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Atlas of Fetal MRI 1st Edition Deborah Levine Digital
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Author(s): Deborah Levine
ISBN(s): 9780824725488, 0824725484
Edition: 1
File Details: PDF, 12.42 MB
Year: 2005
Language: english
Atlas of
Fetal MRI
Atlas of
Fetal MRI
Edited by
Deborah Levine
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Massachusetts, U.S.A.
Boca Raton London New York Singapore

Published in 2005 by
Taylor & Francis Group
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© 2005 by Taylor & Francis Group, LLC
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Preface
Fetal magnetic resonance (MR) imaging has undergone a remarkable growth in the past decade. Fast imaging techniques
allow for images to be obtained in a fraction of a second. With this ability, we have begun to view the fetus in a manner not
previously possible. Although the appearance of fetal anatomy on sonography has been well-established, there are few
resources available that illustrate the MR appearance of normal and abnormal fetal anatomy.
Although ultrasound is the standard imaging technique utilized in pregnancy, there are many cases where sonographic
diagnosis is unclear. In these cases, MR imaging can help clarify diagnosis and thus aid in patient counseling and manage-
ment. This is especially important in evaluation of the fetal central nervous system.
Knowledge of brain anatomy used for pediatric or adult imaging may not be sufficient for evaluation of the fetus, where,
for the brain in particular, changes in appearance occur over time. Abnormalities with a particular differential diagnosis in
pediatric patients can have a different differential diagnosis in the fetus. As interpretation of MR examinations may be
performed by radiologists, obstetricians, and pediatric subspecialists, it is important to have a text that incorporates
fetus-specific information needed by all of these subspecialties.
The illustrations in this text were taken from patients undergoing MR examinations for maternal and fetal indications.
Many of the studies were obtained under research protocols investigating the utility of fetal MR imaging.
There are many excellent textbooks of fetal anomalies. This book is not intended to replace them, rather, it is a resource
to illustrate the changing appearance of fetal anatomy over time and the types of anomalies that can be seen with fetal MR
imaging.
In addition to chapters that deal with normal anatomy and pathology, there are chapters with background information on
safety of MR in pregnancy, techniques of fast imaging, and artifacts.
I hope that this book will give prenatal diagnosticians an improved ability to counsel patients.
Deborah Levine
v
Acknowledgments
Many of the images of the fetal brain were obtained under NIH grant NS37945 and NIBIB EB001998. I am very grateful to
Dr. Herbert Kressel who encouraged my pursuit of fetal magnetic resonance imaging.
This work on fetal imaging would not have been possible without the training I received in Ultrasound. I feel very lucky
to have had as mentors: Barbara Gosink, Dolores Pretorius, George Leopold, Nancy Budorick, Roy Filly, Peter Callen,
Ruth Goldstein, and Vickie Feldstein.
The fetal research program at BIDMC would not have been possible without the support of the MR section chiefs,
Robert Edelman and Neil Rofsky who allowed use of the research magnet and shared their ideas on fast imaging sequences.
Special thanks go to the physicists who aided in sequence optimization, Qun Chen and Charles McKenzie. I am also very
grateful to the many technologists who helped scan patients, in particular Wei Li, Steven Wolff, and Norman Farrar. I would
like to thank Ronald Kukla for his administrative support.
I especially would like to thank the many proof-readers of the book chapters, including Alex Jesurum, Daniel Levine,
Dolores Pretorius, Philip Boiselle, and Donna Wolfe.
vii
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments ....................................................................... vii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
1. Safety of MR Imaging in Pregnancy ..................................................... 1
Deborah Levine
2. MR Imaging of Normal Brain in the Second and Third Trimesters ............................... 7
Deborah Levine, Caroline Robson
3. MR Imaging of Fetal CNS Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Deborah Levine, Patrick Barnes
4. MR Imaging of the Fetal Skull, Face, and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Annemarie Stroustrup Smith, Deborah Levine
5. MR Imaging of Fetal Thoracic Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Deborah Levine
6. MR Imaging of the Fetal Abdomen and Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Vandana Dialani, Tejas Mehta, Deborah Levine
7. MR Imaging of the Fetal Extremities, Spine, and Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Deborah Levine, Tejas Mehta
8. MR Imaging of Multiple Gestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Deborah Levine
9. Current Techniques and Future Directions for Fetal MR Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Charles A. McKenzie, Deborah Levine
10. MR Imaging Before Fetal Surgery: Contribution to Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Bonnie N. Joe, Fergus V. Coakley
11. MR Imaging of the Maternal Abdomen and Pelvis in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Deborah Levine, Ivan Pedrosa
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
ix
Contributors
Patrick Barnes, MD Department of Radiology, Lucille Salter Packard Children’s Hospital, Stanford University, Palo
Alto, California, USA
Fergus V. Coakley, MD Department of Radiology, University of California, San Francisco, California, USA
Vandana Dialani, MD Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School,
Boston, Massachusetts, USA
Bonnie N. Joe, MD Department of Radiology, University of California, San Francisco, California, USA
Deborah Levine, MD Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School,
Charles A. McKenzie, PhD Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School,
Tejas Mehta, MD Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston,
Massachusetts, USA
Ivan Pedrosa, MD Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston,
Massachusetts, USA
Caroline Robson, MB, ChB Department of Radiology, Childrens Hospital, Harvard Medical School, Boston,
Massachusetts, USA
Annemarie Stroustrup Smith, MD Harvard-MIT Division of Health Science and Technology and Harvard Medical
School, Boston, Massachusetts, USA
xi
1
Safety of MR Imaging in Pregnancy
DEBORAH LEVINE
INTRODUCTION TEMPERATURE INCREASES DURING

MR IMAGING
The risks and benefits of all imaging studies that are
carried out during pregnancy need to be discussed with Exposure of patients to MR imaging can produce heat
the patient. In the case of magnetic resonance (MR) related to the radiofrequency pulses. Fluids, such as in
imaging there are theoretical risks of teratogenicity, but the lens of the eye, are known to be relatively poor in
no proven effects in humans. This chapter reviews safety dissipating deposited heat (12). As the fetus essentially
concerns pertaining to MR examinations during preg- lies in a water bath, and because tissues dissipate heat
nancy and illustrates embryonic and fetal anatomy in the by blood flow, it is possible that heat accumulates in
first trimester in examinations performed for maternal the gravid uterus during medical imaging. The reason
indications. why this is of particular concern in pregnant patients is
that the specific absorption rate (SAR) monitor, that docu-
ments the amount of energy deposited over time, is set for
LITERATURE REGARDING POTENTIAL the weight of the patient. However, when performing fetal
TERATOGENIC EFFECTS MR imaging we are actually studying a much smaller
patient (the fetus) in a highly conductive “salt-water”
There is no consistent or convincing evidence to suggest bath (amniotic fluid). In addition, the gravid uterus in
that short-term exposure to electromagnetic fields, such the third trimester often fills the magnet bore: this limits
as that which occurs during MR imaging, harms the devel- the amount of air-flow through the bore and around the
oping fetus (1 – 5). A few studies have linked prolonged or patient, thus potentially decreasing the ability of the
high-level electromagnetic field exposure to deleterious patient to radiate deposited heat to the environment.
effects on embryogenesis, chromosomal structure, or Although body temperature has been shown to rise
fetal development (1,6 –10). However, in humans who during MR imaging at high whole-body SARs (13), in a
have been exposed to diagnostic MR imaging, no delayed study using 4.0 W/kg on pregnant patients at 33– 39
sequelae have been encountered, and it is expected that the weeks gestational age, no maternal temperature changes
potential risk for any delayed sequelae is extremely small were identified (14). In a study of measuring temperature
or nonexistent. In a study by Myers et al. (11), no increased of amniotic fluid, fetal brain, and fetal abdomen in preg-
incidence of growth retardation was observed in follow-up nant pigs, no temperature changes were noted using fast
of 74 pregnancies that had been exposed to in utero MR MR imaging techniques (specifically half Fourier single
echoplanar imaging. shot turbo spin-echo sequences) (15).
1
2 Atlas of Fetal MRI
NOISE DURING MR IMAGING women. The drug should be used only if the benefit justifies
the potential risk to the fetus. The product insert for Mag-
The amount of noise generated during fetal MR imaging is nevist (gadopentetate dimeglumine) states that gadopente-
also of potential concern. A model of sound wave trans- tate dimeglumine slightly retarded fetal development when
mission of a plane-wave sound across an air –water inter- given intravenously for 10 consecutive days to pregnant
face predicts a reduction in sound intensity of almost rats at daily doses of 2.5 times the human dose and when
30 dB in water (16). Using a fluid-filled stomach as a given intravenously for 13 consecutive days to pregnant
model for the gravid uterus, Glover et al. (16) demonstra- rabbits at daily doses of 7.5 times the human dose (20).
ted that the attenuation of the sound intensity is .30 dB at The Omniscan (Gadodiamide) insert states that Omniscan
the frequencies generated during echoplanar imaging. has been shown to have an adverse effect on embryo-
Much higher peak pressures could be obtained by fetal development in rabbits that is observed as an
tapping the abdomen with the fingers. In a study of 25 chil- increased incidence of flexed appendages and skeletal mal-
dren aged 2 –4 years born after having been scanned by formations at dosages as low as 0.5 mmol/kg per day for
echoplanar imaging during pregnancy, there were no 13 days during gestation (approximately two times the
reported cases of hearing damage or abnormalities (17). maximum human cumulative dose of 0.3 mmol/kg) (21).
Therefore, at the current time, for fetal imaging there are
no accepted indications for use of intravenous contrast.
FETAL HEART RATE DURING For assessment of maternal anatomy, the risk-benefit
MR IMAGING ratio must be assessed on an individual basis.
A few in studies have assessed the potential effect of MR

procedures on fetal heart rate and motion (18,19). In a IMAGING IN THE FIRST TRIMESTER
study of fetal cardiotopography during MR imaging,
maternal temperature, heart rate, and blood pressure, as Because the greatest theoretic risk is at the time of organo-
well as fetal heart rate and motion, were measured in genesis, and the small size of the developing fetus/embryo
eight women at 33 – 39 weeks gestational age before, is difficult to evaluate early in pregnancy, we avoid MR
during, and after MR imaging at 1.5 T. No short-term imaging in the first trimester whenever feasible. With cur-
effects were detected (14). rently available techniques, it is not useful to perform MR
examinations for fetal diagnosis in the first trimester.
Figures 1.1 – 1.4 demonstrate first trimester pregnancies
CONTRAINDICATIONS TO MR IMAGING scanned for maternal indications. As shown in these
AND PATIENT COMFORT figures, prior to 13 weeks the developing embryo/fetus
is small and difficult to adequately visualize. Anomalies
As for all patients, there are absolute contraindications to are better detected with ultrasound than with MR
MR imaging in pregnant patients (e.g., a ferromagnetic imaging during this time period. However, MR imaging
cerebral aneurysm clip, cardiac pacemaker), and some can be useful when more information about the location
patients are too claustrophobic to undergo the examin- of a presumed abnormal gestational sac is needed
ation. Use of short bore magnets makes claustrophobia (Fig. 1.5). If MR imaging is needed for maternal diagnosis
less of a concern. However, in patients who have a in the first trimester, then imaging should be performed. In
history of claustrophobia, we have found it helpful to pre- a recent article by Shellock and Crues (22), it is stated that
medicate with sublingual Xanax 0.5 –3 mg given 1 hour “. . . in cases where the referring physician and the attend-
prior to the examination. In addition, for patients who ing radiologist can defend that the findings of the MR pro-
are claustrophobic but do not want to be medicated, we cedure have the potential to affect the care of the mother or
have found it helpful to cover the eyes before the patient fetus . . . the MR procedure may be performed with oral and
enters the magnet bore. An additional problem in scanning written informed consent, regardless of the trimester.”
pregnant patients is that they may have difficulty lying on
their backs, especially in the third trimester. In these cases,
patients can be imaged in the lateral decubitus position. SUMMARY OF RECOMMENDATIONS
According to the Safety Committee of the Society for

INTRAVENOUS CONTRAST Imaging (23), MR procedures are indicated for use in preg-
nant women if other nonionizing forms of diagnostic
Use of intravenous contrast for MR imaging is relatively imaging are inadequate or if the examination provides
contraindicated in pregnancy. Gadolinium is a pregnancy important information that would otherwise require
Category C drug, meaning that there are insufficient exposure to ionizing radiation (i.e., X-ray, CT, etc.). It is
studies to determine potential harmful effects in pregnant required that pregnant patients be informed that, to
Safety of MR Imaging in Pregnancy 3
Figure 1.1 Uterus at 7 weeks gestational age. This representa-

tive sagittal T2-weighted image shows fluid in the intrauterine
gestational sac (S). The embryonic pole is not visualized on
Figure 1.2 Embryo at 9 weeks gestational age. Sagittal
this or other images obtained during the study owing to partial
T2-weighted image of the uterus showing a coronal image of
volume averaging. B, bladder.
embryonic torso. Owing to the small size of the embryo
(arrow), it is difficult to visualize anatomic structures.
Figure 1.4 Fetus at 13 weeks gestational age. (a) Oblique

