetic resonance imaging in preterm infants.
Pediatrics. 2001;107:719–27.
Nwafor-Anene VN, DeCristofaro JD, Baumgart S. Serial head ultra-
sound studies in preterm infants: how many normal studies does
one infant need to exclude significant abnormalities? J Perinatol.
2003;23:104–10.
Orman G, Benson JE, Kweldam CF, Bosemani T, Tekes A, de Jong
MR, et al. Neonatal head ultrasonography today: a powerful
imaging tool! J Neuroimaging. 2015;25(1):31–55. doi:10.1111/
jon.12108.
Steggerda SJ, Leijser LM, Walther FJ, van Wezel-Meijler G. Neonatal
cranial ultrasonography: how to optimize its performance. Early
Hum Dev. 2009;85:93–9. doi:10.1016/j.earlhumdev.2008.11.008.
van Wezel-Meijler G, Steggerda SJ, Leijser LM. Cranial ultrasonog-
raphy in neonates: role and limitations. Semin Perinatol.
2010;34:28–38. doi:10.1053/j.semperi.2009.10.002.
Chapter 2
How to Perform a Neonatal
Head Ultrasonography Study

For an informative, diagnostic ultrasonography (US) study of

the neonatal brain, a modern, technologically advanced, US
unit is essential. Various transducers including vector, curved
array, and linear probes capable of scanning at multiple
megahertz (MHz) settings should be provided and able to
scan at a minimum of 15 MHz in order to reach the optimal
tissue quality. Imaging algorithms should be optimized for the
preterm (PT) and term (FT) neonatal brains. This “tuning”
of the algorithms in cooperation with the manufacturer’s
technical representative can dramatically improve resolution,
contrast, and detection of pathology and can provide a
“high-end” approach for each case.
The study should begin with gray-scale anatomical images
accessed through the anterior fontanel (AF) covering the
entire brain in coronal (Fig. 2.1) and sagittal (Fig. 2.2) planes.
In addition, mastoid fontanel (MF) (Fig. 2.3), posterior fonta-
nel (PF) (Figs. 2.4, 2.5 and 2.6), and suboccipital views
through the foramen magnum should be included for a better
exploration of the contents of the posterior fossa. Depending
on the probe, 3-D data sets may be acquired that allow sec-
ondary multiplanar reconstructions which match the more
typical CT and MRI imaging planes. Imaging should always
take advantage of optimization of all selectable imaging
settings including correct depth penetration, gain, number of
foci, etc. Moreover, the chosen US probe should have a

© Springer International Publishing Switzerland 2016 5

A. Poretti, T.A.G.M. Huisman (eds.), Neonatal Head and
Spine Ultrasonography, DOI 10.1007/978-3-319-14568-6_2
6 2. How to Perform a Neonatal Head…

footprint that matches the size of the acoustic window, be

positioned in the center of the fontanel and maintain good
contact with the scalp through the use of appropriate amount
of US gel (Daneman et al. 2006; Grant and White 1986;
Steggerda et al. 2009; van Wezel-Meijler et al. 2010).
Depending on the pathology encountered, more detailed
assessment of lesions located along the convexity of the cere-
bral hemispheres may require additional scanning with
higher frequency probes and oblique, off-center probe posi-
tioning (Fig. 2.7) (Correa et al. 2004; Di Salvo 2001; Enriquez
et al. 2006; Leijser et al. 2006; Steggerda et al. 2009).
In addition to the gray-scale anatomical imaging, the resis-
tive index (RI) of the intracranial vasculature can be sampled
using Doppler US along an anterior branch of the circle of
Willis, usually one of the anterior cerebral arteries (ACA)
(Figs. 2.8 and 2.9). The RI value is calculated as the ratio
between the maximal end-diastolic and end-systolic flow
velocities (Peak Systolic Velocity-Minimum Diastolic Velocity/
Peak Systolic Velocity). For FT neonates, the normal RI is
0.65–0.75, while PT infants have a slightly higher RI value
(0.77–0.8) (Fig. 2.10) (Huisman et al. 2010; Zamora et al.
2014). The RI values are best measured at the beginning of the
study through the AF without and then with gentle pressure
being applied with the transducer. A large variability in the RI
values acquired with and without pressure may indicate
impaired intracranial autoregulation. Subsequently, the supe-
rior sagittal sinus is sampled for patency and flow direction.
To date, there is no internationally adopted standard for
optimal timing and frequency of neonatal head US. Each
institution uses its own protocol currently (Horsch et al.
2010; Leijser et al. 2006; Nwafor-Anene et al. 2003; Steggerda
et al. 2009; van Wezel-Meijler et al. 2010). The frequency of
head US examinations should be intensified if there is a
sudden deterioration in infant’s clinical state: for example,
sepsis, necrotizing enterocolitis, episodes of apnea and/or
bradycardia, unexplained decrease in hemoglobin level, new
onset of neurological symptoms or ventricular dilatation.
Scanning is also advised before and after major surgery
(van Wezel-Meijler et al. 2010).
 2. How to Perform a Neonatal Head… 7

Finally, communication between neonatologists/pediatri-

cians taking care of the baby and pediatric radiologists
about the symptoms and clinical findings of newborn is
essential to best investigate the clinical suspicions, make the
correct diagnosis, and avoid misdiagnoses.
8 2. How to Perform a Neonatal Head…

Fig. 2.1. Anterior fontanelle approach: coronal view. This technique

is especially important to evaluate the lateral ventricles and choroid
plexus. The corpus callosum appears above the cavum septum pel-
lucidum. Caudate nuclei, putamen and globus pallidus, thalami,
bilateral temporal lobes, uncus, hippocampi, and Sylvian fissures can
be evaluated. The foramen of Monro, brainstem, and posterior fossa
structures are also seen.
 2. How to Perform a Neonatal Head… 9