Figure 1.3 Fetus at 11 weeks gestational age. (a) Oblique sagit- coronal T2-weighted image of fetal torso shows the liver (L)
tal view of fetal torso, arm (arrow), and leg (arrowhead). (b) Axial and the arm (arrow). (b) Oblique coronal view of fetal head
view of fetal head. The intracranial anatomy is poorly visualized shows the cerebral ventricles (v). Note the improvement in
secondary to partial volume averaging and early gestational age. visualization of intracranial anatomy compared with Fig. 1.3.
REFERENCES
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the developing fetus? Am J Roentgenol 1994; 162:1493.
2. Geard CR, Osmak RS, Hall EJ et al. Magnetic resonance
and ionizing radiation: a comparative evaluation in vitro
of oncogenic and genotoxic potential. Radiology 1984;
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3. Kay HH, Herfkens RJ, Kay BK. Effect of magnetic reson-
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Reson Imaging 1988; 6:501 –506.
4. Peeling J, Lewis JS, Samoiloff M et al. Biological effects of
magnetic fields: chronic exposure of the nematode Pana-
grellus redivivus. Magn Reson Imaging 1988; 6:655 –660.
5. Prasad N, Wright DA, Ford JJ et al. Safety of 4-T MR
imaging: study of effects on developing frog embryos.
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6. Beers GJ. Biological effects of weak electromagnetic fields
from 0 Hz to 200 MHz: a survey of the literature with
special emphasis on possible magnetic resonance effects.
Magn Reson Imaging 1989; 7:309 – 331.
7. Carnes KI, Magin RL. Effects of in utero exposure to 4.7 T
MR imaging conditions on fetal growth and testicular
development in the mouse. Magn Reson Imaging 1996;
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8. Heinrichs WL, Fong P, Flannery M et al. Midgestational
exposure of pregnant BALB/c mice to magnetic resonance
imaging conditions. Magn Reson Imaging 1988;
6:305– 313.
9. Tyndall DA, Sulik KK. Effects of magnetic resonance
imaging on eye development in the C57BL/6J mouse.
Teratology 1991; 43:263 – 275.
10. Yip YP, Capriotti C, Talagala SL et al. Effects of MR
Figure 1.5 Pregnancy in myomectomy scar at 8 weeks gesta-
exposure at 1.5 T on early embryonic development of the
tional age. (a) Coronal and (b) sagittal T2-weighted images show
chick. J Magn Reson Imaging 1994; 4:742 –748.
the gestational sac high in the left fundus, separate from the endo-
11. Myers C, Duncan KR, Gowland PA et al. Failure to detect
metrial cavity (arrowheads). The placenta is seen extending into
intrauterine growth restriction following in utero exposure
the myometrium to the uterine serosa (arrow). This is the region
to MRI. Br J Radiol 1998; 71:549– 551.
of the patient’s prior myomectomy. The patient was treated with
12. Shellock FG, Crues JV. Corneal temperature changes
methotrexate.
induced by high-field-strength MR imaging with a head
coil. Radiology 1988; 167:809– 811.
date, although there is no indication that the use of clinical 13. Shellock FG, Schaefer DJ, Kanal E. Physiologic res-
MR procedures during pregnancy produces deleterious ponses to an MR imaging procedure performed at a
effects, according to the FDA, the safety of MR procedures specific absorption rate of 6.0 W/kg. Radiology 1994;
during pregnancy has not been definitively proven (24). 192:865 –868.
According to the American College of Radiology 14. Michel SC, Rake A, Keller TM et al. Fetal cardiographic
White Paper on MR Safety, “Pregnant patients can be monitoring during 1.5-T MR imaging. Am J Roentgenol
accepted to undergo MR scans at any stage of pregnancy 2003; 180:1159 – 1164.
if, in the determination of a . . . designated attending radio- 15. Levine D, Zuo C, Faro CB et al. Potential heating effect in
logist, the risk– benefit ratio to the patient warrants that the gravid uterus during MR HASTE imaging. J Magn
Reson Imaging 2001; 13:856 –861.
the study be performed” (25). The White Paper further
16. Glover P, Hykin J, Gowland P et al. An assessment of the
states that “it is recommended that pregnant patients intrauterine sound intensity level during obstetric echo-
undergoing an MR examination provide written informed planar magnetic resonance imaging. Br J Radiol 1995;
consent to document that they understand the risk/benefits 68:1090 –1094.
of the MR procedure to be performed, the alternative 17. Baker PN, Johnson IR, Harvey PR et al. A three-year follow-
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Safety of MR Imaging in Pregnancy 5
18. Poutamo J, Partanen K, Vanninen R et al. MRI does not 23. Shellock FG, Kanal E. Policies, guidelines, and recommen-
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2
MR Imaging of Normal Brain in the Second and Third Trimesters
DEBORAH LEVINE, CAROLINE ROBSON
INTRODUCTION guidelines provided by Chi et al. (8) describe gestational

ages at which 25 – 50% of brain specimens demonstrate
One of the best-accepted applications of fetal magnetic res- particular cortical landmarks, with an interval of 2
onance (MR) imaging is assessment of the central nervous weeks between the earliest appearance of a particular
system (CNS) (1–5). The anatomic detail provided by MR landmark and its occurrence in 75– 100% of the brains
imaging allows for direct visualization of the brain parench- (8). Magnetic resonance maturation appears slightly
yma, which can aid in the diagnosis of CNS abnormalities. delayed relative to neuroanatomic studies due to various
The changing appearance of the brain throughout gestation factors: (1) neuroanatomic studies being performed on
can make assessment of abnormalities challenging; thus, it thin slices being directly visualized; (2) MR slice thickness
is helpful to have a frame of reference for the normal (3 – 5 mm) being much greater than that used in the ana-
appearance of anatomy over time. In particular, knowledge tomic studies (15 – 30 mm); (3) image quality issues such
of the normal appearance and maturation of the developing as suboptimal signal-to-noise; and (4) limited spatial resol-
sulci and gyri is helpful in the appropriate diagnosis and ution compared with neuroanatomic studies.
counseling of anomalous fetuses in whom cortical develop- Normal cortical development in the second and third
ment may be delayed or altered. There are no accepted indi- trimesters is illustrated in Figs. 2.1 –2.14, which are
cations for fetal MR imaging in the first trimester; therefore presented in order of gestational age. In general, fetuses
this chapter details the developmental changes that are with mild ventriculomegaly and other CNS anomalies
observable from 14 weeks gestational age and beyond. have delayed cortical development as compared with
normal fetuses (Table 2.2) (6).
CORTICAL DEVELOPMENT—
AN OVERVIEW
Second Trimester
Cortical maturation, as manifested by the progressive
appearance, deepening, and increasing complexity of At 14 weeks, the cerebral convexities are smooth. The
cerebral sulci, is clearly demonstrated by fetal MR imaging. ventricles occupy most of the cerebral hemispheres. The
However, normal maturation as visualized on MR examin- choroid plexus, which is well visualized sonographically
ations follows a predictable course that lags behind the as an echogenic structure filling the cerebral ventricles,
time sequence for maturation described in neuroanatomic is not well visualized on MR imaging (Fig. 2.1). A thin
specimens (6,7). Table 2.1 reviews the appearance of sulci rim of smooth parenchyma is present. The interhemi-
in normal fetuses with respect to gestational age in neuro- spheric fissure separating the cerebral hemispheres is
anatomic (8) and MR studies (6,7). The neuroanatomic well-developed.
7
Table 2.1 Reported Appearance of Sulci with Respect to Gestational Age
Detectable Detectable Detectable Detectable

Neuropathologic in 25 – 75% of in .75% of in 25 – 75% of in .75% of
appearance brains in study brains in study brains in study brains in study
in 25– 50% of by Levine (6) by Levine (6) by Garel et al. (7) by Garel et al. (7)
brains (8)a (weeks) (weeks) (weeks) (weeks) (weeks)
Sulci/fissures of the medial cerebral surface

Interhemispheric 10 — 10b — —
Parietoocipital 16 — 18 – 19 — —
Cingulate 18 24 – 25 26 – 27 22 –23c 24– 25
Secondary cingular 32 — — 31 33
Calcarine 16 — 18 – 19 22 –23c 24– 25
Secondary occipital 34 32 34
Sulci of the ventral surface
Collateral 23 — — 24 –25 27
Occipitotemporal 30 — — 29 33
Sulci of the lateral surface
Sylvian 14 — 16 – 17 — —
Parietooccipital 16 — 18 – 19 — —
Circular 18 — 18 – 19 — —
Superior frontal 25 — — 24 –25 29
Inferior frontal 28 30 – 31 34 – 35 26 29
Superior temporal 23 26 – 27 28 – 29 26 27
Inferior temporal 30 28 – 29 32 – 33 30 33
Interparietal 26 — — 27 28
Insular 34 30 – 31 32 – 33 33 34
Secondary Frontal 32 32 – 33 34 – 35 — —
Secondary Temporal 36 32 – 33 34 – 35 — —
Secondary Parietal 33 — 34 – 35 — —
Superior occipital 34 34 – 35 36 – 37 — —
Inferior occipital 34 34 – 35 — — —
Tertiary Frontal 40 38 – 39 — — —
Sulci of the vertex
Central 20 — 26 – 27 24 –25 27
Precentral 24 — 26 – 27 26 27
Postcentral 25 26 – 27 28 – 29 27 28
a
This article describes the 2 week interval between when a sulcus is seen in 25–50% and when it is seen in 75–100% of fetuses.
b
Unreported data.
c
The earliest gestational age studied in this study was 22 weeks.
At 16 weeks, the Sylvian fissure is visualized as a is not reliably seen until 24 – 25 weeks gestation
shallow concavity or groove along the lateral convexity. (Fig. 2.5).
The Sylvian fissure deepens over time, becoming more At 22 weeks, the lateral hemispheres are smooth and
angular as the frontal and temporal opercula form the insulae are wide open (Fig. 2.4). The temporal lobe
(Fig. 2.6). The parietooccipital and calcarine fissures, on remains smooth until 23 weeks. The precentral and post-
anatomic specimens, are seen at 16 weeks gestational central gyri appear at 26 weeks (Fig. 2.6), first as shallow
age. They are generally observed on MR examinations grooves that deepen as gestational age progresses.
by 20 –22 weeks (Fig. 2.4). On T2-weighted imaging, three distinct layers are seen
The callosal sulcus separates the corpus callosum and comprising cerebral parenchyma (Fig. 2.2) (9). The inner-
overlying cingulate gyrus, which is seen at 18 weeks most layer is of low signal intensity and corresponds to the
(Fig. 2.2). The central sulcus appears on the superior germinal matrix. The middle region is of intermediate
parasagittal aspect of the cortex at 20 weeks gestation signal intensity and corresponds to a less cellular region
in anatomic specimens. Although the central sulcus has of developing white matter; and the outermost hypointense
been observed on MR images as early as 22 weeks, it layer corresponds to the developing cortex.
Normal Brain in the Second and Third Trimesters 9
Figure 2.1 Normal anatomy on T2-weighted images at 14 weeks gestational age. Axial image (a) shows the posterior fossa containing
the developing cerebellar hemispheres (CH) and fourth ventricle (FV) with communication between the fourth ventricle and the cisterna
magna. Sequential coronal images (b– d) show the smooth cerebral hemispheres. The lateral ventricles (LV) are relatively prominent
compared with the brain parenchyma. In (b) the lateral ventricles occupy most of the parietal lobes. The diencephalon (Di) connects
the cerebral hemispheres with the brainstem. Image through the frontoparietal region (c) shows the interhemispheric fissure between
the lateral ventricles. The developing temporal lobe (TL) is visible on each side. The Sylvian fissure has not yet developed sufficiently
for visualization on MR imaging. Coronal image through the frontal lobes (d) reveals the frontal horns of the lateral ventricles. Infero-
laterally, the developing globes are visible (arrowheads).
overlying cortex, and a relative decrease in the amount

Third Trimester of extra-axial cerebrospinal fluid (Fig. 2.14).
By 28 –30 weeks, numerous new sulci and gyri develop