Fig. 2.2. Anterior fontanelle approach: midline sagittal view. The

cerebellar vermis appears as an echogenic image in the posterior
fossa. The fourth ventricle is placed in front of the vermis, the cis-
terna magna is placed below the cerebellar vermis and appears
hypoechogenic. The corpus callosum is seen as a curve from anterior
to posterior, cingulate gyrus appears above and parallel to it.
Visit https://textbookfull.com
now to explore a rich
collection of eBooks, textbook
and enjoy exciting offers!
10 2. How to Perform a Neonatal Head…

Fig. 2.3. Transmastoid approach: axial image. This technique allows

to study the anatomy of the posterior fossa in more detail.
 2. How to Perform a Neonatal Head… 11

Fig. 2.4. Posterior fontanel approach: coronal image. This technique

allows to study the anatomy of the posterior fossa in more detail
and shows the craniocervical junction, cerebellar hemispheres
(arrowheads), and cerebellar vermis (asterix) in high detail.
12 2. How to Perform a Neonatal Head…

Fig. 2.5. Posterior fontanel approach: sagittal image. This technique

allows to study the anatomy of the posterior fossa in more detail and
shows the pons (long arrows) and remaining brainstem (short
arrows) in high detail.
 2. How to Perform a Neonatal Head… 13

Fig. 2.6. Posterior fontanel approach: axial image. This technique

allows to study the anatomy of the posterior fossa in more detail and
shows the pons (long arrows) in high detail.
14 2. How to Perform a Neonatal Head…

Fig. 2.7. High-resolution, high-frequency linear transducers allow to

study the anatomy of the brain surface in high detail. This sagittal
head ultrasound image has been acquired through the anterior fon-
tanelle. The subarachnoid space is filled with clear, hypoechogenic
CSF, the pia mater is seen as a hyperechogenic thin layer following
the contour of the brain gyri, extending into the brain sulci. The
cerebral cortex is slightly hypoechogenic in contrast to the mildly
hyperechogenic subcortical white matter. The stripes within the WM
represent the acoustic reflections of the intramedullary vessels.
Random documents with unrelated
content Scribd suggests to you:
 Instigation
CHAPTER XVI.
THE train in which Carl was riding rolled slowly through the outskirts
of a southern city and he looked out at the rows of negro cottages
and hovels that plaintively cringed underneath the wide foliage of
willow and magnolia trees. Most of the cottages were unpainted and
grey with the impersonally chaste kiss of time, while the hovels were
mere flimsy boxes covered with black tar paper. Sunflowers and
morning glories stood amid the weeds and twined about the slanting
fences like gaudy virgins dismayed at their sight of a lewdly
disordered room and appealing to the sunlight for protection. Negro
women in faded sunbonnets and wrappers could sometimes be seen
shuffling down the thickly dusty roads and negro children, in weird
incoherences of tattered clothes, tumbled around the humble
doorsteps. The children were little black madmen unconsciously
dodging a huge fist that was concealed beneath the scene. The dust
of a late August morning had dropped upon all things, sifting its
listless sadness into every crevice and crack, and even the fierce sun
could not dispel this invasion.
Every shade of this scene was an accurately friendly answer to Carl’s
mood and he squandered the brooding light of his eyes upon all of
the visual details outside of the train window. The mask of careless
bitterness upon his face said its hello to the cowering and sinister
apathy of the houses and people, and viciously he longed to leap out
of the window and join the unashamed animal rites which these
hovels and human beings were parading. Here an alien race was
standing amid clouds of evil-smelling squalor and staring at its
broken longings and dreams—staring with a wild hopelessness. This
race had lost its own civilization and was clumsily imitating that of
the white man, not because of any innate desire, but because it had
been forced to blend into its surroundings or perish, and Carl felt
that all of his life had also been an animated lie of flesh and speech,
devised to aid him in escaping from the contemptuous eyes that
vastly hemmed him in. And now, with the feelings of a man who had
neatly murdered himself, he was planning to turn the knives of his
thoughts and emotions upon other people, not for revenge, but
because the marred ghost of himself harshly desired to convince
itself that it was still alive. If this ghost had yielded to the
subterfuges of kindness and gentleness it would have become too
much aware of its own thin remoteness from life, and cruelty alone
could induce it to believe that it was still welded to the actualities of
existence.
As Carl sat at the window he could often hear the grotesquely
quavering, boldly mellow laughter of negro men trudging to their
work, but these sounds did not express humor to him. They held the
strong effort of men to flee from tormenting longings and the
numbly vicious rebuke of poverty, and the sounds which these men
released merely symbolized the long strides of their fancied escape.
Laughter can be merely the explosive sound with which human
beings seek to demolish each other—the indirect weapon of self-
hatred. Carl laughed with a strained loudness, throwing a magnified
echo to the negroes on the dusty roads outside, and a drowsily
plump, middle-aged woman in an opposite seat opened her mouth
widely and huddled into a corner, fearing that she might be attacked
by a maniac. He gave her a glance and feasted upon her fear, for
her shrinking attitude was falsely and deliciously persuading the
ghost of himself that it still held a potency over other people.
Sometimes a song crazily drifted to Carl’s ears from one of the negro
cottages—a song that was weighted with loosely undulating sadness
—and he listened with a stern greediness. Music is a huge,
treacherous sound made by thoughts and emotions to console them
for their feeling of minute mortality, and after it has given them its
dream of permanent size it disappears, slaying the illusion with
silence. Now it brought a delusion of substantiality to the ghost
within the mould of Carl’s flesh and he listened in a trance of
gratitude. Lost in the obliterations of his grief, he felt infinitely nearer
to these abject, musical negroes outside than to the artificially silent,
stiffly satisfied white people with whom he was riding. Grief, which is
an insane tyrant among emotions, has an effortless way of crossing
all boundaries and walls, but it does not reveal any hidden oneness
between human beings. Grief places men and women in a vacuum
of renunciation, or shows them that they have little connection with
the people around them and that they have been enduring an alien
camp. Ruled by this latter discovery, Carl looked with an undisguised
hatred at the formal, complacent white people in the railway coach
and felt that he was deeply related to the negroes outside.
Almost three months had passed since the invisible knife had swung
into the middle of his being, and since he had staggered across the
agitated sincerity of night to the peaceful compassion of the young
school teacher. Now and then he remembered their silent walk down
the sturdy brightness of the country road—a silence which had been
a soft wreath ironically thrown upon the weakness of words—and
the troubled way in which she had helped him brush his clothes and
wash his face, and the stumbling simplicity of the words with which
she had tried to comfort him. Although he had been a stranger to
her, she had thrown aside that distrust which is born of sensual pride
and a cheaply purchased worldly wisdom, influenced by the helpless
directness of his demeanor and by the supple humility which a grief
of her own had once left within her. The force of her fearlessness
had fallen upon him like the sweeping touch of another world, and in
his daze he had actually believed that she had been sent by the
woman whom he had lost as an alert messenger striving to teach
him how to hold his ghostlike shoulders up beneath a future burden.
If she had held a human aspect to him he would have hated and
reviled her, for then she would have been merely an atom in the
vast, turbid reality that had slowly lured him to an imbecilic torture.
He accepted the curves of her body as an unearthly visitation and
possessed them as one who passes through a fragile ritual. But after
his departure from her, as he once more walked down the shaggy,
solid country road, she had tiptoed away from him with a spectral
quickness, and the clamor of a world had once more attacked him,
like the scattered falsehoods of an idiot. The rustle of trees had
become an insignificant whisper of defeat; the songs of birds had
changed to the shrill vacuities with which a monster entertained
himself; the colored groups of flowers had become the pitiful
remains of a violated carnival; the earth beneath his feet had altered
to the stolid aloofness of a giant moron; and the sunlight had
seemed to be a theatrical accident.
When he had reached the city, with its orderly ranks of houses and
factories and its dully precise pavements, the scene had been to him
a cunning mirage made by dying people to suppress their realization
of the advancing destruction. The people on the streets had held the
complicated glee and perplexity of an insane slave trying to extract
an imaginary importance from his bondage. He had longed to jump
at their throats and silence the feverish lie that was reviling the