T1-WEIGHTED IMAGING
(Figs. 2.9 and 2.10). The insular cortex forms the base of
the Sylvian fissure and this region ultimately becomes
T1-weighted imaging in fetal MR examinations is typi-
covered as the opercula develop and mature. As a result,
cally performed to assess blood products or fatty lesions.
the Sylvian fissure narrows on parasagittal and coronal
Fetal motion frequently limits anatomic information due
images (Figs. 2.7– 2.13). On the parasagittal images, the
to relatively long scan times. At 13 –14 weeks, the germ-
Sylvian fissure slopes slightly upwards from front to
inal matrix appears as a band of increased signal intensity
back (Figs. 2.11 –2.13). The germinal matrix is much
along the lateral ventricular wall (10). It has been reported
less prominent, and the cortex is observed as having two
that at 16 – 18 weeks there are five distinct layers of signal
layers: the inner layer, which is of relatively high signal
intensity that represent the innermost hyperintense germ-
intensity, and the outer layer with slightly lower signal
inal matrix; a hypointense band of developing white
intensity (9).
matter; a hyperintense layer of migrating neuroblasts;
By 32 –35 weeks, secondary sulci appear throughout
another hypointense layer of developing white matter;
the cortex (Figs. 2.11 and 2.12). By term, tertiary sulci
and the outermost hyperintense cerebral cortex (10).
have formed but are often poorly seen because of a relative
decrease in the contrast between white matter and the (text continued on page 20)
Figure 2.2 Normal anatomy on T2-weighted images at 18 weeks gestational age. Parasagittal image (a) demonstrates the developing
frontal and temporal lobes containing the frontal horn (FH) and temporal horn (TH) of the lateral ventricle. Primitive fetal ventricular
morphology is seen. Notice the relatively prominent trigone of the lateral ventricle (TLV). Midline sagittal image (b) reveals the callosal
sulcus (CS) separating the corpus callosum below from the cingulate gyrus above. Axial image (c) through the posterior fossa reveals the
frontal (FL) and temporal lobes (TL) separated by the developing hypointense sphenoid ridge that separates the anterior cranial fossa from
each middle cranial fossa. Within the posterior fossa the developing cerebellum is well seen and the cerebellar hemisphere (CH) and
cerebellar vermis (CV) are indicated. The cisterna magna and cisterns around the cerebellum are relatively prominent at this stage of
development. A more cephalad axial image (d) reveals early development of the circular or Sylvian fissure (SF) separating the frontal
and temporal lobes. The hypointense germinal matrix (GM) is visible along the lateral aspect of the lateral ventricles. Coronal images
through the parietal lobes (e) and frontal lobes (f) reveal the hypointense cerebral cortex (Cx), relatively hyperintense white matter
(WM), and intermediate intensity germinal matrix (GM). Within the parietal lobe (PL) the trigone of the lateral ventricles is observed
and contains choroid plexus (CP).
Figure 2.3 Normal anatomy on T2-weighted images at 20 weeks gestational age. Parasagittal images (a and b) reveal the developing
frontal (FL), and temporal lobes (TL). The cortical surface remains smooth prior to sulcal and gyral development. The trigone (TLV) and
temporal horn (TH) of the lateral ventricle remain relatively prominent. Notice the relative prominence of the occipital horn (OH)
compared with the frontal horn (FH). Midline sagittal image (c) reveals the developing body (BCC) and splenium (SCC) of the
corpus callosum. Within the posterior fossa are the developing cerebellar vermis (CV) and fourth ventricle (FV). The medulla oblongata
(MO) of the brainstem is also visualized. Axial images (d and e) show the bodies of the lateral ventricles (BLV) and interhemispheric
fissure (IHF). Coronal images (f– h) demonstrate features similar to those seen at 18 weeks gestation; however, there has been further
interval development of the Sylvian fissures (SF). The cavum of the septum pellucidum (CSP) lies between the frontal horns of the
lateral ventricles and above the third ventricle (TV). The extra-axial cerebrospinal fluid spaces (EAS) surrounding the cerebral hemi-
spheres and interhemispheric fissure are relatively prominent at this stage. (OL, occipital lobe; CH, cerebellar hemisphere; PL, parietal
lobe; CP, choroid plexus; WM, white matter; Cx, cortex.)
Figure 2.4 Normal anatomy at 22 weeks gestational age. Sagittal T2-weighted images from lateral to midline (a–c) demonstrate interval
deepening of the Sylvian fissure (SF) between the frontal (FL) and temporal lobes (TL). Note the normal prominence of the occipital horn
(OH) relative to the frontal horn (FH) of the lateral ventricles. On the midline image (c), the hypointense corpus callosum (CC) is more
readily seen. The midbrain (M), pons (P), and medulla oblongata (MO) that comprise the brainstem are all well seen. Axial T2-weighted
image through the posterior fossa (d) reveals that there has been interval growth of the cerebellar hemispheres (CH) and vermis (CV),
but the cisterna magna (CM) remains conspicuous. The fourth ventricle (FV) is dorsal to the pons. More cephalad axial images (e and f)
and coronal images from posterior to anterior (g–h) reveal further maturation of the frontal (FL), temporal (TL), occipital lobe (OL), parietal
lobe (PL), and germinal matrix (GM). The cavum of the septum pellucidum (CSP) is apparent between the frontal horns of the lateral ven-
tricles (LV) and lies cephalad to the third ventricle (TV). Notice the calcarine sulcus (CaS) that indents the posteromedial surface of the
cerebral hemisphere. Coronal T1-weighted image (i) clearly demonstrates the slightly hyperintense cortex (Cx), deep to which is hypointense
white matter (WM). The germinal matrix (GM) lies between the white matter and the ventricles. (IHF, interhemispheric fissure.)
Figure 2.5 Normal anatomy on T2-weighted images at 25 weeks gestational age. Parasagittal image (a) reveals an indentation in the
cortex corresponding to the central sulcus (CeS) between the frontal and parietal lobes. Axial image through the posterior fossa (b) reveals
further interval growth of the cerebellar hemispheres (CH) and cerebellar vermis (CV). The fourth ventricle (FV) is bounded laterally by
the middle cerebellar peduncles (MCP). More cephalad axial images (c and d), and coronal images from posterior to anterior (e– g) reveal
the trigone or atrium of the lateral ventricle (ALV) bounded posteromedially by the hypointense fibers of the splenium of the corpus cal-
losum (SCC). The frontal horns (FH) and bodies of the lateral ventricles (BLV) are separated by the septal leaflets (SL) from the cavum of
the septum pellucidum (CSP) which extends posteriorly into the cavum vergae. The extraaxial spaces (EAS) remain relatively prominent.
The suprasellar cistern (SSC) is visible medial to the temporal lobes above the sphenoid bone that forms the central skull base.
(PL, parietal lobe, TV, third ventricle.)
Figure 2.6 Normal anatomy on T2-weighted images at 26 weeks gestational age. Parasagittal images (a and b) show the insula (In) at
the base of the Sylvian fissure (SF) between the developing frontal (FL) and temporal lobes (TL). The central sulcus (CeS) demarcates the
anterior border of the parietal lobe (PL), and is bounded posteriorly by the postcentral gyrus (PostCG) and anteriorly by the precentral
gyrus (PreCG). Axial images of the posterior fossa (c and d) show greater definition of the medulla oblongata (MO), and pons (P) ante-
riorly, the middle cerebellar peduncles (MCP) and fourth ventricle (FV). The cerebellar hemispheres (CH) and cerebellar vermis (CV)
now have a striated appearance due to hyperintense cerebrospinal fluid that can be distinguished between the cerebellar folia (CF). The
cisterna magna (CM) and extraaxial cerebrospinal fluid spaces (EAS) ventral to the temporal lobes (TL) remain conspicuous. The hypoin-
tense ethmoid bone (E) between the developing globes, sphenoid (S) and petrous bones (PB) can be distinguished. A more cephalad axial
image (e) at the level of the midbrain demonstrates the optic nerves (ON) within the suprasellar cistern, ventral to the midbrain (M) and
interpeduncular cistern. Vermian fissures (VF) are also seen at this level. At the level of the third ventricle (f) the linear hypointense vein
of Galen (VOG) can be faintly distinguished coursing posteriorly to the straight sinus (SS) which drains into the torcula herophili (TH).
The calcarine sulcus (CaS) and one of the temporal sulic (TS) are also seen. Axial image (g) at the level of the cavum of the septum
pellucidum (CSP) shows the crossing fibers of the genu of the corpus callosum (GCC) separating the interhemispheric fissure from
the cavum. Posteriorly the splenium of the corpus callosum (SCC) is also seen. Intermediate signal intensity choroid plexus (CP) can
be discerned within the atrium of the lateral ventricle. Axial image close to the vertex (h) demonstrates the central sulcus (CeS), inter-
hemispheric fissure (IHF), falx cerebri (FC) and superior sagittal sinus (SSS). (FH, frontal horn.)
Figure 2.7 Normal axial anatomy at 27 weeks gestational age. Axial image through the posterior fossa (a) reveals the frontal (FL) and
temporal lobes (TL), cerebellar hemispheres and vermis as well as the cisterna magna (CM) and suprasellar cistern (SSC). Axial image
(b) at the level of the third ventricle (TV) demonstrates formation of the frontal (FO) and temporal opercula (TO) that will ultimately
cover the insular cortex (InC). The ambient and quadrigeminal plate cistern (QPC) lies between the tectum and the occipital lobes. More
cephalad axial images (c–f) and an axial T1-weighted image (g) reveal cortex (Cx), white matter (WM) and germinal matrix (GM). Note
the prominent cavum vergae. Deep gray matter structures such as the caudate nucleus head (CNH) and thalamus (Th) can now be distin-
guished. The corpus callosum (CC) is well seen on axial images. The superior frontal sulcus (SFS), pre (PreCS) and post (PostCS) central
sulci and gyri (PreCG, PostCG) are all visible. The hypointense linear falx cerebri (FC) extends into the interhemispheric fissure. The triangu-
lar signal void of the superior sagittal sinus (SSS) runs along the dorsal aspect of the falx.
Figure 2.8 Parasagittal T2-weighted image (a) reveals deepening of the central sulcus (CeS) and narrowing of the Sylvian fissure (SF).
On a more medial image (b), the precentral (PreCS) and postcentral (PostCS) sulci can now be observed. Midline sagittal image (c) shows
the cingulate gyrus (CG) and sulcus (CiS) above the corpus callosum (CC). The parietooccipital (POS) and calcarine sulcus (CaS) are also
visible. The colliculi of the tectum of the midbrain (Te) and fissures of the cerebellar vermis (CV) are demonstrated. Coronal T2-weighted
images from posterior to anterior (d– g) demonstrate additional features such as parietal sulci (PS), the superior (SFS) and inferior frontal
sulci (IFS), the superior temporal sulcus (STS), the tentorium cerebelli (TC), the torcula herophili (ToH), and the straight sinus (SS). The
choroidal fissure (ChF) is seen medial to the temporal horns and above the parahippocampal gyrus (PHG).
Figure 2.9 Normal anatomy on T2-weighted images at 28 weeks gestational age. Parasagittal image (a) demonstrates increased
undulation of the margins of the Sylvian fissure (SF), precentral (PreCS), central (CeS), and postcentral (PostCS) sulci. The superior
temporal gyrus (STG) is visible between the Sylvian fissure and the superior temporal sulcus (STS). Midline sagittal image (b)
clearly reveals the aqueduct of Sylvius (Aq) above the fourth ventricle (FV). The parietooccipital (POS) and calcarine (CaS)
sulci are again seen. The optic chiasm (OpC) is visible in the suprasellar cistern. Axial images (c and d) reveal signal voids of
the vertebral arteries (VA) ventrolateral to the medulla oblongata (MO), and the basilar artery (BA) ventral to the pons. The left
internal carotid artery (ICA) lies adjacent to the anterior clinoid process. The occipital horn (OH) of the lateral ventricle and the
CaS are also shown. Coronal images from posterior to anterior (e –g) demonstrate the superior sagittal sinus (SSS), interhemispheric
fissure (IHF) and falx cerebri (FC), fourth ventricle, aqueduct of Sylvius, and temporal horn of the lateral ventricle (TH). The extra-
axial spaces have become less prominent and there has been progressive deepening of sulci such as the Sylvian fissure (SF), cingulate
sulcus (CiS) superior (STS) and inferior temporal (ITS) sulci. The choroidal fissure (ChF) is less well visualized due to interval
maturational narrowing.
Figure 2.10 Normal anatomy at 30 weeks gestational age. Sagittal T2-weighted images (a and b) reveal further convolutional matu-
ration. Parietal sulci (PS) are now observable. Axial T2-weighted images (c, d and f) clearly demonstrate the colliculi of the midbrain and
aqueduct of Sylvius (Aq) ventral and medial to the quadrigeminal plate cistern (QPC). Also shown are the cingulate sulcus (CiS), cavum
of the septum pellucidum (CSP) third ventricle (TV), trigone of the lateral ventricle (TLV), insula (Ins), straight sinus (SS), falx cerebri
(FC), and superior sagittal sinus (SSS). Axial T1-weighted image (e) reveals similar findings of the white matter (WM) and cortex (Cx)
described in Fig. 2.7. Coronal T2-weighted image (g) demonstrates the cingulate sulcus (CiS), Sylvian fissure (SF) and choroid plexus
(CP) within the lateral ventricle.
Figure 2.11 Normal anatomy on T2-weighted images at 32 weeks gestational age. Parasagittal (a) and midline sagittal (b) images
demonstrate an increased number of sulci (s) and gyri such as the superior frontal gyrus (SFG), cingulate gyrus (CG), precuneus
(PCu), and cuneus (Cu). The cerebellar vermis (CV) has enlarged relative to the cisterna magna (CM). Axial image at the level of the
posterior fossa (c) demonstrates the hypointense petrous bones and fluid-containing cochlea (Co). A more cephalad image (d) at the
level of the pons (P) and middle cerebellar peduncles (MCP) demonstrates the trigeminal nerves (TN) traversing the cerebellopontine
angle cistern. Coronal image (e) reveals that the frontal and temporal opercula are covering the insula with progressive narrowing of
the Sylvian fissure (SF). High-resolution coronal images (f and g) through the suprasellar cistern demonstrate the midline pituitary infun-
dibulum (PI) extending inferior to the third ventricle to the pituitary gland (PG) which blends with the hypointense sphenoid bone. Ventral
to this are the optic nerves (ON). Notice also the leaflets of the septum pellucidum (LSP) separating the frontal horns of the lateral
ventricles from the cavum of the septum pellucidum, which lies cephalad to the third ventricle.
Figure 2.12 Normal anatomy on T2-weighted images at 34 weeks gestational age. Sagittal (a and b), axial (c), and coronal (d – f)
images reveal progressive gyral and sulcal (s) maturation. The parietal sulcus (PS), the inferior temporal sulcus (ITS), and Sylvian
fissure (SF) are shown. Notice the relationship between the cavum of the septum pellucidum (CSP) and third ventricle (TV). Note the
gyrus rectus (GR), olfactory gyrus (OG), and olfactory tract (OT).
However, in most MR examinations, only three layers above which ventriculomegaly was defined as being
(germinal matrix, white matter, and cortex) are readily dis- present. There is no reason to believe that atrial diameter
cerned (Figs. 2.4, 2.7, and 2.10). In the fetal brain in the measurements would differ when estimated with MR
third trimester, the cortical ribbon is of slightly higher imaging as opposed to sonography. However, one challenge
signal than the underlying parenchyma (Figs. 2.7 and 2.10). with MR imaging is standardization of the axial view of the
head. If an oblique view is obtained, the atria can appear
falsely enlarged. In our review of 128 fetuses referred for
NORMAL VENTICULAR SIZE AND non-CNS indications between the gestational ages of 15
CONFIGURATION and 39 weeks, no fetus was found with an atrial diameter
.10 mm on MR examination (12). The 10-mm rule,
Cardoza et al. (11) sonographically evaluated 100 healthy described on a sonographic axial view of the fetal atrium,
fetuses between the gestational ages of 14 and 38 weeks is therefore the measurement we use as the upper limit of
and found that the normal atrial diameter remained stable normal on MR imaging. Measurement of the atrial diameter
through gestation with an average measurement of is probably more reliable on sonography where the pro-
7.6 + 0.6 mm. An upper limit of 10 mm (þ4 SD) was set scribed plane of measurement can be obtained during
Figure 2.13 Normal anatomy on T2-weighted images at 36 weeks gestational age. Sagittal (a and b), axial (c), and coronal (d) images
reveal decreased conspicuity of the extraaxial cerebrospinal fluid spaces and increased tortuosity of sulci. The midline sagittal image
(b) reveals the vein of Galen (VOG) coursing into the straight sinus (SS). As the white matter undergoes myelination, there is less T2
prolongation (hyperintensity) and the contrast in signal between the white matter and gray matter is reduced.
real-time scanning. However, shadowing artifacts often finding, as long as the overall contour and size of the ven-
make it impossible to get an accurate sonographic measure- tricles appears normal, especially during the first two tri-
ment of the ventricle on the side of the brain closest to the mesters (Fig. 2.4).
maternal anterior abdominal wall. For these “upside” ven-
tricles, MR measurements are likely more accurate than
sonographic measurements. In a study comparing ventricu- CAVUM OF THE SEPTUM PELLUCIDUM
lar measurements on ultrasound and MR imaging, there AND CAVUM VERGAE
were no significant differences in these measurements in
fetuses with ventriculomegaly (3). The cavum of the septum pellucidum should always be
In fetuses, the atria and occipital horns of the lateral observed after 20 weeks (Figs. 2.4– 2.6). On T2-weighted
ventricle appear prominent with respect to the frontal images, the septal leaflets should be visible as linear
horns (13). This should not be considered as an abnormal hypointense structures between the frontal horns of the
(Fig. 2.1). Folia are not visible. Care should be taken not
to overcall vermian defects early in the second trimester,
since the inferior vermis is incompletely formed at that
time. At 16– 18 weeks, the vermis is best appreciated on
sagittal and axial images (Fig. 2.2). By 20 weeks, the per-
ipheral cerebellar cortex demonstrates low signal intensity
(Fig. 2.3). By 20– 23 weeks, the brainstem has posterior
low signal in the dorsal pons and medulla (Fig. 2.4). The
tectum has low signal intensity (Fig. 2.8). This low
signal intensity reaches the midbrain by 32 weeks ges-
tation corresponding to the region of the medial longitudi-
nal fasciculus (14). The cerebellar hemispheres develop a
striated appearance due to intervening hyperintense cere-
brospinal fluid in the cerebellar fissures and hypointense
cerebellar folia (Fig. 2.6). By 32 weeks, prominent cer-
ebellar folia are identified that increase in number as the
Figure 2.14 Normal anatomy on coronal T2-weighted image fetus approaches term (Fig. 2.11) (14).
at 38 weeks gestational age. With maturation there has been
further reduction in contrast between the gray and white matter
and the cerebrospinal fluid spaces are less conspicuous. These
factors make analysis of the sulcal gyral morphology more CORPUS CALLOSUM
complex as the fetus approaches term.
The corpus callosum is the largest of the commisures that
connect the two cerebral hemispheres. It is visible on axial
view of the brain as a narrow band of tissue in the shape of
lateral ventricles (Figs. 2.10 and 2.11). The cavum vergae
a capital “I” running between the lateral ventricles
can be prominent as a normal variant (Fig. 2.7).
(Figs. 2.5 and 2.6). On coronal and sagittal imaging, the
corpus callosum appears as the curved structure separating
GERMINAL MATRIX the cingulum superiorly from the lateral ventricles infer-
iorly (Figs. 2.3, 2.4 and 2.7). The rostral end of the
The germinal matrix appears as a smooth dark region on corpus callosum first appears by the 12th week of gestation
T2-weighted imaging (Fig. 2.2). This will look abnormally (15) in the region that will later be the anterior body of the
thick and dark in cases of germinal matrix hemorrhage corpus callosum (16). Development progresses both caud-
(Chapter 3, Fig. 3.62). A nodular appearance will be ally to form the body and splenium, and rostrally to form
seen in cases of subependymal tubers (Chapter 3, Figs. the genu and rostum. The entire corpus callosum should be
3.40 and 3.41). formed (although it will continue to grow) by the 20th
week of gestation.
POSTERIOR FOSSA AND MIDBRAIN
SUBARACHNOID SPACE
The cerebellum and brainstem at 14– 15 weeks gestation
are of homogenous intermediate signal intensity
The subarachnoid space can appear quite prominent
(Fig. 2.3). The subarachnoid space gradually becomes
less conspicuous during the latter half of the third trimester
Table 2.2 Time Lag Between Sulcal Appearance in MR and (Figs. 2.13 and 2.14). The clinical significance of a promi-
Neuroanatomic Studies nent subarachnoid space with underlying normal
appearance of the cortex is unknown.
Mean time Range
Group laga + SD (weeks) (weeks) p
Normal 1.9 + 2.2 0–8 — CONCLUSION

Mild ventriculomegaly 4.4 + 3.2 0–8 ,0.01
Other CNS anomaly 4.3 + 5.6 0 – 21 ,0.01 Knowledge of the normal progression of cortical matu-
a
Time lag refers to the difference between sulcal appearance in neuroana- ration and normal appearance of neuroanatomy over
tomic and MRI studies. time will aid in the diagnosis of fetal CNS abnormalities.
Source: From Levine and Barnes (6). Examples of CNS pathology are illustrated in Chapter 3.
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3
MR Imaging of Fetal CNS Abnormalities
DEBORAH LEVINE, PATRICK BARNES
INTRODUCTION hemiatrophy, hydrocephalus, hemorrhage, infarction, and

metabolic/degenerative diseases. In some cases, there
Numerous reports document the ability of magnetic reson- may be combined malformative and encephaloclastic
ance (MR) imaging to provide superior characterization of abnormalities.
fetal central nervous system (CNS) abnormalities when
compared with ultrasound (1 – 14). It is beyond the scope
of this atlas to detail the embryology, neuropathology, VENTRICULOMEGALY
and clinical aspects of all the potential CNS anomalies.
This information is available in a number of well-known Ventriculomegaly refers to enlargement of the cerebral
texts and publications (15 – 17). In this atlas we attempt ventricles without specifying a cause. It is diagnosed on
to present and illustrate information that is most pertinent prenatal sonograms when the lateral ventricles measure
to performing and interpreting MR imaging of fetal 10 mm or greater on a transverse image at the level of
abnormalities. In this chapter, we first address ventriculo- the glomus of the choroid plexus (19). This measurement
megaly, and then use a modification of the van der Knaap can be obtained on MR images in a manner similar to that
and Valk classification (18) to present some of the most with ultrasound. Ventriculomegaly can be graded into
common and important congenital and developmental mild (10 – 15 mm), moderate (.15 mm with .3 mm of
abnormalities of the CNS. This classification is based on adjacent cortical thickness), and severe (ventriculomegaly
the gestational timing of insults that give rise to such with ,2 mm of adjacent cortical thickness) categories (4).
abnormalities. During the major “formational” period Ventricular measurements with fetal MR imaging corre-
(i.e., up to 5 –7 weeks gestational age), insults result late well with those obtained sonographically (4). Hydro-
in “primary” malformations of the CNS. These include cephalus is the term that indicates increased ventricular
disorders of dorsal and ventral neural tube formation; or subarachnoid space volume due to abnormal cerebro-
disorders of neuronal, glial, and mesenchymal prolifer- spinal fluid (CSF) dynamics (i.e., CSF overproduction,
ation, differentiation, and histogenesis; and disorders of CSF underabsorption, or CSF pathway obstruction). This
migration and cortical organization. Insults that occur term is not ordinarily used unless a causal abnormality is
during the “postformational” or maturational period (i.e., specifically identified.
after 5 –7 weeks gestational age) are encephaloclastic The cause of fetal ventraculomegaly is often not easy to
and result in “secondary” injury of formed structures. Such define. If mild, it may be a transient and possibly normal
injury may include hydranencephaly, porencephaly, multi- finding (Figs. 3.1 and 3.2). Ventriculomegaly may be
cystic encephalopathy, encephalomalacia, leukomalacia, related to cerebral dysgenesis (e.g., in association with
25
Figure 3.1 Mild isolated ventriculomegaly at 19 weeks. Sagittal (a and b), axial (c and d), and coronal (e–g) T2-weighted images and
coronal T1-weighted image (h) show mildly dilated ventricles without other abnormalities. Only the anterior portion of the corpus callosum
(arrows) is visualized, which is a normal finding on MR at this gestational age. Note the normal orbit, cerebellum, and mantle thickness.
Fetal CNS Abnormalities 27
Figure 3.2 Mild ventriculomegaly at 26 weeks gestational

age. Sagittal (a) and oblique axial (b) T2-weighted images.
Note smooth hypointense cortical band (arrows), which is a
normal finding at this gestational age.
aneuploidy, Figs. 3.3 and 3.4), corpus callosal hypogenesis

(Fig. 3.5), or lissencephaly. Ventriculomegaly may be an
ex vacuo phenomenon (e.g., atrophy secondary to infec-
tion or infarction, Fig. 3.6). Finally, ventriculomegaly
may represent hydrocephalus (Fig. 3.7) associated with a Figure 3.3 Mild ventriculomegaly at 26 weeks gestational
wide range of developmental or acquired etiologies. age in fetus with trisomy 21. Sagittal (a), axial (b), and coronal
The outcome of ventriculomegaly depends on the cause (c) T2-weighted images show mildly large third (arrow) and
and degree of ventricular enlargement, any associated lateral ventricles including temporal horns (t).
Figure 3.4 Mild ventriculomegaly with triploidy at 19 weeks gestational age. Sonographic biometry showed head measurements
2 weeks less than expected for gestational age and abdominal circumference 4 weeks less than expected. Coronal T2-weighted
images of head (a and b) show mild ventriculomegaly. Coronal view of head and torso (c) shows the relatively small size of the body
as compared to the head, consistent with severe intrauterine growth restriction.
Figure 3.5 Severe ventriculomegaly associated with Walker–Warburg syndrome at 33 weeks gestational age. Sagittal T2-weighted image
(a) shows hypogenesis of the corpus callosum with a thin genu and anterior body (white arrowheads) and a relatively small cerebellum (c)
within a large posterior fossa. Axial (b and c) and coronal (d–f) T2-weighted images show colpocephaly with slit-like frontal horns (arrows)
and massively dilated occipital horns. The frontal horns diverge normally. This combination of findings suggests dysgenesis of the corpus
callosum. The gyral pattern is abnormally smooth for this gestational age, suggesting abnormal cortical development. Black arrowhead
denotes region of porencephaly in (f). The autopsy at birth confirmed muscular dystrophy, subcapsular cataracts, cerebellar hypoplasia, an
interhemispheric cyst, hypogenesis of the corpus callosum, and an abnormal gyral pattern with regions of lissencephaly and polymicrogyria.
Fetal CNS Abnormalities 29
Figure 3.6 Ventriculomegaly and cerebral clefts at 30 weeks gestational age. Axial (a and b) and coronal (c) T2-weighted images and
sagittal T1-weighted images (d and e) show moderate ventriculomegaly, with bilateral transmantle defects, or clefts. These may represent
either porencephaly or schizencephaly. The T2 low intensities and T1 high intensities along the margins of the defects suggest hemorrhage
or mineralization (arrows). This and the presence of ependymal and cortical septations suggest an encephaloclastic origin occurring
beyond 22– 23 weeks gestational age (i.e., porencephaly) rather than an earlier migrational disorder (i.e., schizencephaly).
Figure 3.7 Severe ventriculomegaly at 32

weeks gestational age. Sagittal (a) and coronal
(b – d) T2-weighted images. The head size is
enlarged. There is a thin smooth mantle. The lack of
extra-axial CSF space suggests that the ventriculo-
megaly represents hydrocephalus rather than a
purely dysgenetic process. However, there are dys-
genetic features including cerebellar vermian and
hemispheric hypogenesis (arrows), a kinked brain-
stem (arrowhead), a large fourth ventricle, and a
small posterior fossa. [(a) From Levine et al. (23)]
Figure 3.8 Mild ventriculomegaly at 18 weeks gestational age. Axial (a– c) and coronal (d) views demonstrate mild ventriculomegaly.
Although the lateral ventricles only measure 11 mm, there is a thin surrounding mantle. The cerebellum (arrows) is hypoplastic.
abnormalities (Figs. 3.8 and 3.9), the gestational age at feature of neural tube defects (24). A box-like appearance of
which it develops, and its progression (Fig. 3.10) (20). the frontal horns is often associated with absence of the
Fetal MR imaging is particularly helpful in showing associ- septum pellucidum (24). Colpocephaly (i.e., disproportion-
ated anomalies that may be missed by ultrasound (4,8,21– ate dilatation of the atria and occipital horns with small
23). However, at times, the etiology of ventriculomegaly frontal horns) is often present with hypogenesis of the
cannot be determined by prenatal imaging (Fig. 3.11). corpus callosum. However, a similar contour may be seen
When isolated, mild ventriculomegaly (10–12 mm) is not as a normal developmental phase, especially when there is
associated with adverse postnatal outcomes in the majority only mild relative disproportion. Therefore, it is important
of cases. However, in other cases, it may be associated with to examine the ventricles in multiple planes (Fig. 3.13).
developmental delay. Measurements of cortical thickness, When the extracerebral CSF spaces are effaced and the
cortical volume, and ventricular volumes, along with head size is enlarged in association with ventriculo-
more quantitative assessments of maturation, may prove megaly, an obstructive component to the ventriculomegaly
to be predictive of postnatal outcome. can be surmised. When the extracerebral CSF spaces
The symmetry, proportion, and contour of the are prominent and the head size is small in association
ventriculomegaly are important factors. The significance with ventriculomegaly, hypogenesis is likely. In some
of isolated asymmetric ventriculomegaly is often indetermi- cases, both hypogenesis and hydrocephalus can coexist,
nate (Fig. 3.12). An angular lateral ventricular contour is a or the hydrocephalus develops subsequently.
Exploring the Variety of Random
Documents with Different Content
CHAPTER VII.
ENTERING INTO POSSESSION.
It was Mr. Paine who settled with the cabman. It had not struck me
that we had been passing through an over-savoury neighbourhood;
we drew up in front of a perfectly disreputable-looking house. Not
that it was particularly small; there were three storeys; but it looked
so dirty. And if there is one thing I cannot stand it is dirt. I could
easily believe that no one had lived in it for twenty years; it was
pretty plain that the windows had not been cleaned for quite as long
as that.
“Well,” I declared as I got out of the cab, “of all the dirty-looking
places I ever saw! If no one is to be allowed to set foot inside except
Emily and me, who do you suppose is going to clean those
windows?”
“That, I am afraid, is a matter which you must arrange with Miss
Purvis; the will makes no exception in favour of window cleaners.”
“Then all I can say is that that’s a nice thing.” I turned to Emily.
“This is going to turn out a pretty sort of romance—charwomen is
what we shall have to commence by being.”
“I’m not afraid of a little work,” she laughed.
I looked at the door.
“That writing on the label said that we were not to go into the
house when anyone was looking. How are we going to manage that?
Are you and the cabman to turn your backs?”
“I don’t think that that is necessary; this shall be an exception.
After you’ve opened the door we’ll hand the luggage to you when
you’re inside.”
Mr. Paine and the cabman were not by any means the only two
persons who were looking. Our stoppage in front of No. 84 had
created quite a wave of interest. People were watching us at doors
and through windows, and a small crowd of children had gathered
round us in a circle on the pavement. As it was out of the question
for us to wait till all eyes were off us, I straightaway disobeyed at
least one of the directions which were on the label.
What looked like an ordinary opening for a latchkey was in its
usual place on the right hand side of the door, but when I slipped
my key into that it turned round and round without producing any
visible effect whatever. So I examined the other side. There, sure
enough, so high up as to be almost beyond my reach, was what
looked like a small dab of green paint. When I pushed the key
against it it gave way. The key went into the apparently solid wood-
work right up to the handle. I gave it an upward jerk; the door was
open. However neglected the windows were, that lock seemed to be
in good condition.
The door had opened about an inch. We all stared at it as if
something wonderful had happened. I confess that I was a little
startled, because I had used so little force that it was a wonder to
me how it had come open. The children, giving a sort of cheer, came
crowding close round. Mr. Paine had to order them back. I pressed
my hand against the door. As it swung upon its hinges a bell
sounded somewhere in the house. It seemed to come from upstairs,
with a shrill, metallic clanging.
“There might be someone in already, who wanted to have warning
of anyone’s approach.”
This was Emily. She was staring into the passage as if she
expected to see something strange.
“Come,” said Mr. Paine. “Let me help you in with the luggage; then
I must leave you. People are taking a greater interest in the
proceedings than is altogether desirable. You may find them a
nuisance if you don’t look out.”
The crowd was being reinforced by children of an older growth.
Loiterers were stopping to stare. People were coming out of their
houses. As Mr. Paine said, their interest was becoming too
demonstrative. He helped the cabman to get our boxes into the
passage. Then he went. We shut the door after him in the faces of
the crowd. Emily and I were left alone.
It was an odd sensation which I felt during those first few
moments in which I realised that she and I were alone in my Uncle
Benjamin’s old house. I was conscious of a foolish desire to call the
crowd to keep us company. Emily Purvis was hardly the kind of girl I
should myself have chosen to be my sole companion in a tight place;
and I had a kind of feeling that before very long it might turn out
that I was in a tight place now.
It had all come on me so suddenly. More things had happened in a
few hours than in all my life before. Yesterday I had thought myself
a fixture at Cardew & Slaughter’s; with marriage with Tom in the far-
off distance; when the skies had fallen; or he had become a
shopwalker and I a buyer; or we had saved up enough to start a
small shop of our own. Now, Cardew & Slaughter’s had gone from
me for ever. So far as money went I was free to marry Tom next
week. But there was this horrid house—already I was calling it horrid
—and my uncle’s absurd conditions. If I was to observe them during
the rest of my life I might as well write myself a nun at once, and
worse. Better Cardew & Slaughter’s—or anything.
We could hear the sound of traffic and voices in the street. Within
the house all was still. There was no window over the door. In the
passage it was so dark that it was as much as we could do to make
out where we were. Emily put her hand upon my arm, as if she
wished to make sure that I was close.
“It’s no good our stopping here,” I said. “We’d better light a candle
and look about us. If the whole house is as light as this it must be a
cheerful place to live in.”
Acting on Mr. Paine’s suggestion, as we had come along in the cab
we had bought some candles and matches, and enough provisions
to carry us on to to-morrow. Routing out a box, I struck a match. I
gave Emily a candle and took one myself.
“Now to explore!”
We were brought to a standstill at the very start. In front of us
was a door which led into a room opening out of the passage, or
ought to have done. When I tried the handle I found that it was
locked. I shook it, I even thumped at the panels, I searched for a
key; it was no good. Against us the door was sealed.
“This is a comfortable beginning! If all the doors are locked it will
be really nice. Perhaps Uncle Benjamin intended that I should merely
have the run of the passage and the stairs.”
Such, however, fortunately or otherwise, was not the case. The
room behind the one which was closed was the kitchen; that was
open, and a delightful state it was in. Not only was it inches thick in
dust, but it was in a state of astonishing confusion. Pots and pans
were everywhere. The last person who had used that kitchen to
cook a meal in had apparently simply let the utensils drop from her
hand when she had done with them, and left them lying where they
fell. There was a saucepan here, a frying-pan there, a baking tin in
the corner. Another thing we soon became conscious of—that the
place was alive with cockroaches.
“What is it we are stepping on?” asked Emily.
“Why, it’s beetles.”
She picked up her skirts, she gave a scream, and back she
scurried into the passage. I am not fond of the creatures; I never
met anyone who was; but I am not afraid of them, and I was not
going to let them drive me out of my own kitchen.
“There’s one thing wanted, and that’s light and fresh air. Only let
me get those shutters down, and the window open, and then we’ll
see. I should say from the smell of the place that there has never
been any proper ventilation since the house was built.”
But it was easier said than done. Those shutters would not come
down. How to begin to get them down was more than I could
understand. To my astonishment, when I rapped them with my
knuckles, they rang.
“I do believe,” I said, “they’re made of iron—they’re a metal of
some kind. They seem to have been built into the solid wall, as if
they had never intended them to be moved. No wonder the place
smells like a vault, and beetles, and other nice things, flourish, if
they’re fixtures.”
A scullery led out of the kitchen. It was in the same state. One
crunched blackbeetles at every step. There was a shutter before the
window, which had evidently never been meant to be taken down.
Where, apparently, there had been a door leading into a backyard or
something, was a sheet of solid metal. No one was going to get out
that way in a hurry; or in either.
“But what can be the meaning of it all?” I cried. “There must be
an object in all this display of plate armour, or whatever it is. The
place is fortified as if it were meant to stand a siege. I shall begin to
wonder if there isn’t a treasure hidden somewhere in the house; a
great store of gold and precious stones, and that Uncle Benjamin
made up his mind that at any rate thieves should not break through
and steal.”
“Oh, Pollie, do you think there is? Perhaps it’s in the next room—
perhaps that’s why the door is locked.”
“Perhaps so; and perhaps the key’s upstairs, waiting for us to
come and find it. Anyhow we’ll go and see.”
When I rejoined Emily it struck me that she was not looking quite
so happy as she might have done; as if the romance was not taking
altogether the shape she either expected or desired. I led the way
upstairs. There was a carpet on them; but by the illumination
afforded by a guttering candle, it only needed a glance to see that, if
you once took it up, you would probably never be able to put it
down again—it would fall to pieces. We had hardly gone up half-a-
dozen steps when there came a clitter-clatter from above. Emily,
who was behind, caught me by the skirt.
“Pollie! Stop! Whatever’s that? There’s someone there!”
“Rats, most likely. In a house like this there are sure to be all sorts
of agreeable things. Where there aren’t blackbeetles there are rats;
and where there’s either there’s probably both.”
Rats it was. Before we had mounted another tread two or three
came flying down, brushing against our skirts as they passed. You
should have heard Emily scream.
“Don’t be silly,” I said. “You talk about liking romance, and you
make all that fuss because of a rat or two.”
“It isn’t exactly that I’m afraid of them, but—they startled me so. I
daresay I shan’t mind them when I’ve got used to them, only—I’ve
got to get used to them first.”
She was likely to have every opportunity. Presently two or three
more came down. They seemed to be in a hurry. One, which was
not looking where it was going, struck itself against my foot, and
squeaked. Emily squealed too. When we reached the landing we
could hear them scampering in all directions.
On that floor there were three rooms and a cupboard. The
cupboard was empty. So was one of the rooms; that is, so far as
furniture was concerned. But it was plain where, at any rate, some
of the rats were. When I went into the room I stepped on a loose
board. As it gave way beneath my tread I never heard such an
extraordinary noise as came from under it. Apparently a legion of
rats had their habitations underneath that flooring. I half expected
them to rush out and make for us. I was out of the room quicker
than I went in, and took care to close the door behind me. Emily had
turned as white as a sheet.
“I can’t stop in this place—I can’t.”
I was scornful.
“I thought you couldn’t. You’ll remember I told you that you
wouldn’t be my companion long. I knew that was the sort you were.”
“It isn’t fair of you to talk like that—it isn’t. I don’t mind ordinary
things—and I’ll not leave you, you know I won’t. But all those rats!
Did you hear them?”
“I heard them, and they’ll hear me before long. There’s going to
be a wholesale slaughter of rats, and blackbeetles. There’ll soon be
a clearance when they’ve sampled some of the stuff I know of. I’m
not going to be driven out of my own house by trifles.”
One of the other rooms was a bedroom, a sort of skeleton of one.
There was some carpet on the floor, or what had been carpet. There
was an iron bedstead, on which were the remains of what might
have been a mattress. But there were no signs of sheets or blankets;
I wondered if the rats had eaten them.
After what we had seen of the rest of the house, the third room,
which was in front, was a surprise. It was a parlour; not the
remnants of one, but an actual parlour. There was what seemed to
be a pretty good carpet on the floor. There was a round table, with a
tapestry cover. There were two easy chairs, four small ones, a
couch. On the sideboard were plates and dishes, cups and saucers.
On the stove, which was a small kitchener, was a kettle, two
saucepans, and a frying pan, all of them in decent order. Although
the usual shutters screened the window, the place was clean,
comparatively speaking. And when I went to a cupboard which was
in one corner, I found that in it there were coals and wood.
“It is not twenty years since this room was occupied, there’s that
much certain; nor, from the look of it, should I say it was twenty
hours. I should say there had been a fire in that stove this very day,
and there’s water in the kettle now.”
“What’s this?”
Emily was holding out something which she had picked up from
the floor. It was a woman’s bracelet, a gold bangle; though I had
never seen one like it before. It was made of plain, flat gold, very
narrow, twisted round and round; there was so much of it that,
when it was in its place, it must have wound round the wearer’s
arm, like a sort of serpent, from the wrist to the elbow. At one end
of it was something, the very sight of which gave me quite a qualm.
CHAPTER VIII.
THE BACK-DOOR KEY.
“Look!” I said. “Look!”

“Look at what? What’s the matter with you, Pollie? Why are you
glaring at me like that?”
“Don’t you see what’s at the end of it?”
She turned the bangle over.
“It isn’t pretty, but—it’s some sort of ornament, I suppose.”
“It’s that thing which was in the scrap of paper, or its double.”
“Pollie! Are you sure?”
“Certain. I’ll back myself to know that wherever it turns up.”
Taking the bracelet from her I eyed it closely. There was no
mistaking the likeness; to one end was attached the very double of
that painted little horror. Emily criticised it as she leant over my
shoulder.
“It looks as if it were meant for a man who mostly runs to head.
And what a head it is! Look at his beard, it reaches to what may be
meant for feet. And his hair, it stands out from his scalp like bristles.”
“Don’t forget his eyes, how they shine. They must be painted with
luminous paint, or whatever they call the stuff, which lights up in the
dark. The other night they gleamed so I thought the creature was
alive. And his teeth—talk about dentist’s advertisements! I believe
it’s meant for one of those heathen gods who are supposed to live
on babies, and that kind of thing. He looks the character to the life.
But fancy your picking it up from the floor! That’s not lain there
twenty years. There’s not a speck of rust upon it. It’s as bright as if
it had just come off somebody’s arm.”
“Pollie, do you think there’s anybody in the house besides we
two?”
“My dear, I haven’t the faintest notion; you can use your senses as
well as I can, and are quite as capable of putting two and two
together. One fact’s obvious, it’s not long since somebody was in this
room. But we’ve the rest of the house to see; I can tell you more
when we’ve seen it. Come, let’s go upstairs.”
Putting the bracelet on the table, I left the room. Emily seemed
reluctant to follow. I fancy that if she had had her way she would
have postponed the remainder of our voyage to later on—a good
deal later on. And, on the whole, I hardly wondered, because,
directly we began to go upstairs, such a noise came from above,
and, indeed, from everywhere, that you would have thought the
whole place was alive; and so it was—with rats. I had heard of the
extraordinary noises the creatures could make, but I had never
realised their capacity till then. Emily stood trembling on the bottom
step.
“I daren’t go up, I daren’t.”
“Very well, then; stop where you are. I dare, and will.”
Off I started; and, as I expected, directly I moved, she rushed
after me.
“Oh, Pollie, don’t leave me, don’t. I’d sooner do anything than
have you leave me.”
On that top floor there were again three rooms. And again, one of
them was empty. It was a sort of attic, at the back. So far as I could
make out it had no window at all; it was papered over if it had one.
But talk of rats! It was a larger room than the one below, and
seemed to be still more crowded. We could not only hear them, we
could see them. There they were, blinking at the candlelight out of
the floor and walls, and even ceiling. It was a cheerful prospect. I
had heard of rats, when they had got rid of everything else, eating
human beings. We two could do nothing against these multitudes; I
felt sure that the mere fright of being attacked would be enough to
kill Emily. I said nothing to her, but I thought of it all the same.
The door next to the attic was fastened. Whether it was locked or
not I could not make out. It felt as solid as if it never had been
opened, and had been never meant to open. When I struck it with
my knuckles, it returned no sound. That it was something else
besides a mere wooden door was obvious.
“Another treasure room!” I laughed.
But Emily did not seem pleased.
“I don’t like these locked-up rooms. What is there on the other
side?”
“I thought you were so fond of mystery.”
“Not mystery like this.” She lowered her voice. “For all we know
there may be people inside, who, while we can’t get at them, can
get at us whenever they choose.”
I laughed again; though conscious there was sense in what she
said.
“Let’s go and look at the other room and see if that’s locked up
too.”
But the door of that yielded at a touch. It, also, had had
occupants less than twenty years ago—a good deal less. It was
furnished as a bedroom. There was a chest of drawers, a washstand,
toilet-table, chairs, and a bed. On the latter the bedding was in
disorder; sheets, blankets, pillows tumbled anyhow, as if somebody,
getting out of it in a hurry, had had no time to put it straight. There
was a lamp upon the toilet table, the blackened chimney of which
showed it had been smoking; even yet the smell of a smoky lamp
was in the air. The drawers were all wide open. One, which had been
pulled right out, was turned upside down upon the floor, as if the
quickest way had been chosen to clear it of its contents.
“It looks,” said Emily, standing in the doorway, looking round her
with doubtful eyes, and speaking as if she were saying something
which ought to have been left unspoken, “as if someone had just got
out of bed.”
Throwing the bedclothes back, I laid my hand against the sheets.
It might have been my imagination, but they seemed warm, as if,
since someone had been between them, they had not had time to
cool. Not wishing to make her more nervous than she was already, I
hardly knew how to answer her; more especially as I myself did not
feel particularly comfortable. If, as appearances suggested,
somebody had been inside that bed, say, within the last half-hour,
who could it have been? and what had become of him or her, or
them? Crossing to the dressing-table, I touched the lamp-glass. It
was hot, positively hot. I could have sworn that it had been burning
within the last ten minutes or quarter of an hour. That was proof
positive that someone had been there—lamps do not burn unless
somebody lights them, and they do not go out unless somebody
puts them out. Who could it have been? The discovery—and the
mystery!—so took me aback that it was all I could do to keep myself
from screaming. But, as Emily was nearly off her head already, and I
did not want to send her off it quite, I just managed to keep my
feelings under. All the same, I did not like the aspect of things at all.
To stop her from noticing too much, I tried my best to keep on
talking.
“This is our bedroom, I suppose. How do you like the look of it?
Not over cheerful, is it?”
“Cheerful?” I could see she shuddered. “Does any light ever get
into the room?”
Where the window ought to have been were the usual massive
and immovable shutters.
“The person who put up those shutters wasn’t fond of either light
or air. But you wait, I’ll have them down, I like plenty of both. You
heard Mr. Paine’s story about the shutters having made their
appearance in a night? If they did, then there was witchcraft used,
or I’m a Dutchman. It took weeks, if not months, to get them there.
If the walls have to be pulled to pieces I’ll have them moved. Give
me a week or two and you won’t know the place. I’ll turn it inside
out and upside down. Because Uncle Benjamin had his ideas of what
a house ought to be like, dark as pitch, and alive with rats, not to
name blackbeetles, it doesn’t follow that his ideas are mine, so I’ll
show him.”
“We can’t do all that, you and I alone together.”
“Catch me trying! Before we’re many hours older I’ll have an army
of workmen turned into the house.”
“What about the conditions? No one is to be allowed to enter
except us two, especially no man.”
“Bother the conditions! Do you think I mind them? Uncle Benjamin
must have been stark staring mad to think that I would. If I’m only
to live in such a place as this on such terms as those, then I’ll live
out of it—that’s all. By the way, where’s the envelope which was in
that box? I took it out of my dress pocket. ‘This envelope is for Mary
Blyth, and is not to be opened by her till she is inside 84, Camford
Street.’ Well, now Mary Blyth is inside 84, Camford Street—a nice,
sweet, clean, airy place she’s found it! So I suppose that now she
may open the envelope. Let’s hope that the contents are calculated
to liven you up, because I feel as if I wanted something a little
chirrupy.”
Inside was a sheet of blue writing paper. It was not over clean,
being creased, and thumb-marked, and blotted too. On it was a
letter, written by somebody who was not much used to a pen. I
recognised Uncle Benjamin’s hand in a moment, especially because I
remembered how, in his letters to mother, which I had in my box,
the lines kept getting more and more slanting, until the last was
screwed away in a corner, because there was no room for it
anywhere else. And here was just the same thing. He began straight
enough, right across the page, but, long before he had reached the
bottom, he was in the same old mess.
“I need no ghost to tell me that this is from my venerated uncle. I
remember his beautiful neatness. Look at that, my dear, did you ever
see anything like those lines for straightness?”
I held up the page for Emily to see. She actually smiled, for the
first time since she had been inside that house.
“Now let’s see what the dear old creature says. Do hope it’s
something comforting. What’s this?” I began to read out aloud.
“‘Dear Niece,—Now that you are once inside the house, you will
never sleep out of it again.’ Shan’t I? We shall see. Nice prospect,
upon my word. ‘You may think you will, but you won’t. The spell is
on you. It will grow in power. Each night it will draw you back. At
your peril do not struggle against it. Or may God have mercy on
your soul.’ This is—this is better and better. My dear, Uncle Benjamin
must have been very mad. ‘You are surrounded by enemies.’ Am I? I
wasn’t till I had your fortune. I’m beginning to wonder if I shouldn’t
have been better off without it. ‘Out of the house you are at their
mercy. They watch you night and day. When you are out, they are
ever at your heels. Sooner or later they will have you. Then again
may God have mercy on your soul. But in the house you are safe. I
have seen to that. Do not be afraid of anything you may see or hear.
There is That within these walls which holds you in the hollow of Its
hand.’ That last line, my dear, is in italics. It strikes me that not only
was Uncle Bennie mad, but that writing novels ought to have been
his trade. As you are so fond of saying, this is something like a
romance; and I wish it wasn’t. Emily, what’s the matter with you
now?”
She had come to me with a sudden rush, gripping my arm with
both her hands—I doubt if she knew how hard. I could see that she
was all of a tremble.
“I—I thought I heard someone downstairs.”
“Not a doubt of it—rats.”
“It—it wasn’t rats. It sounded like footsteps in the room beneath.”
“When I’ve finished uncle’s letter we’ll investigate; but I think
you’ll find it was rats—they’ve got footsteps. Let me see, where was
I? Oh, yes—‘Its hand. Go out as little as you can.’ To be sure. I’m not
fond of going out—especially with such a house as this to stop in.
‘Be always back before nine. It is then the hour of your greatest peril
begins. Should you ever be out after nine—which the gods forbid—
let no one see you enter. They will be watching for you in the front.
Go to Rosemary Street at the back. Between thirteen and fourteen
there is a passage. At the end there is a wall. Climb it. There are two
stanchions one above the other on the right. They will help you.
Drop into the yard. Go to the backdoor. You will see a spot of light
shining at you. Put the key in there. Turn three times to the left. The
door will open. Enter and close quickly lest your enemies be upon
you. If they enter with you may God have mercy on your soul. From
your affectionate uncle, Benjamin Batters. P.S.—You will find the back
door key on the parlour table.’ Shall I? That’s story number one at
any rate. I haven’t found any back door key on the parlour table,
and I never saw one there. Did you?”
“There—wasn’t one—I noticed—there was nothing on the table—
when you put that bangle down.”
I wished Emily would not speak in that stammering way, as if
there was a full stop between each word or two. But I knew it was
not the slightest use my saying so just then; that was how she felt.
“Of course. I did leave that bangle on the table, didn’t I? That’s
one thing which we’ve found in uncle’s dear old house which seems
worth having; and one thing’s something. Let’s go and have another
look at it.”
Down the stairs again we went; Emily sticking close to my side as
if she would rather have suffered anything than have let me get a
yard away from her. One of the pleasantest features of my new
possession seemed to be that every time we moved from one room
to another about a hundred thousand rats got flurried; it sounded
like a hundred thousand by the din they made. And Emily did not
like them scurrying up and down the stairs when she was on them;
nor, so far as that went, did I either.
When we reached the parlour, I made a dart at the table.
“Why, where’s that bangle? I put it down just there, I remember
most distinctly. Emily, it’s gone! Whatever’s this? I do believe—it’s
that back-door key!”
It was, at any rate, a key; and bore a family likeness to the one
which was attached to the chain which was about my waist. I stared,
scarcely able to credit the evidence of my own senses. Between our
going from that room and our returning to it a miracle had
happened; a transformation had taken place; a bangle—and such a
bangle! had become a key. Apparently the back-door key of Uncle
Benjamin’s “P.S.!”
BOOK II.
84, CAMFORD STREET.
(THE FACTS OF THE CASE ACCORDING TO EMILY PURVIS.)

CHAPTER IX.
MAX LANDER.
Talk about romance! I never could have believed that after wishing
for a thing your whole life long you could have had enough of it in
so short a space of time. In the morning Pollie Blyth heard, for the
very first time, that a fortune and a house had been left to her, and,
before the night of that same day was over, she wished that it had
not. And here had I been looking, ever since I was a teeny-weeny
little thing, for a touch of romance to give existence a real live
flavour, and then, when I got it, the best I could do was to wonder
how I had been so silly as ever to have wanted it.
Poor Pollie! That first night in Camford Street she would go out.
She said she must go and see her Tom. That he would be waiting,
wondering what had become of her, and that nothing should keep
her from him. Nothing did. I could not. And when I suggested that it
might be as well for her to be a little careful what she did that very
first night, she actually proposed that I should stop in that awful
house by myself, and wait in it alone till she returned.
I would not have done such a thing for worlds, and she knew it.
As a matter of fact I could not have said if I was more unwilling to
leave the place, or to stay in it, even with her. The extraordinary
conditions of her dreadful old uncle’s horrible will weighed on me
much more than they seemed to do on her. I felt sure that
something frightful would happen if they were not strictly observed.
Nothing could be clearer than his repeated injunction not to be out
after nine, and her appointment with Mr. Cooper was for half-past
eight.
Cardew and Slaughter are supposed to close at eight, but she
knew as well as I did what that really meant. It was a wonder if one
of the assistants got out before nine. Mr. Cooper was in the heavy,
and the gentlemen in that department were always last. If he
appeared till after nine I should be surprised, and, if we were at the
other end of London at that hour, with the uncle’s will staring us in
the face, what would become of us? Being locked out of Cardew and
Slaughter’s was nothing to what that would mean.
But Pollie would not listen to a word. She is as obstinate as
obstinate when she likes, though she may not think it.
“My dear,” she said, “I must see Tom. Mustn’t I see Tom? If you
were in my place, and he was your Tom, wouldn’t you feel that you
must see him?”
There was something in that I acknowledged. It was frightful that
you should be cut off from intercourse with the man you loved
simply because your hours would not fit his. But then there was so
much to be said upon the other side.
“I’m sure he’ll be punctual to-night, he’ll be so anxious. And you
know sometimes he can get off a little earlier if he makes an effort.
You see if he isn’t there at half-past eight. I’ll just speak to him, then
start off back at once. He’ll come with us, we shall be back here
before nine, and then he’ll leave us at the door.”
That was how it was to turn out, according to her. I had my
doubts. When you are with the man to whom you are engaged to be
married half an hour is nothing. It’s gone before you know it’s
begun.
It was eight o’clock when we left the house. I thought we should
never have left it at all. We could not open the door. It had no
regular handle; no regular anything. While we were trying to get it
open the house was filled with the most extraordinary noises. If it
was all rats, as Pollie declared, then rats have got more ways of
expressing their feelings than I had imagined. It seemed to me as if
the place was haunted by mysterious voices which were warning us
to be careful of what we did.
“Of course if we’re prisoners it’s just as well that we should know
it now as later on. How do you open this door?”
Just as she spoke the door opened.
“How did you do that?” I asked.
“I don’t know.” She seemed surprised. “I was just pushing at the
thing when—it came open. There’s a trick about it I expect; we’ll
find out what it is to-morrow, there’s no time now. At present it’s
enough that it’s open; out you go!”
When we were out in the street, and she pulled it to, it shut
behind us with an ominous clang, like the iron gates used to do in
the barons’ castle which we read about in the days of old. We took
the tram in the Westminster Bridge Road, then walked the rest of
the way. It was half-past eight when we arrived. As I expected, of
course Mr. Cooper wasn’t there.
“Pollie, we ought not to stop. We ought to be in before nine this
first night, at any rate. We don’t know what will happen if we’re not.”
“You can go back if you like, but I must and will see Tom.”
Nine o’clock came and still no Mr. Cooper. I was in such a state I
was ready to drop. It was nearly a quarter-past before he turned up.
Then they both began talking together at such a rate that it was
impossible to get a word in edgeways. When I did succeed in
bringing Pollie to some consciousness of the position we were in,
and she asked Mr. Cooper to start back with us at once, he would
not go. He said that he had had such a narrow escape the night
before, and had had such difficulty in getting in—so far as I could
make out he had had to climb up a pipe, or something, and had
scraped a hole in both knees of his trousers against the wall—that
he had determined that it should be some time before he ran such a
risk again, and had therefore made up his mind that he would be in
extra early as a sort of set-off. It was no good Pollie talking. For
some cause or other he did not seem to be in the best of tempers.
And then, when she found that, after all our waiting, he would not
see us home, she got excited. They began saying things to each
other which they never meant. So they quarrelled.
Finally Mr. Cooper marched off in a rage, declaring that now she
had come into a fortune she looked upon him as a servant, and that
though she had inherited £488 9s. 6d. a year, and a house, he would
not be treated like a lackey. She was in such a fury that she was
almost crying. She assured me that she would never speak to him
again until she was compelled, and that they would both be grey
before that time came. All I wanted to do was to keep outside the
quarrel, because they had behaved like a couple of stupids, and to
find myself in safe quarters for the night.
“I don’t know, my dear Pollie, if you’re aware that it’s past half-
past ten. Do you propose to return to Camford Street?”
“Past half-past ten!” She started. Her thoughts flew off to Mr.
Cooper. “Then he’ll be late again! Whatever will he do?”
“It’s not of what he’ll do I’m thinking, but of what we’re going to
do. After what your uncle said, do you propose to return to Camford
Street at this hour of the night?”
“We shall have to. There’s nowhere else to go. I wish I’d never
come to see him now; it hasn’t been a very pleasant interview, I’m
sure.” I cordially agreed with her—I wished she had not. But it was
too late to shut the stable-door after the steed was stolen. “Let’s
hurry. There’s one thing, I’ve got the back-door key in my pocket, if
the worst does come to the worst.”
What she meant I do not think she quite knew herself. She was in
a state of mind in which she was inclined to talk at random.
We had not gone fifty yards when a man, coming to us from
across the street, took off his hat to Pollie. I had noticed him when
she was having her argument with Mr. Cooper, and had felt sure that
he was watching us. There was something about the way in which
he kept walking up and down which I had not liked, and now that
Mr. Cooper had gone I was not at all surprised that he accosted us.
He looked about thirty; had a short light brown beard and whiskers,
which were very nicely trimmed; a pair of those very pale blue eyes
which are almost the colour of steel; and there was something about
him which made one think that he had spent most of his life in open
air. He wore what looked, in that light—he had stopped us almost
immediately under a gas-lamp—like a navy blue serge suit and a
black bowler hat.
“Miss Blyth, I believe, the niece of my old friend Batters. My name
is Max Lander. Perhaps you have heard him speak of me.”
His manner could not have been more civil. Yet, under the
circumstances, it was not singular that Pollie shrank from being
addressed by a stranger. Putting her arm through mine, she looked
him in the face.
“I don’t know you.”
“Have you never heard your uncle speak of me—Max Lander?”
“I never knew my uncle.”
“You never knew your uncle?” He spoke, in echoing her words,
almost as if he doubted her. “Then where is your uncle now?”
“He is dead.”
“Dead?”
“If you knew my uncle, as you say you did, you must know that
he is dead. Come, Emily, let us go. I think this gentleman has made
a mistake.”
“Stop, Miss Blyth, I beg of you. Where did your uncle die?”
“I don’t know where exactly, it was somewhere in Australia.”
“In Australia!” I never saw surprise written more plainly on a
person’s face. “But when?”
“If, as you say, you knew him, then you ought to know better than
I, who never did.”
“When I last saw Mr. Batters he didn’t look as if he meant to die.”
He gave a short laugh, as if he were enjoying some curious little
joke of his own.
“Where did you see him last?”
“On the Flying Scud.”
“The Flying Scud? What’s that?”
“My ship. Or, rather, it was my ship. The devil knows whose it is
now.”
“Mr. Lander, if that really is your name, I don’t know anything
about my uncle, except that he is dead. Was he a sailor?”
“A sailor?” He seemed as if he could not make her out. I stood
close to him, so that I saw him well; it struck me that he looked at
her with suspicion in his eyes. “He was no sailor. At least, so far as I
know. But he was the most remarkable man who ever drew breath.
In saying that I’m saying little. You can’t know much of him if you
don’t know so much. Then, if he’s dead, where’s Luke?”
He spoke with sudden heat, as if a thought had all at once
occurred to him.
“Luke? What is Luke?—another ship?”
“Another ship? Great Cæsar!” Taking off his hat, he ran his fingers
through his short brown hair. “Miss Blyth, either you’re a chip of the
old block, in which case I’m sorry for you, and for myself too, or,
somewhere, there’s something very queer. Hollo! Who are you?”
While we had been talking a man had been sidling towards us
along the pavement. He had on a long black coat, and a hat
crammed over his eyes. As he passed behind Mr. Lander he stopped.
Mr. Lander spun round. On the instant he tore off as if for his life.
Without a moment’s hesitation Mr. Lander rushed full speed after
him. Pollie and I stood staring in the direction they had gone.
“Whatever is the matter now?” I asked. “What did the man do to
Mr. Lander?”
“Emily, that’s the man who slipped the paper into my hand last
night—you remember? There’s a cab across the road; let’s get into it
and get away from here as fast as we can.”
We crossed and hailed the cabman. As he drew up beside the
kerb, and we were about to enter, who should come tearing over the
road to us again but Mr. Lander. He was panting for breath.
“Miss Blyth, I do beg that you will let me speak to you. If not
here, then let me come with you and speak to you elsewhere.”
“I would rather you did not come with us, thank you, I would very
much rather that you did not.”
He stood with his hand on the apron of the hansom in such a way
that he prevented us from entering.
“Miss Blyth, you don’t look like your uncle—God forbid! You look
honest and true. If you have a woman’s heart in your bosom I
entreat you to hear me. Your uncle did me the greatest injury a man
could have done. I implore you to help me to undo that injury, so far
as, by the grace of God, it can be undone.”
He spoke in a strain of passion which I could see that Pollie did
not altogether relish. I didn’t either.
“I will give you my solicitor’s name and address, then you can call
on him, and tell him all you have to say.”
“Your solicitor! I don’t want to speak to your solicitor; he may be
another rogue like your uncle. I want to speak to you.”
Before Pollie could answer, another man came up. He touched his
hat to Mr. Lander.
“I beg your pardon, sir, but this is the young lady I told you about.
Miss Blyth will remember me, because I was so fortunate as to do
her a small service last night. May I hope, Miss Blyth, that you have
not forgotten me?”
The man spoke in a small, squeaky voice, which was in ridiculous
contrast to his enormous size. It was actually the creature who had
paid the bill for us the night before at Firandolo’s—one shilling and
threepence! My impulse was to take out my purse, give him this
money, and be rid of him for good and all. But, before I had a
chance of doing so, Mr. Lander turned upon him in quite a passion.
“What do you mean by thrusting in your oar? Get out of it, Ike
Rudd!”
“I beg your pardon, sir, I’m sure, if I’m intruding, and the young
lady’s; but, seeing that I was able to do her a little service, I thought
that perhaps she might be willing——”
Mr. Lander cut him short with a positive roar.
“Don’t you hear me tell you to take yourself out of this, you
blundering ass!”
In his anger with Mr. Rudd he moved away from the cab. Without
a moment’s delay Pollie jumped into it, and dragged me after her.
“Drive off, and don’t stop for anyone!”
It was done so quickly that before Mr. Lander had an opportunity
to realise what was happening the driver gave his horse a cut of the
whip. The creature gave a bound which it was a wonder to me did
not upset the hansom, and when his master struck him again he
galloped off as if he were racing for the Derby.
After we had gone a little way—at full pelt!—the driver spoke to us
through the trap-door overhead.
“Where to, miss?”
“Is he following us?”
“Not he. He tried a step or two, but when he saw at what a lick
we were going he jerked it up. He went back and had a row with the
other chap instead, the one who came up and spoke to him I mean.
They’re at it now. Has he been bothering you, miss?”
“I don’t know anything at all about him. He’s a perfect stranger to
me. I think he must be mad. Drive us to the Westminster Bridge
Road, if you are sure that he’s not following.”
“I’ll see that that’s all right, you trust me.” He swung round a
corner. “He’s out of sight now, I should think for good; but if he does
come in sight again I’ll let you know. What part of the Westminster
Bridge Road?”
Pollie hesitated.
“I’ll tell you when we get there.”
CHAPTER X.
BETWEEN 13 AND 14, ROSEMARY STREET.
A church clock struck as we rolled along.

“That sounds like nine—a quarter-past eleven. What shall you do if
we can’t get in at all?”
“Not get into my own house? My dear, this is not a case of Cardew
and Slaughter’s. What is going to keep me out of my own house—if I
choose to enter it with the milk!—I should like to know.”
I did not know. I could not even guess. But all the same I had a
sort of feeling that someone could—and might. “My own house”
came glibly from her tongue. That morning there had been ten
shillings between her and the workhouse; already she had become
quite the woman of established means. I might have been the same
had the case been mine. You never know. It must be so nice to have
something of your very own.
We were nearing the Westminster Bridge Road. Again the driver
spoke to us from above; he had hardly slackened pace the whole of
the way.
“Coast clear, miss; not had a sight of the party since we lost him.
Where shall I put you down?”
“I’ll stop you in a minute; keep on to the left.” Pollie spoke to me.
“What did it say in the letter was the name of the street in which is
the entrance to the back door?”
“Rosemary Street.”
“Of course! I couldn’t remember its stupid name.”
“But I shouldn’t tell him to put us down just there. You don’t know
who may be waiting for us.”
I was leaning over the front of the cab, keeping a sharp look-out.
There were the crowded trams and omnibuses, and many people on
the pavements; but I noticed nothing in any way suspicious.
“Who should be waiting for us? Haven’t we shaken Mr. Lander off?
Didn’t the cabman say so?”
“Yes. But—you never know.”
“What do you mean? What are you driving at?”
“Nothing. Only it’s past nine. The letter said that it was the time
your greatest peril began.”
“What nonsense you do talk! Do you think I pay attention to such
stuff? Lucky I’m not nervous, or you’d give me the fidgets. The
sooner everybody understands that I intend to go in and out of my
own house at any time I please the less trouble there is likely to be.
I’m not a child, to be told at what time I’m to come home.”
I was silent. She spoke boldly enough; a trifle too boldly I
thought. There was an unnecessary amount of vigour in her tone, as
if she wished to impress the whole world with the fact that she was
not in the least concerned. But she acted on the hint all the same—
she stopped the cab before we reached our destination.
“It’s all right now, miss,” said the driver. It was rather a novel
sensation for us to be riding in cabs, and the fare we paid him did
make a hole in one’s purse. It was lucky there was that four hundred
and eighty-eight pounds nineteen shillings and sixpence to fall back
upon. “You’ve seen the last of that fine gentleman, for to-night at
any rate. Good-night, miss, and thank you.”
I was not so sure that it was all right. We might have seen the last
of “that fine gentleman,” as the cabman called Mr. Lander, though
there was nothing particularly “fine” about him that I could see; but
there might be other gentlemen, still less “fine,” who had yet to be
interviewed. When the hansom had driven off, as we walked along
the pavement, I felt more and more uncomfortable, though I would
not have hinted at anything of the kind to Pollie for worlds.
“Have we passed Camford Street?” she wondered. “I don’t know
which side of it is Rosemary Street.”
“I’m sure I don’t. You had better ask.”
We were standing at the corner of a narrow street, a pretty dark
and deserted one it seemed. Pollie turned to make enquiries of some
passer-by. A man came towards us.
“Can you tell me which is Rosemary Street?” she said.
“This way! this way!”
He took her by the arm and led her into a gloomy-looking street,
as if he were showing her the way. She must have been purblind, or
completely off her guard, to have been tricked by him so easily,
because directly he spoke I recognised him as the person in the long
black coat who had fled from Mr. Lander. I myself was taken by
surprise, or I would have called out and warned her. But I suppose
that I was bewildered by his sudden and wholly unexpected
appearance, because, instead of bidding her look out, I went after
her into the narrow lane, for really it seemed to be no more.
The moment we were round the corner two other figures
appeared out of the darkness as if by magic. But by now Pollie had
taken the alarm.
“Let me go!” she cried to her conductor. “Take your hand away
from my arm!”
He showed no inclination to do anything of the kind.
“This way! this way!” he kept repeating, as if he were a parrot. He
spoke with a strong foreign accent—as if his stock of English was not
a large one.
But Pollie was not to be so easily persuaded. She stood stock still,
evincing every disposition to shake herself free from his grasp.
“Let me go! let me go!”
The taller of the two newcomers uttered some words in a
language which I had never heard before. Giving Pollie no time to
guess what he was about to do he produced a cloth and threw it
over her head. The other man sprang at her like a wild animal.
Between them they began to bear her to the ground. I was not
going to stand quietly by and see that kind of thing go on. I may not
be big, and I do not pretend to be brave, but I am not an absolute
coward all the same.
The smaller of the newcomers had taken me by the arm. I did my
best to make him wish that he had not. I flew at him.
“You villain! Let me go, or I’ll scratch your eyes out!”
The little wretch—he was little; I do not believe he was any bigger
than I was, or perhaps I should not be alive to tell this tale—actually
tried to throw a cloth over my head. When I put up my arms, and
stopped his doing that, he began to dab it against my mouth, as if to
prevent my screaming. There was a nasty smell about that cloth. It
was damp. All of a sudden it struck me that he was trying to take
away my senses with chloroform, or some awful stuff of that kind.
And then didn’t I start shrieking; I should think they might have
heard me on the other side of the bridge.
In less than no time—or so it seemed to me—a policeman came
round the corner. Apparently he was the only one who had heard;
but he was quite enough.
“What’s the matter here?” How I could have kissed him for his
dear official voice. “What’s the meaning of all this?”
Those three cowards did not wait to explain. Really before the
words were out of his lips they were off down the lane like streaks of
lightning. All my man left behind him was the smell of his horrid
cloth. Beyond disarranging my hat and my hair, and that kind of
thing, I knew that he had not damaged me almost before, so to
speak, I examined myself to see.
“Has he hurt you?” asked the constable. “What was he trying to
do?”
“He has not hurt me, thanks to you; but in another half second
I’m quite sure he would have done. He was trying to chloroform me,
or something frightful, I smelt it on his cloth.”
“Who’s this on the ground?”
It was Pollie. In my excitement I had quite forgotten to notice
what had become of her. She lay all of a heap. Down I plumped on
my knees beside her.
“Pollie!” I cried. “Has he killed you?”
“No fear,” said the policeman. “She’s only a bit queer. I shouldn’t
be surprised if they’ve played the same sort of trick on her they tried
to play on you.”
It was so. That policeman was a most intelligent man, and quite
good-looking, with a fair moustache which turned up a little at the
ends. They had endeavoured to stupefy her with some drug; the
policemen said he didn’t think it was chloroform, it didn’t smell like
it. I didn’t know—to my knowledge I have never smelt chloroform in
my life, nor do I ever want to. They had so far succeeded that she
had nearly lost her senses, but not entirely. When I lifted her head
she gave several convulsive twitches, so that it was all I could do to
retain my hold. Then she opened her eyes and she asked where she
was.
“It’s all right,” I told her. “They’ve gone. I hope they haven’t hurt
you.”
She sat up, and she looked about her. She saw me, and she saw
the constable, which fact she at once made plain.
“Oh, you’re a policeman, are you? It’s as well that there are such
things as policemen after all.” Her meaning was not precisely clear,
but I hardly think it was altogether flattering to the force, which was
ungrateful on her part. “I don’t think they’ve hurt me. I believe it
was the keys they were after, though they’ve left them both behind.
Perhaps that was because they hadn’t time to properly search for
them.” She was feeling in her pocket. “But they have taken Uncle
Benjamin’s letter—the one in which he told us how to get in at the
back door.”
There was a pause. I realised all that the abstraction might mean.
If it had told us how to enter, it would tell them too. It was lucky
they had had to go without the key.
“Do you know the men?” inquired the officer. “You had better
charge them.”
“Charge them?” She put her hand up to her head, as if she were
dazed. I rather fancied she was making as much of her feelings as
she could. Unless I was mistaken she was endeavouring to gain time
to consider the policeman’s words. Under the circumstances it might
not be altogether convenient to charge them, even though they had
proved themselves to be such utter scoundrels. “But I don’t know
what men they were.”
“That doesn’t matter; I daresay we know. You mustn’t allow an
outrage like this to pass unnoticed; they might have murdered you.
I’ll take the charge.”
“Thank you.” She stood up. He had produced his notebook. “I
don’t think I’ll trouble you. There are circumstances connected with
the matter which render it necessary that I should think it over.”
“What’s there to think about? It was an attempt to rob with
violence, that’s what it was; as clear a case as ever I knew. Come,
give me your name, miss, then I’ll have the particulars. What
name?”
“I’m afraid you must excuse me. When I’ve thought the matter
over you shall hear from me again, but I cannot act without
consideration. Thank you all the same.”
She carried it off with an air which took the constable aback. He
was not best pleased. He eyed her for a second or two, then he
closed his notebook with a snap.
“Very good. Of course, if you won’t make a charge I can’t take it.
All I can say is, that if you find yourself in the same hole again, it’ll
about serve you right if no one comes to help you. It’s because
people won’t go into court that there’s so much of this sort of thing
about. What’s the good of having laws if you won’t let them protect
you.”
Off he strode in a huff. I stared after him a little blankly.
“I don’t think, Pollie, that you need have been quite so short with
him. What he says is true; we might have been murdered if it hadn’t
been for him.”
“I wasn’t short with him; I didn’t mean to be. But I couldn’t
charge them—could I? Besides, I want to get in. I didn’t want to
have him hanging about, for I don’t know how long, watching us.”
“Someone else may be watching us.”
“No fear of that; they’ve had enough of it for to-night.”
“So you said before, and hardly had you said there was nothing to
fear when they had us at their mercy. It’s my belief that what your
uncle said in that letter—which now they’ve got—is true, and that we
are in peril, dreadful peril, and that though we mayn’t know it
someone is watching us all the time. For my part I should like that
policeman to have kept his eye upon us until we were safe indoors.”
“After what my uncle said about allowing no one to see us enter?”
“It’s a pity you are not equally particular about everything your
uncle said, my dear.”
Off we started down the lane, or street, or whatever it was. If I
had had my way, after all that had happened, I would not have
attempted to enter the house until at any rate next morning; I would
rather have wandered about the streets all night. But I could see
that she was set on at least trying to get in. I did not wish to
quarrel, or to be accused of a wish to desert her after promising to
be her companion. So I stuck to her side. Presently she spoke.
“Do you know, Emily, I believe I haven’t got the very clearest
recollection of the directions in uncle’s letter. Didn’t he say
something about a passage?”
“He said that there was one between 13 and 14 Rosemary Street.
The question is, is this Rosemary Street? We don’t know.”
“We’ll soon find out. Which are 13 and 14? It’s so dark it’s hard to
tell.”
It was dark; which fact lent an additional charm to the situation.
On one side were the backs of what seemed like mews; all they
presented to us was a high dead wall. On the other was a row of
cottages. If they were occupied all the inhabitants were in bed.
There was not a light to be seen at any of the windows. Pollie began
to peer at the numbers on the doors.
“This is 26.” She passed on. “And this is 25; so 13 and 14 must be
this way.” We went farther along the street. “Here is 14—and here’s
the passage.”
There was a passage, between two of the mean little houses. But
so narrow an one that, if we had not been on the look-out for it, we
should have passed it by unnoticed. Such was the darkness that we
could not see six feet down it, so that it was impossible to tell where
it led to, or what was at the end. I did not like the idea of venturing
into it at all. I would have given almost anything to have flown down
the street and sought the protection of that nice policeman. My
heart was going pitter patter; I could feel it knocking against my
corsets. I did not know if Pollie really was nervous, though I do not
believe that it was in feminine human nature to have been anything
else; but she behaved as though she wasn’t. I could not have made
believe so well. She apparently did not hesitate about what was the
best, and proper, and only thing to do. There was not even a tremor
in her voice.
“What did uncle say—at the end there is a wall?”
“I—I think he did.”
“Then now for the wall.”

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INTRODUCTION TEMPERATURE INCREASES DURING

A few in studies have assessed the potential effect of MR

According to the Safety Committee of the Society for

Figure 1.1 Uterus at 7 weeks gestational age. This representa-

Figure 1.4 Fetus at 13 weeks gestational age. (a) Oblique

1. Elster AD. Does MR imaging have any known effects on

DEBORAH LEVINE, CAROLINE ROBSON

INTRODUCTION guidelines provided by Chi et al. (8) describe gestational

Table 2.1 Reported Appearance of Sulci with Respect to Gestational Age

Detectable Detectable Detectable Detectable

Sulci/fissures of the medial cerebral surface

overlying cortex, and a relative decrease in the amount

By 28 –30 weeks, numerous new sulci and gyri develop

Normal 1.9 + 2.2 0–8 — CONCLUSION

REFERENCES acquisition with relaxation enhancement sequence.

DEBORAH LEVINE, PATRICK BARNES

INTRODUCTION hemiatrophy, hydrocephalus, hemorrhage, infarction, and

Figure 3.2 Mild ventriculomegaly at 26 weeks gestational

aneuploidy, Figs. 3.3 and 3.4), corpus callosal hypogenesis

Figure 3.7 Severe ventriculomegaly at 32

“Look!” I said. “Look!”

(THE FACTS OF THE CASE ACCORDING TO EMILY PURVIS.)

A church clock struck as we rolled along.

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