truthful stare of his eyes and only his physical exhaustion had
prevented him from doing this. Grief is a spontaneous welcome sent
to the insanity that lurks within all human beings, and its invitation
greets a responsive strength or a frightened weakness of
imagination, according to the man or woman who receives it.
And so he had plodded back to his home, carrying within him a
numb confusion that was sometimes disrupted by vicious impulses,
and forcing the ghost of himself into a motion which it could not
understand. He had tried to answer the angry and uneasy questions
of his parents with plausible lies at his own expense. Yes, he had
met someone who had given him bad news and in a fit of temper he
had rushed from the railroad station and deserted his valises. What
was in the telegram? Oh, just a message from a friend. Where had
he been for the past two days? Why, he had gone on a spree and
had slept off his drunkenness at the house of a friend. Shouldn’t he
be locked in an insane asylum? Yes, but life had already granted him
that favor. With a glib tongue he tried to serenade the barren
comedy of improbabilities to which he had returned, but he scarcely
heard the words that he was uttering, and as he wrung them from
the empty ghost that was within him he longed to strike his parents
in the face and feed greedily upon their rage and astonishment, in
an effort to convince himself that he was still substantially powerful,
still able to assert his reality by injuring the people around him. With
an act of this kind he could destroy the indifferent fantasy of life and
change it to a tangible and active opponent. The man standing
before him—his father—was merely an irritating puppet whose lack
of understanding moved jerkily, governed by the hands of an
ignorant dream.
With a cry of hatred, Carl struck his father in the face and watched
him reel back against the wall of the dining-room with a feeling of
warm triumph. He struck him again and revelled in the blood that
decorated the man’s lips. His mother shrieked with fear; his father
returned the blows; and the two men fought around the room,
overturning chairs and vases. Several neighbors, brought by the
cries of his mother, rushed in and overpowered him. Together with
his father, they held him down while someone summoned a patrol
wagon, and he was taken to a cell in a police station. As he sat in
the flatly smelling semi-gloom of the cell he caressed, with an
overpowering fondness, the blood that had stiffened upon parts of
his face, for it mutely testified that he had conquered the remote lie
around him and altered it to a satisfying enemy. He had persuaded
himself that he was still alive, and the blows which he had given his
father had been the first proof of this illusory emancipation.
Throughout the night, as he shifted upon the iron shelf that was his
bed, he muttered to himself at regular intervals, “I am alive, I am
still alive,” as though he were trying to preserve a triumphant dream
that would soon disappear, and the grief within him rocked to and
fro upon the words, using them as a cradle.
But when the morning dodged shamefacedly into his cell, bringing
with it a faint retinue of city sounds, the annoying fantasy returned
with full vigor, and the ghost within him stealthily assumed
possession of his flesh. Once more he was a thinly wounded
spectator, filled with an impotent hatred at the melee about him and
longing for the lusty release of physical motion. Two small boys,
lying upon their stomachs, peered through the grating of his cell
window, which stood on a level with the sidewalk outside, and jibed
at him. He cursed them incessantly, with an anger that was not
directed at them, but at the meaningless tensions of their voices,
and with the tumult of his own voice he vainly strove to shake the
wraith within him to firmer outlines.
As he stood before the magistrate a few hours later, an incredulous
sneer was on his face, as though the man at the desk above him
were a pompous, talkative scarecrow, and with a stubborn silence he
confronted the questions that were thrown at him. In a low,
hesitating voice his father declared that he feared that his son had
become insane, and the judge ordered an examination by one of the
city physicians. Carl was returned to his cell, after his parents had
pelted him with half-angry and half-bewildered sentences in an ante-
room of the court, and as he sat again in his cell, surveying the rigid
jeer of the iron bars, his hatred began to listen to the advice of
cunning—a cunning pilfered from the wilted depths of his despair. He
began to see that physical blows and silence were crude and
ineffective weapons in his attack upon the insulting commotion of
life and that, if he desired to injure human beings so that both he
and they might become real for a moment, he must use more
indirect and ingenious methods.
When the city physician, a tall, briskly-balanced man with no
imagination, questioned him in his cell, he became a blandly
appealing and submissive actor.
“Yes, doctor, I had a nervous breakdown from overstudy, you know,
and for a time I’m afraid that I lost my reason. They tell me that I
struck my father and this has horrified me, as I haven’t the slightest
recollection of what I did. But I’ve gathered myself together now
and I can promise you that I’ll never lose control of myself again—
never! And I’m awfully sorry for what I did. I can assure you of the
sincerity of my repentance.”
The physician was putty in Carl’s adroit hands—this composed young
man with an intelligent, contrite speech must, of course, be quite
sane. Carl, as he spoke to this man, slowly formed an evil grin
beneath the cool mask of his face, and he relished the task of
showering upon this man earnest platitudes, smooth imitations of
that limited sleep known as “common sense,” and words of self-
reproach, because this trickery brought back to him his old sense of
power over his surroundings and offered a subtle outlet for his
hatred of life. The physician ended by shaking his hand with a genial
respect and when evening came he was given his freedom.
He returned to his home, repeating the soft treachery of his words
while his fists still longed to lunge out at the faces in front of him,
but the shrewdness of a ghost determined to regain a semblance of
life by cleverly deceiving and punishing the people around it came to
his rescue and controlled his body. His parents had felt wrathful at
the presence of something which they could only dimly see and
which he made no effort to clarify, but life had taught them to make
a god of submission, and a heavy tenderness mingled with an alert
fear crept into their posture toward him. He trudged back to the
loquacious, coarse emptiness of his clerkship at the tobacco shop
and shunned the world that he had previously inhabited, for he
feared that if he met anyone whom he knew he would feel again the
irresistible inclination to interrogate their throats, and he knew that
these impulses would only lead to his own destruction. When he
accidentally met some acquaintance on the street, he would hurry
on like a nervous criminal, ignoring the other’s greetings.
He prowled about the city, still in search of a violent dream that
could offer its delusion of reckless strength to the mutilated spirit
whose complaints drove him on. He ran to the soiled raptures of
prostitutes and sensually oppressed, adventurous girls who could be
picked up on the streets, and gave them a twisted symphony of
blows, curses, whispered insinuations, lies, while he revelled in the
illusion of cruelty that was lending a false reality to the thin futilities
of his mind and flesh. With a mixture of brutality and delicately
simulated caresses, he overawed these women and they felt
themselves in the presence of a charming, abstracted fiend, whose
kaleidoscopic insincerity only made them long to change it to a
gesture of actual love. He sought the company of thieves and
hoodlums, and at first they distrusted him because his restrained
manners and gently removed look were not proper credentials, but
when they saw how eager he was for the impact of fists, and how
he could take a blow and rise with a grin of stunned delight, they
accepted him as an eccentric brother. They did not know that these
actions were not born of courage, but were caused by a gigantic
longing for physical pain—pain that could shock his numb spirit into
a feeling of sharply hideous communion with an actual world.
But finally this life began to weary him because it could not reach
the flimsy loneliness that stood within him. He carried within him at
all times an audience of ghostly thoughts and emotions, and they
were at last becoming bored with the stolen melodrama. He
determined to practice an economy in movements and words, and
he walked alone at night and on streets where the possibility of
meeting someone who knew him would be distant. He watched the
syncopated gliding of people with the irritation of a stranger. The
men and women who drifted or bobbed along were cardboard
mannikins to him and he vainly tried to give life to their flatness and
lack of color. Sometimes he would pause and touch his arm and
face, wondering at the odd inadequateness of their presence. Olga
had become a living but invisible being who was constantly groping
for him, with eyes unused to the outlines of earth, and sometimes
finding his shoulder in a fleeting and accidental way. When this
happened, he would turn around abruptly and berate his inability to
extract her form from the concealing air. At such times he would
often speak to her. “Olga ... Olga ... what is this unsought blindness
that has come to both of us?” he would cry into the night air of a
street. “A cruel chicanery ... a blurred and simple pause ... a little
fantasy within a huge one? Am I a coward rolling in the mud that
stretches before a vast gate? Life seems a fantastic conspiracy,
panting and rattling in its efforts to hide the emptiness beneath it....
Olga ... take me to your burnished hermitage ... I am tired.”
He would walk on, trying to imagine what her answer had been, and
winning an elusive and deliberately wrought consolation that stayed
for an hour and then gradually departed. His life had settled into the
recurrence of these reactions, when a second invitation arrived from
his wealthy uncle in the southern city, and he had accepted merely
because he wanted a new arena for his struggle with a discredited
reality—fresher targets and a change in the illusion’s surface.
And now he was seated in the train that slowly rolled through the
outskirts of a southern city and giving his eyes to the squalid negro
section that unfurled before him....
 CHAPTER XVII.
He turned from the window and strove to place an expression of
close-lipped serenity on his face, for the train had almost reached
the station. He had not seen his uncle for years and he played with
dim memories of the man’s appearance. When he walked down the
station platform he found that his uncle, Doctor Max Edleman, was
waiting just outside of the iron gates. Doctor Edleman was a man of
sixty years, sturdily rotund, with a tall body that was beginning to be
disgraced by its expanding paunch. His head was unusually large
and ruled by small blue eyes and the sharply turned breadth of a
nose. His great, thick lips were tightly withdrawn to an outline of
benign patience and his florid face ridiculed the trace of wrinkles
that had flicked it. His greyish blonde hair was still fairly abundant,
and all of him suggested a man who was uniquely intact because he
had scarcely ever allowed life to clutch him familiarly. Since he was
an Alsatian Jew, he kissed Carl carefully on both cheeks, and this
annoyed Carl, not from the usual masculine reasons, but because he
felt that this was a jocose insult from a fantasy that despised him,
but he submitted with a flitting grimace.
He took Carl to an automobile and after they had been driven away
he smothered him with questions.
“Your dear mother tells me that you have been acting queerly of
late,” he said, in the heavily-measured way of speaking he had. “You
have been refusing to speak to anyone and staying away from home
—bringing worry to your dear mother. It seems to me that you have
given enough care and trouble to your parents, and that it’s about
time that you acted like a normal man. I understand that you have
been dissipating and going with dissolute people. You are twenty-
five now and there is no longer any excuse for this wildness. What
have you to say for yourself?”
“Don’t ask me to explain things that you couldn’t understand,” said
Carl, returning to act in the falsely unpleasant play. “I have had a
great grief and I’m trying in my own way to make it a friend of mine.
If I tell you that your questions bring back wounds, I am sure that
you will not desire to hurt me.”
He gave his uncle words that would appease and disarm him, while
at the same time evading his queries, and this game gave him a
smooth semblance of life.
“So-o, so-o, I have no desire to penetrate your secrets,” said Dr.
Edleman, in a kindly voice that feebly strove to comprehend. “I am
simply advising you to pull yourself together. Show some
consideration for the people around you.”
He continued to offer the benevolent adulterations of his advice, and
as Carl listened he suddenly thought of a high-school teacher who
had once rebuked him for bringing to class a theme entitled “Women
Who Walk the Streets,” and with a vaporously swinging amusement
in his heart he almost felt human again. This fantasy could hold a
blustering smirk now and then—its only extenuation. But the
nearness vanished as his uncle’s voice became a swindling
monotone, angering him with its formal pretense of life. Carefully,
and with a ghostlike insincerity that bribed his voice with lightness,
he gave words that could hold this man at arm’s length. The strain
of adapting his words to the intelligence of the man beside him
brought him a closer relation to the bickering phantasmagoria of
men and their motives without in any way summoning his own
thoughts and emotions. Dr. Edleman felt that his nephew was
skillfully attempting to defend a selfish past and bringing into the
service of this motive a graceful keenness of mind, but beyond this
point Carl’s words were unable to affect him.
“I have always admired your brilliancy,” he said, “and I only wish
that you would use it in the right way. A young man must pay some
attention to the desires and opinions of older people. It will be a
glad day for me when I see that you are using your talents to bring
happiness to other people. A glad day.”
Carl gave a sigh to the grave dullness that marched forth in his
uncle’s voice and meditated upon the curious differences in sound
with which people petted their limitations and discretions. These
differences were known as words, and when they pleased a great
number of people they were hailed as symbols of genius or power,
but Carl could see no distinction between any of them. Like a horde
of tired servants, they pranced to the prides and hatreds of men and
then returned to their common grave, and only their exact
arrangement gave them a flitting assumption of life. “What is the
difference between this old man and myself? Several keys to false
doors of thought and emotion, misplaced or lost in his youth and
found in mine.” Through reiterating these plausibilities he tried to
give bulk and texture to the fantasy of existence.
The automobile stopped before the Edleman home, which was a
large two-story structure—a partial reproduction of the Colonial
period modified to conform to the more exuberant inclinations of an
Alsatian Jew. Four broad, high wooden pillars, painted white, rose
over a wide veranda and ended in a slanting roof of black slate, and
the walls were of red brick courted by an abundance of vines. A
large garden, with tons of fruit trees and brilliant episodes of
flowers, surrounded the house and was enclosed by a level hedge of
shrubs and a low iron fence. An impression of dreamlessly cluttered
luxury, verging in spots upon bland somnolence, proclaimed the
empty heart of the place, but it was almost a distinct flattery to Carl,
who had grown tired of aggressive angles and plain surfaces. Here,
at least, the mirage held a sleek flirtation with bunches of color and
burdened curves.
His aunt Bertha, a short, stout woman in a gown of brown taffeta
and white lace, welcomed him in a babbling and languid fashion and
showed him to his room. She was a softly shallow woman whose
major interests were card parties and the lingering intricacies of
gossip. The flabby roundness of her face was in the last grip of
middle age and her mind was as scanty and precisely glistening as
the greyish-brown hair that slanted back from her low forehead.
After the dinner, she hurried off to the mildly mercenary rites of a
bridge whist party and Carl was left to wander idly around the
garden. He sat on the grass beneath a persimmon tree and played
with lazy, cruel thoughts in which he slapped a man’s face or
tortured a woman’s cheek, still moved by his old mania to profane
the empty dream which life had become to him, forcing it into a
vigorous duplicate of reality.
The bright afternoon, with its myriads of shrilly clear and hissing
sounds, was like a troubled falsetto rapture and he weakly fought to
bring it nearer to his senses. As he sat beneath the tree he resolved
to give his mind some labor with which it could transform the vision
to a more solid picture, and he thought of the people who would
soon be embarrassing him with their mouths and eyes. They were
Jews of a kind that had rapidly spread over the south. The older
people among them had migrated to the south some forty years
previously and had gradually won large or comfortable fortunes by
means of their thriftiness and trading abilities. They were now
contented grand-and great-grand-parents, surrounded by two
generations of their offspring, and all of them were strangely
indifferent to the austere mysticism for which the Jewish race is so
verbosely noted. Dreamless, voluble, self-assured, they angled with
their religion in a half-hearted way and blackmailed, with money, the
occasional flutters of mental curiosity. They had picked up several
mannerisms of the south—softly drawling voices and unhurried
movements—and the only things that distinguished them as Jews
were the curved gusto of their faces and the fact that they mingled
only with each other—a last, lukewarm trace of loyalty left by the
surge of centuries of past incidents.
Carl went into the house and returned, with paper and pencil, to his
station beneath the persimmon tree. He strove to write a poem to
the woman whom he had lost. It was a torture that, like a starved
monster, devoured the softer spaces within his heart. It was as
though he were endeavoring to compress the ruins of an entire
world, making them narrower and narrower, more and more alive,
until at last they formed the body of a woman. The effort brought
him an actual physical pain; drops of sweat were born on his
forehead, and his spirit reeled like a mesmerized, beaten drunkard.
“All of life is a lie unless I make her appear on this paper,” he cried
aloud to the persimmon-tree leaves, for the lack of better gods. He
detested his own futility and sought to avenge himself upon it. When
the poem was finished he fell into a troubled, plundered sleep in
which his consciousness busily made reports that were unheeded.
He could still see the trees and flowers, but they were like the edge
of the universe miraculously brought near to his eyes. Finally, with
an effort like a straight line thrusting aside several worlds, he roused
himself and read the poem. It failed to satisfy him; it was a tangle of
treacherous promises and pleading fragments—the line of one of her
arms, with an ashen delicateness; the nervously boyish rebuke of
her eyes; the tenuous defiance of her heart; the curled merriments
of her hair—fragments fastened to a slip of white paper and lacking
the great surge of breath that could have whirled them into a
speaking whole. He had written other poems to her and they had
produced the same result; but still, huddled under the tree, he
continued to write, much like a dying man who has no choice save
to gasp for breath, only in his case it was a ghost that struggled to
avoid a second death. The ghost was seeking to escape a final
extinction. He wrote until the lengthened shadow of the tree told
him that he must return to the house; but it took him at least ten
minutes before he could censure his face and control his breath. At
last, with the thinly passive mask once more adjusted and held by
the slenderest of threads, he walked from the garden.
At supper he met his cousin, Dr. Joseph Rosenstein, who was living
at the Edleman home and who treated him with a suspecting
affability. The presence of a poet is always a vague challenge to
those people who feel that he is somehow at variance with the
complacent finalities of their lives, but who cannot draw the
difference into a clearer antagonism. For this reason they try to
cover their distrust with a nervous and questioning amiability. After
jovially advising Carl to write a sonnet to a doctor, protesting to a
great admiration for the prettiness of poetry, and asking Carl
whether he didn’t think that practical people were also of some use
in the world, Rosenstein deserted the farce and began to discuss the
technical details of an operation with Dr. Edleman. Bertha Edleman
uttered some placid remarks concerning the possibility of Carl’s
writing short stories that would bring him a great deal of money;
inquired after his parents in a detailed but listless way; and then,
with more vigor, commenced to speak of engagements, marriages
and divorces within her immediate circle. Dr. Edleman, by turns
waggish and blunt, presided over the groups of corrupted words.
Since Carl was anxious not to provoke these people, he stooped to
the task of uttering pleasantly obvious remarks in a timid and
deliberate fashion, and since they secretly felt that his work gave
him a rank lower than theirs, they liked the subdued and abashed
manner in which he spoke.
 CHAPTER XVIII.
After that evening he managed to protect his loneliness with clever
words. He told the Edlemans that he was looking for material for
short stories and that he intended to roam about the city; and,
elated at his purpose, they did not object. Since most of his relatives
were still displaying their dignity, jewelry, and card-playing abilities at
northern summer resorts, he found it easy to be alone.
In the midst of his restless, empty wanderings he often sat for a
while in a little park that rustled and nodded upon the top of a bluff
overlooking a broad river. There he would stare out at the wide,
yellowish-brown flat of water, and the dull green convolutions of the
distant shore, and the water would become an ethereal canvas
where he painted fugitive salutes to the woman who had fled from
life’s semblances. Under the spell of a melting daze he would sit for
hours, almost unconscious of the fact that he held a body of slowly
breathing flesh. At one end of the park the line of benches turned
sharply in toward the city, and this shaded place, guarded by bushes
and trees, was known as “Rounder’s Corner.” It was frequented by
thieves, drug peddlers, sly, lacquered women and an occasional
vagrant, and they gathered there from twilight on and drained the
fierce insincerities of conversation and whiskey, with sometimes the
lucid edge of cocaine. Since Carl came to this spot only during the
afternoons, he did not see these people until, one evening, he
managed to absent himself from the Edleman home on the pretense
of desiring a trip on a river steamboat, and strolled into the park.
He sat on a bench and looked around him, trying to become
interested in the immediate contortions of the fantasy. One glance
told him the identity of the social circle into which he had dropped
and he felt a jerk of attention, for the more openly rough and cruel
people in life were to him reflections of his ghostly self, spied in a
coarsely exaggerated mirror but none the less valid. Fresh from the
lazy inanities of the Edleman house, he felt a little baffled vigor—the
ghost lamenting its lack of exercise—and he longed to roll once more
in that plastic phenomenon which men insist on calling mud. It was
only through plastering himself with the concentrated moistness of
earth that he could force himself to believe, for a time, in the reality
of life, and he welcomed his chance to repeat this process. He
scanned the whispering, laughing, loose-faced people around him
and turned over in his mind different ways of approaching them,
since he knew how easy it was to heap fuel upon their suspicions.
A woman dropped down beside him on the bench. She was young in
actual years—not more than twenty-three—but her body had been
slashed by a premature herald of middle age and her rounded face
was too softly plump and wrinkled a little under the eyes and below
the chin. Youth and age were stiffly twined about her in lines that
protested against each other. Her body was short and held a
slenderness that was unnaturally puffed a bit here and there, giving
an impression of incongruous inflation rather than of solid flesh. Her
black hair was a plentiful mass of artificial curls and pressed against
a wide straw hat, festooned with tulips made of gaudy cloth, and
she was clad in loosely white muslin with a crimson sash around her
waist. The effect was that of a school girl playing the part of a street
walker in an amateur theatrical and, if you looked at her clothes
alone, the illusion remained. It was only destroyed by a glance at
her face, for the outward costumes of reality are often unconsciously
amateurish, as though they were striving to obliterate the
professional aspect held by the faces of human beings—a psychic
confession. Men and women can never quite memorize their parts in
life and their clothes sometimes express this absent-mindedness.
As he looked at this woman Carl noticed that her eyes were not
those of the usual flesh trader—shifting and infantile—but were filled
with a tense distraction. The mere sullen aftermath of whiskey, or
the departure of a man? No, it almost seemed that she was actually
brooding over emotions that had removed her leagues from the
bench against which her body was pressed. Eyes are often unwitting
traitors and they tell the truth more readily than the rest of the face,
or words, since human beings are not so conscious of what their
eyes are announcing. The two holes in the mask of the face are
often transparent or careless admissions, while the remainder of the
face is immersed in a more successful deception. Carl was interested
by the fact that this woman seemed to ignore his presence and was
staring straight ahead of her. He began to believe that her
indifference was genuine and he watched her more closely. Finally
she tossed her head, with a gesture that expressed the defiant
return of consciousness, and glanced at him. Then she threw him
the usual “Hello, honey,” and with a disgusted grimace he dismissed
a certain ghostly audience within him, telling it that the play would
not begin. For a while he spoke to her, throwing slang pebbles at her
with an oppressed exactitude and brushing aside her lustreless
insinuations, a little weary of the unconvincing comedy. Suddenly the
stunt nauseated him and he fled back to his own metaphoric tongue.
“Do you see that woman passing by?” he asked. “She has a face half
like a twitching mouse and half like a poised cat. I have known such
women. They are continually robbing certain men of emotions in
order meekly to hand back their thefts to other men. With a mixture
of cruelty and weak submission they entertain their own emptiness.”
He looked away from her, expecting a silence or the affront of
cracked laughter and preparing to leave. Her answer swung his head
toward her.
“You may be speaking to such a woman. Life has undressed me to
all people except myself, and I don’t know what I am. I think that I
was born to be a nun, but something kicked me down a dirty
hallway and when I woke up there were many hands reaching for
me and it didn’t seem important to me whether they took me or not.
But I think that I was born to be a nun.... Does that interest you?”
He stared at her with his mouth almost describing a perfect O and
his eyes opened to a wild uncertainty. For a moment he felt that
they were both quite dead and that her spirit had been ravished by
waiting words.
“In God’s name, what have you been doing?” he cried.
“Playing a part, with the assistance of your indifferent slang,” she
said.
“Why?”
“I started out by talking to you as I do to most men. You broke into
a rough speech and I parried as usual. The evening was
commencing in its usual convincing manner. Then I began to see
that you were acting. There was a strain on your face, and
sometimes you stopped in the middle of a delicate simile.... I knew
that I might be wrong, so I kept on talking as you expected me to
talk.”
On her face was the smile of a beggar whose tinselled metaphors
have been pummeled and disheveled by surface realities. The plump
curves of her face seemed to fit less snugly beneath the flat deceit
of rouge.
“I am a fool,” he said. “Your eyes told me something, but I spat
upon it. I think that you had better leave me.”
“I have no intention of leaving you,” she said.
They sat and stared at each other.
“Do you give yourself to different men every night?” he asked, as
though his sophistication, in an instant curve, had retreated to an
anxious child long concealed within him.
“I give them what they are able to take, and that is little. They want
to clutch me for a time, but I don’t feel them unless they stop my
breathing. A man walks into a house, wipes his feet on the mat,
spits into one of the cuspidors, and leaves with a vacant smile on his
face.”
“Why do you want them to come in?”
“They give me money for whiskey and leisure time in which I can
read. I’ve never been able to find a simpler way of getting these
things.”
The explanation was clear and delicate to him.
“Of course, the whiskey makes you sneer like a queen, and the
books bring you affairs with better men,” he said.
“All that I want to do is to pray to my thoughts with appropriate
words, and every night until two in the morning I pay for the
granting of this wish.... But I think that I was born to be a nun.”
“I think that I was born to be a monk, covering the walls of his cell
with little images, all of them contorting his bright hatred for a
world,” he said. “I think that something also kicked me into a mob of
prattling marionettes, leaving me exposed to the shower of
unintended blows. I have often looked behind me and vainly tried to
see who this first enemy was, but I am afraid that he does not
return until you die.”
With their silence they continued the dialogue for a time.
“Have you a man who takes your money and kicks you?” he asked.
“No. Every now and then some dope peddler pays me a visit, but I
have a gun and I know how to use it. I sent one of them to a
hospital once. They call me Crazy Georgie May and they’re always
afraid of something that they can’t understand.”
“I have a proposition to make to you,” he said. “We’ll live together
without touching each other and each of us will be the monk and
nun that he should have been. I am a ghost who wants to return to
life and you are a living person who wants to go back to the ghost
that was kicked into an insincere ritual of flesh. We’ll erect a unique
monastery of thought and emotion, and pay for it with the slavery of
your hands or mine.... Will you live with me in this fashion?”
“Yes, if only to see whether it can be done,” she answered instantly.
They rose from the bench and walked away together—a noble rascal
and an ascetic prostitute.
Typography and Printing by Printing Service Company, Chicago.
Electrotyped by Simpson-Bevans Company, Chicago.
 Transcriber’s Notes
A number of typographical errors were corrected silently.
Cover image is in the public domain.
Table of contents was augmented with chapter references.
*** END OF THE PROJECT GUTENBERG EBOOK BLACKGUARD ***

Updated editions will replace the previous one—the old editions

will be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States
copyright in these works, so the Foundation (and you!) can copy
and distribute it in the United States without permission and
without paying copyright royalties. Special rules, set forth in the
General Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the

free distribution of electronic works, by using or distributing this
work (or any other work associated in any way with the phrase
“Project Gutenberg”), you agree to comply with all the terms of
the Full Project Gutenberg™ License available with this file or
online at www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand,
agree to and accept all the terms of this license and intellectual
property (trademark/copyright) agreement. If you do not agree
to abide by all the terms of this agreement, you must cease
using and return or destroy all copies of Project Gutenberg™
electronic works in your possession. If you paid a fee for
obtaining a copy of or access to a Project Gutenberg™
electronic work and you do not agree to be bound by the terms
of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only

be used on or associated in any way with an electronic work by
people who agree to be bound by the terms of this agreement.
There are a few things that you can do with most Project
Gutenberg™ electronic works even without complying with the
full terms of this agreement. See paragraph 1.C below. There
are a lot of things you can do with Project Gutenberg™
electronic works if you follow the terms of this agreement and
help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright
law in the United States and you are located in the United
States, we do not claim a right to prevent you from copying,
distributing, performing, displaying or creating derivative works
based on the work as long as all references to Project
Gutenberg are removed. Of course, we hope that you will
support the Project Gutenberg™ mission of promoting free
access to electronic works by freely sharing Project Gutenberg™
works in compliance with the terms of this agreement for
keeping the Project Gutenberg™ name associated with the
work. You can easily comply with the terms of this agreement
by keeping this work in the same format with its attached full
Project Gutenberg™ License when you share it without charge
with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project

Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project
Gutenberg™ work (any work on which the phrase “Project
Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed,
viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United

States and most other parts of the world at no cost and
with almost no restrictions whatsoever. You may copy it,
give it away or re-use it under the terms of the Project
Gutenberg License included with this eBook or online at
www.gutenberg.org. If you are not located in the United
States, you will have to check the laws of the country
where you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is

derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of
the copyright holder), the work can be copied and distributed to
anyone in the United States without paying any fees or charges.
If you are redistributing or providing access to a work with the
phrase “Project Gutenberg” associated with or appearing on the
work, you must comply either with the requirements of
paragraphs 1.E.1 through 1.E.7 or obtain permission for the use
of the work and the Project Gutenberg™ trademark as set forth
in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is

posted with the permission of the copyright holder, your use and
distribution must comply with both paragraphs 1.E.1 through
1.E.7 and any additional terms imposed by the copyright holder.
Additional terms will be linked to the Project Gutenberg™
License for all works posted with the permission of the copyright
holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files
 containing a part of this work or any other work associated with
Project Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute

this electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1
with active links or immediate access to the full terms of the
Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if
you provide access to or distribute copies of a Project
Gutenberg™ work in a format other than “Plain Vanilla ASCII” or
other format used in the official version posted on the official
Project Gutenberg™ website (www.gutenberg.org), you must,
at no additional cost, fee or expense to the user, provide a copy,
a means of exporting a copy, or a means of obtaining a copy
upon request, of the work in its original “Plain Vanilla ASCII” or
other form. Any alternate format must include the full Project
Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™
works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or

providing access to or distributing Project Gutenberg™
electronic works provided that:

• You pay a royalty fee of 20% of the gross profits you derive
from the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
 payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt
that s/he does not agree to the terms of the full Project
Gutenberg™ License. You must require such a user to return or
destroy all copies of the works possessed in a physical medium
and discontinue all use of and all access to other copies of
Project Gutenberg™ works.

• You provide, in accordance with paragraph 1.F.3, a full refund of

any money paid for a work or a replacement copy, if a defect in
the electronic work is discovered and reported to you within 90
days of receipt of the work.

• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project

Gutenberg™ electronic work or group of works on different
terms than are set forth in this agreement, you must obtain
permission in writing from the Project Gutenberg Literary
Archive Foundation, the manager of the Project Gutenberg™
trademark. Contact the Foundation as set forth in Section 3
below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend

considerable effort to identify, do copyright research on,
transcribe and proofread works not protected by U.S. copyright
law in creating the Project Gutenberg™ collection. Despite these
efforts, Project Gutenberg™ electronic works, and the medium
on which they may be stored, may contain “Defects,” such as,
but not limited to, incomplete, inaccurate or corrupt data,
transcription errors, a copyright or other intellectual property
infringement, a defective or damaged disk or other medium, a
computer virus, or computer codes that damage or cannot be
read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except

for the “Right of Replacement or Refund” described in
paragraph 1.F.3, the Project Gutenberg Literary Archive
Foundation, the owner of the Project Gutenberg™ trademark,
and any other party distributing a Project Gutenberg™ electronic
work under this agreement, disclaim all liability to you for
damages, costs and expenses, including legal fees. YOU AGREE
THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT
EXCEPT THOSE PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE
THAT THE FOUNDATION, THE TRADEMARK OWNER, AND ANY
DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE
TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL,
PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE
NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you

discover a defect in this electronic work within 90 days of
receiving it, you can receive a refund of the money (if any) you
paid for it by sending a written explanation to the person you
received the work from. If you received the work on a physical
medium, you must return the medium with your written
explanation. The person or entity that provided you with the
defective work may elect to provide a replacement copy in lieu
of a refund. If you received the work electronically, the person
or entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund.