Download the full version of the ebook at

https://ebookultra.com

Musculoskeletal X Rays for Medical Students

and Trainees 1st Edition Andrew K. Brown

https://ebookultra.com/download/musculoskeletal-x-
rays-for-medical-students-and-trainees-1st-
edition-andrew-k-brown/

Explore and download more ebook at https://ebookultra.com

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

Clinical Methods in Ophthalmology A Practical Manual for

Medical Students 2nd Edition K Dadapeer

https://ebookultra.com/download/clinical-methods-in-ophthalmology-a-
practical-manual-for-medical-students-2nd-edition-k-dadapeer/

ebookultra.com

X rays and extreme ultraviolet radiation principles and

applications Second Edition Attwood

https://ebookultra.com/download/x-rays-and-extreme-ultraviolet-
radiation-principles-and-applications-second-edition-attwood/

ebookultra.com

On call x rays made easy 1st Edition Iain Au-Yong

https://ebookultra.com/download/on-call-x-rays-made-easy-1st-edition-
iain-au-yong/

ebookultra.com

Clinical Psychology for Trainees Foundations of Science

Informed Practice 2nd Edition Andrew C. Page

https://ebookultra.com/download/clinical-psychology-for-trainees-
foundations-of-science-informed-practice-2nd-edition-andrew-c-page/

ebookultra.com
Cosmic Rays and Particle Physics 2nd Edition Thomas K.
Gaisser

https://ebookultra.com/download/cosmic-rays-and-particle-physics-2nd-
edition-thomas-k-gaisser/

ebookultra.com

Applied Radiological Anatomy for Medical Students 1st

Edition Paul Butler

https://ebookultra.com/download/applied-radiological-anatomy-for-
medical-students-1st-edition-paul-butler/

ebookultra.com

Urology A Handbook for Medical Students 1st Edition Brew

S.

https://ebookultra.com/download/urology-a-handbook-for-medical-
students-1st-edition-brew-s/

ebookultra.com

Textbook of Biochemistry for Medical Students 7th Edition

Vasudevan

https://ebookultra.com/download/textbook-of-biochemistry-for-medical-
students-7th-edition-vasudevan/

ebookultra.com

Textbook of Biochemistry for Medical Students 6th Edition

Dm Vasudevan

https://ebookultra.com/download/textbook-of-biochemistry-for-medical-
students-6th-edition-dm-vasudevan/

ebookultra.com
Musculoskeletal X Rays for Medical Students and
Trainees 1st Edition Andrew K. Brown Digital Instant
Download
Author(s): Andrew K. Brown, David G. King
ISBN(s): 9781118458730, 1118458737
Edition: 1
File Details: PDF, 63.31 MB
Year: 2016
Language: english
Musculoskeletal X‐rays
for Medical Students and Trainees
This title is also available as an e‐book.
For more details, please see
www.wiley.com/buy/9781118458730
or scan this QR code:
Musculoskeletal
X‐rays
for Medical Students
and Trainees

Andrew K. Brown
Consultant Rheumatologist
York Teaching Hospital NHS Trust; and
Senior Lecturer in Medical Education and Rheumatology
Hull York Medical School

David G. King
Consultant Musculoskeletal Radiologist
York Teaching Hospital NHS Trust; and
Honorary Senior Lecturer
Hull York Medical School
This edition first published 2017 © 2017 by John Wiley & Sons, Ltd.

Registered Office
John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial Offices
9600 Garsington Road, Oxford, OX4 2DQ, UK
The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
350 Main Street, Malden, MA 02148-5020, USA

For details of our global editorial offices, for customer services and for information about how to apply for
permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell

The right of the authors to be identified as the authors of this work has been asserted in accordance with the UK
Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in
any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by
the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names
and product names used in this book are trade names, service marks, trademarks or registered trademarks of their
respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold
on the understanding that the publisher is not engaged in rendering professional services. If professional advice or
other expert assistance is required, the services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding, and discussion only
and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis,
or treatment by health science practitioners for any particular patient. The publisher and the author make no
representations or warranties with respect to the accuracy or completeness of the contents of this work and
specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular
purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the
constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to
review and evaluate the information provided in the package insert or instructions for each medicine, equipment,
or device for, among other things, any changes in the instructions or indication of usage and for added warnings
and precautions. Readers should consult with a specialist where appropriate. The fact that an organization
or Website is referred to in this work as a citation and/or a potential source of further information does not
mean that the author or the publisher endorses the information the organization or Website may provide or
recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may
have changed or disappeared between when this work was written and when it is read. No warranty may be
created or extended by any promotional statements for this work. Neither the publisher nor the author shall be
liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Names: Brown, Andrew K., author. | King, David G., author.

Title: Musculoskeletal X-rays for medical students and trainees / Andrew K. Brown, David G. King.
Description: Chichester, West Sussex, UK ; Malden, MA : John Wiley & Sons Inc., 2015. |
Includes bibliographical references and index. | Description based on print version record and CIP data
provided by publisher; resource not viewed.
Identifiers: LCCN 2014040930 (print) | LCCN 2014040575 (ebook) | ISBN 9781118458716 (Adobe PDF) |
ISBN 9781118458723 (ePub) | ISBN 9781118458730 (pbk.)
Subjects: | MESH: Musculoskeletal Diseases–radiography.
Classification: LCC RC925.7 (print) | LCC RC925.7 (ebook) | NLM WE 141 | DDC 616.7/07572–dc23
LC record available at http://lccn.loc.gov/2014040930

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be
available in electronic books.

Cover images: © Andrew K. Brown and David G. King

Set in 10/13pt Frutiger by SPi Global, Pondicherry, India

1 2017
    v

Contents

Preface, vii
Acknowledgements, viii

Part 1: Introduction, 1
1 Musculoskeletal X‐rays, 3
Introduction, 3
Basic principles of requesting plain radiographs of bones and joints, 4
Basic principles of examining and reporting plain radiographs of bones and joints, 6
Normal anatomy on musculoskeletal X-rays, 8

Part 2: Pathology, 21
2 Trauma, 23
Bone and joint injuries, 23
Specific injuries, 41
Spine, 58
Paediatric fractures, 67
Fractures in child abuse, 73
Further reading, 76
3 Arthritis, 77
Osteoarthritis, 77
Rheumatoid arthritis, 80
Crystal arthropathy, 83
Gout, 83
Calcium pyrophosphate disease, 86
Psoriatic arthritis, 91
Axial spondyloarthritis (ankylosing spondylitis), 95
4 Tumours and tumour‐like lesions, 98
Radiological evaluation of the patient, 98
X-rays – general principles, 101
Malignant tumours, 105
Bone metastases, 105
Multiple myeloma, 107
Plasmacytoma, 108
Osteosarcoma, 110
Chondrosarcoma, 111
Ewing’s sarcoma, 113
Benign tumours, 114
Exostosis (Osteochondroma), 115
vi   Contents

Osteoid osteoma, 116

Tumour‐like lesions, 117
Simple bone cyst, 118
Infection, 119

5 Metabolic bone disease, 120

Osteoporosis, 120
Osteomalacia, 121
Hyperparathyroidism, 122
Chronic kidney disease metabolic bone disorder, 124
Haemochromatosis, 126

6 Infection, 128
Routes of spread, 128
Causative organisms, 128
Osteomyelitis, 129
Septic arthritis, 134
Infective discitis, 136

7 Non‐traumatic paediatric conditions, 138

Developmental dysplasia of the hip, 138
Perthes’ disease, 140
Tarsal coalition, 141
Osteochondritis dissecans, 143
8 Other bone pathology, 144
Paget’s disease of bone, 144
Hypertrophic Osteoarthropathy (HOA), 147
Avascular necrosis, 147
9 Joint replacement, 149
Hardware failure and aseptic loosening, 149
Infection, 154
Malalignment and instability, 155
Periprosthetic fracture, 156

Part 3, 157
Self-assessment questions, 159
Self-assessment answers, 172
Index, 185
    vii

Preface

X-rays of bones and joints play a central role in musculoskeletal medicine and surgery, but the approach to
evaluation and interpretation of X‐rays is not always well taught or easily understood. This book should provide
greater insight into the mysteries of the plain film X-ray and is ideal for medical students, doctors in training,
physiotherapists, nurse practitioners and radiographers.
The book covers radiological anatomy as well as the main areas of pathology in which plain film assessment
is clinically useful. The importance of correlation with relevant clinical findings and other imaging modalities
will be highlighted and discussed where appropriate.
To make the radiological signs clear, each illustration consists of a pair of images, the first a standard X-ray
and the second with coloured overlays added to precisely define each abnormality. By covering up the second
image, the reader can also use this format to practise X‐ray interpretation.
Our approach is largely based on the authors’ combined experience of teaching medical students, trainees in
emergency medicine, orthopaedics and rheumatology, as well as professions allied to medicine, over many
years. By using this book, the reader will learn how the clues or signs found on an X-ray can be extracted and
put together to aid in making a diagnosis and informing disease management.
We hope this book will provide an interesting and enjoyable way to obtain a clearer understanding of X-rays
from the basics to more subtle findings across a broad range of musculoskeletal medicine.

Andrew K. Brown
David G. King
viii   

Acknowledgements

We would like to thank our colleagues at York Teaching Hospital for their help with finding suitable images for
this book and especially Mike Pringle in the Department of Medical Illustration and Photography for his help
and advice. We are also grateful to the students of Hull York Medical School for acting as subjects while we
were developing our ideas and the material for this book.
Part 1
Introduction
    3

1 Musculoskeletal X‐rays

Introduction

Despite the availability of a wide range of imaging techniques to visualise musculoskeletal structures, plain
radiographs or X-rays remain an important and widely used first‐line investigation. It is probably the most
readily available and least expensive imaging modality and is easily accessible to patients and healthcare
professionals. As such, all medical professionals require at least a basic level of knowledge and training in the
fundamental principles of requesting, interpreting and reporting plain radiographs of bones and joints.

Musculoskeletal X-rays for Medical Students and Trainees, First Edition. Andrew K. Brown and David G. King.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
4   Introduction

Basic principles of requesting plain radiographs of bones and joints

Which structures?
Before requesting an X-ray, the clinician should already have a good idea of the likely nature of the clinical
problem and which musculoskeletal structures may be affected and what may or may not be visualised on an
X-ray. For example, radiographs are best at detecting pathological changes in bones, joints and cartilage, such
as joint space narrowing, fracture, subluxation and dislocation. However, many soft tissue structures such as
ligaments, tendons and synovium are not well visualised, and alternative imaging may be more appropriate to
provide additional useful information to aid diagnosis and treatment.
Clinical assessment including the patient’s symptoms and a physical examination will usually determine the
site or region that is to be evaluated by X-ray. Exceptions may include a patient with rheumatoid arthritis where
X-rays of both hands and feet may be used to evaluate the extent of disease or structural damage which may
be repeated serially to compare any disease progression over time.

Which views?
It is important to consider which views are chosen to visualise a particular region of interest. This is because
the X-ray beam creates a two dimensional shadow of a structure so selecting the correct view will maximise
sensitivity. A basic principle is that two views should be requested, ideally 90° apart, which are usually obtained
in antero‐posterior (AP) and lateral or oblique views. This is particularly important in a trauma context where
fracture or dislocation may be missed if only a single view is acquired but may be less important for the
assessment of arthritis. There are a number of established techniques and protocols for optimal image
acquisition using standardised views of most musculoskeletal sites. Specialist views may also be considered in
particular clinical situations, such as a ‘skyline view’ for the patello‐femoral joint or ‘through‐mouth view’ for
the cervical spine. As well as the particular plane used to acquire the radiographic image, the position of the
patient should also be considered. For example, weight‐bearing views with the patient in a standing position
are often much more informative in evaluating cartilage loss in the knees of a patient with osteoarthritis or in
providing additional information concerning biomechanical changes in the feet.

Compare both sides and review previous images

Particularly in equivocal cases, it may be informative to compare findings in a symptomatic area with the
same region on the opposite side of the body or to look at the same region on a previous X-ray. For example,
in a patient with hip pain, an AP X-ray of the pelvis allows some comparison between both hip joints, or in a
patient with rheumatoid arthritis, comparison with a previous X-ray of the hands allows interpretation of any
progression of erosive joint damage.

Correlation with clinical and other imaging findings

Any X‐ray findings always need to be interpreted in clinical context, with an individual’s symptoms, clinical
examination findings and any other investigation results in mind. It may be necessary to perform additional
imaging using alternative techniques such as ultrasound, computed tomography or magnetic resonance
imaging, which may offer important additional or confirmatory information. Discussion with a specialist
musculoskeletal radiologist is frequently helpful, and sharing and reviewing more challenging cases at a
musculoskeletal radiology meeting involving clinicians and radiologists are often productive.

Safety considerations
Whilst undertaking a radiographic assessment is a well‐regulated process and is generally considered safe, it is
important to remember that the procedure exposes a patient to ionising radiation and a number of important
safety precautions need to be considered. This is particularly important in children and young adults and when
the area includes any organ which is more sensitive to ionising radiation such as the thyroid, breasts or gonads.
In women of childbearing age if the area involves the abdomen, spine or pelvis, it is essential to ask the patient
about the possibility of pregnancy and an X-ray in these circumstances should only be performed if absolutely
necessary, such as a suspected pelvic fracture.
 Musculoskeletal X‐rays   5

The amount of radiation exposure varies depending on the structure being visualised. Radiographs of deeper
structures, such as the pelvis or lumbar spine, subject the patient to considerably greater radiation exposure
than that of more peripheral structures, such as an examination of a single limb joint. The number of views and
images obtained are proportional to the amount of radiation received. In all circumstances, it is important to be
able to justify any radiation exposure on the basis of potential risk and benefit. The Department of Health
Policy on Ionising Radiation (Medical Exposure) Regulations 2000 [1] covers these aspects in detail.
6   Introduction

Basic principles of examining and reporting plain radiographs

of bones and joints

Everyone should have a straightforward strategy for reviewing and interpreting musculoskeletal X-rays,
including some basic principles and a systematic approach that can be routinely followed. It can often feel
intimidating to review, interpret and describe an X-ray, but this need not be complex or jargon‐heavy and
confident use of simple descriptive language is all that is required. Undoubtedly, knowledge of musculoskeletal
anatomy and understanding of pathological processes affecting bone, cartilage, joints and soft tissues will
help, but a lot of information can be gained from describing any obvious abnormal or different appearances
using simple descriptions, words and phrases. Even if you see an abnormality, it is still important to continue to
evaluate the whole X-ray in case other findings are present. If an obvious change is not present or immediately
apparent, then it is useful to be able to fall back on a standard framework with which to organise your
thoughts and report your observations. An example of such an approach is outlined as follows:
1. Check patient identification details and labelling.
Do the patient and X‐ray identification details correspond, is it the correct X-ray being viewed, date and
time, left or right?
2. Is the image quality satisfactory? Are imaging angles optimal?
Consider densities, penetration and blackening of film (see “X‐ray densities” below) and any
inappropriate rotation and viewing angles. Also consider all additional views and patient position, has the
region of interest been included?

X‐ray densities

To understand the appearance of different densities on an X-ray, it is useful to consider the basic concept of
how it has been produced. The image is essentially a shadow made by sending X-rays through an area of
the body onto a detector behind. For about 100 years, the detector used was film. More recently, film has
been swapped for electronic digital detectors but the concept remains the same. Where there is only air
between the X‐ray source and the detector, such as in the area around a limb, the film will be very exposed,
that is blackened. Dense structures, such as bone, will stop most X-rays and the film will be less exposed,
that is more white. Soft tissues produce intermediate shades of grey.
Assuming there is no metallic foreign body or other man‐made artefact, there are only four densities to
think about on an X-ray: calcium is white and gas is black. Of the soft tissues, fat is a darker shade of grey
because it is a little less dense to X-rays than other soft tissues. All other soft tissues are the same lighter
shade of grey, as is fluid (see Figure 1.1).

3. Describe any obvious abnormality using simple descriptive language.

Name the specific bone (e.g. right tibia) and describe the location of any abnormality (e.g. proximal,
middle or distal; head, neck or shaft; cortex or medulla). Basic terminology used for the paediatric and
adult skeleton is shown in Figure 1.2. A combination of these terms and specific anatomical names
should be used.
4. Use a systematic approach to consider specific musculoskeletal structures (bones, joints, cartilage and
soft tissues).
• Bone alignment – are there any changes in position which may suggest a fracture or dislocation?
• Bone cortices – follow the outline of each bone as any breach in the cortex may indicate a fracture or
an erosive arthritis.
• Bone texture – Altered density or disruption in the usual trabecular pattern within the substance of the
bone may indicate pathology.
• Joint and cartilage – a careful look at the joint space may demonstrate changes such as joint space
narrowing due to cartilage loss or calcification of the cartilage (chondrocalcinosis) or new bone
formation (e.g. osteophytes in osteoarthritis).
 Musculoskeletal X‐rays   7

• Soft tissues – remember to look at the soft tissues as well as the bones as they can hold helpful clues.
For example, it may be possible to see if joint swelling is present and, therefore, that there must be
something significant wrong with that joint. This will be discussed further in the chapter on trauma
but also applies to any cause of joint swelling.
5. Review all views and X‐ray images, compare both sides and adjacent joints and re‐examine any previous
imaging.
6. Always consider clinical findings and correlation with other imaging and test results.
7. If there is still uncertainty, review all the available information once more, discuss the case with a
musculoskeletal radiologist, and consider reviewing the case at a multidisciplinary radiology conference.

Figure 1.1 X-ray of the forearm illustrating the naturally occurring densities in a patient. White = calcium (in bone), dark
grey = fat, lighter grey = all other soft tissue structures. Surrounding air is black.

Child Adult

Diaphysis
Shaft

Metaphysis
Growth
Plate

Ossification Epiphysis
centre
Joint ‘space’ = articular
cartilage thickness

Figure 1.2 Recommended terminology for describing bone anatomy in adults and children.
8   Introduction

Normal anatomy on musculoskeletal X-rays

This section features a series of paired standard X‐ray images of each region, annotated with important
anatomical structures. It will be useful to refer back to these as you read through the remaining chapters.

Figure 1.3 Normal hand.

 Musculoskeletal X‐rays   9

Figure 1.4 Normal wrist, PA view.

Remember trapezium is adjacent to the thumb.

10   Introduction

Figure 1.5 Normal wrist, lateral view (see the 4 Cs in Chapter 2).
 Musculoskeletal X‐rays   11

Figure 1.6 Normal elbow, AP view.

12   Introduction

Figure 1.7 Normal elbow, lateral view.

Figure 1.8 Normal shoulder, AP view.

 Musculoskeletal X‐rays   13

Figure 1.9 Normal shoulder, axial view.

Figure 1.10 Normal cervical spine, lateral view.

14   Introduction

Figure 1.11 Normal cervical spine, AP view.

Figure 1.12 Normal cervical spine, through‐mouth view.

Figure 1.13 Normal lumbar spine and sacroiliac joints, AP view.

Figure 1.14 Normal lumbar spine, lateral view.

16   Introduction

Figure 1.15 Normal pelvis, AP view.

 Musculoskeletal X‐rays   17

Figure 1.16 Normal hip, lateral view.

Figure 1.17 Normal knee, AP view.

18   Introduction

Figure 1.18 Normal knee, lateral view.

On the lateral view, the medial condyle is round; lateral femoral condyle is indented due to a sulcus.

Figure 1.19 Normal knee, sky‐line patella view.

On the patella, the Lateral patellar facet = Large

Figure 1.20 Normal ankle, AP view.

Figure 1.21 Normal ankle, lateral view.

20   Introduction

Figure 1.22 Normal foot, AP and oblique views (note bipartite medial sesamoid bone which is a normal variant).
Cuneiform bones: l = lateral, i = intermediate, m = medial.

Reference
1. The Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R 2000), The Department of Health 2012. Available
at: https://www.gov.uk/government/publications/the‐ionising‐radiation‐medical‐exposure‐regulations‐2000 (accessed on
19 September 2014).
Part 2
Pathology
    23

2 Trauma

Bone and joint injuries

Introduction
This section describes general concepts of trauma imaging, including how to evaluate an X-ray in order to
detect bone and joint injuries and how to describe the findings. Basic X‐ray signs and more subtle clues for
spotting injuries are also described. Some specific injuries are discussed in the second part of the chapter,
including a section on paediatric injuries. Other imaging modalities, such as MRI, CT and ultrasound, have an
important role in trauma, and so are mentioned when relevant.

X‐ray appearances of fractures

In most cases, a fracture is visible because there
is a radiolucent (dark) line running through the
bone. The bony fragments on either side of
the fracture separate, leaving a less dense gap
between them. This is often accompanied by
some change in the normal alignment at the
fracture site (displacement) (Figure 2.1). When
a fracture is undisplaced, the line of the fracture
may be less easy to see (Figure 2.2).
If the fragments are not separated or
separation is obscured by the projection of
the X-ray, the only sign of a fracture might be
a subtle step or irregularity of the bony cortex
(Figure 2.3). The cortex normally has a smooth
contour, and it is important to follow this closely
around the margin of each bone looking for any
step or discontinuity.
If the bone fragments are impacted rather
than separated, the fracture may show as a
band of increased density. This is because the
amount of bone per unit volume is doubled at
the site where the two fragments have been
forced into each other (Figure 2.4). A similar
increase in density will also occur where
fragments are overlapping due to the
projection, rather than impacted.
Also, localised swelling of the soft tissues
may be visible on the X-ray, adjacent to a recent Figure 2.1 Fracture of the distal humerus. Signs: Deformity of the
injury. The skin contour over the fracture site is bone due to displacement at the fracture site. The darker fracture
displaced by the swelling (Figure 2.5). Swelling line (orange) interrupts the dense bone structure.

Musculoskeletal X-rays for Medical Students and Trainees, First Edition. Andrew K. Brown and David G. King.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
24   Pathology

Figure 2.2 Undisplaced fracture of the radial styloid process. Signs: The normal shape of the bone is preserved, but a subtle
less dense, that is dark, fracture line (orange) can be seen separating the radial styloid from the rest of the bone.

Figure 2.3 Minimally displaced fracture of the radial neck. Signs: The cortex normally has a smooth contour. Carefully
following the cortex around the margin of the radius (yellow) reveals a small step just distal to the head.
 Trauma   25

Figure 2.4 Minimally displaced fracture of the neck of the femur. Signs: Increased density partially crossing the femoral
neck due to impaction at the fracture site (orange) and steps in the cortex medially and laterally (yellow).

Figure 2.5 Soft tissue swelling overlying an undisplaced transverse fracture of the lateral malleolus (orange). The localised
swelling is best appreciated by looking at the silhouette of the skin surface against the darker surrounding air (green).

of the soft tissues can occur in the absence of a fracture and therefore it is a secondary sign; nonetheless, it
can be a useful clue pointing to an abnormality at the corresponding site.

Osteochondral fractures
The term ‘osteochondral fracture’ is used when there is a fracture of part of a joint surface. The injury involves
an area of articular cartilage and the attached underlying bone. These injuries are caused when bone on one
side of a joint impacts against the opposite side. When any injury involves a joint, it is important to look closely
at the articular surfaces as osteochondral fractures are often subtle. Cartilage is not visible on X-rays, but the
26   Pathology

Figure 2.6 Osteochondral fracture of the lateral corner of the dome of the talus. Signs: Following the outline of the
articular surface reveals an interruption in the cortex (yellow) and a small fragment of calcium density (green). This is slightly
displaced and projected within the joint space. Fractures of the medial or lateral corner of the dome of the talus are
relatively common but easy to miss on X-rays. In fact, one‐third of fractures are not visible on initial X-rays. It is important to
look closely at the dome of the talus in any patient with an ankle injury.

attached piece of bone from the articular cortex can be seen, often visible as a thin flake (Figure 2.6). It may be
undisplaced or lie away from the ‘donor’ site elsewhere in the joint. For example, in the knee it may come to
rest in the medial or lateral recess of the suprapatellar pouch. The bony component of the osteochondral
fragment has a smooth, rounded articular surface on one side and an irregular uncorticated appearance on the
surface which has fractured. Make a careful search for (i) any displaced intra‐articular fragment and (ii) a defect
in the articular cortex of the joint. Although the visible bony part of the fragment often appears small, there
will be a larger attached articular cartilage component. As damage to a joint surface has long‐lasting sequelae
in terms of pain and stiffness, an apparently small fragment may have considerable significance.

Avulsion fractures
If a soft tissue structure is put under sufficient tension, it may either rupture or pull off a fragment from its
bony attachment, that is an avulsion fracture. Therefore, avulsion fractures only occur at the insertions of
ligaments, tendons, muscles or joint capsule. It is helpful to consider which soft tissue attachment is involved
when looking at the X-ray (Figure 2.7).

Stress and insufficiency fractures

Although most fractures are caused by a single traumatic incident, a stress fracture can occur when a lesser
degree of force is applied repeatedly. For example, stress fractures may be seen in the tibial shaft in sports
which involve running; the pars interarticularis of the lumbar spine in fast bowlers; and the third metatarsal
in people who undertake an unaccustomed amount of walking (Figure 2.8).
Stress fractures occur when repeated forces on the skeleton are abnormally high although the underlying
bone strength is normal. However, if the skeleton is subjected to a normally tolerable force but the bone
strength is low and a fracture occurs, this is known as an insufficiency fracture or a fragility fracture
(Figure 2.9). This situation is most commonly seen in patients with osteoporosis.
 Trauma   27

Figure 2.7 Two avulsion fractures are visible on the AP view of this adolescent patient’s knee. The fragment coloured green
is a fracture of the tibial eminence, avulsed by the anterior cruciate ligament. The fragment coloured orange is an avulsion
of the tibial cortex by the attachment of the lateral joint capsule. Although this lateral injury looks innocuous, it has a
strong association with ACL and meniscal tears and is named a Segond fracture.

Figure 2.8 A typical stress fracture of the distal shaft of the index metatarsal. The fracture is undisplaced and no fracture line is
visible on the film, but its presence is shown by the callus which has developed on either side of the fracture site (orange).
28   Pathology

Figure 2.9 An elderly woman with back pain but no history of a specific injury. The film shows mildly and moderately
severe wedge fractures of two vertebral bodies (blue). The fractures do not show specific radiological signs to indicate that
they are fragility fractures. This comes from the history and exclusion of other causes.

Pathological fractures
The term ‘pathological fracture’ is generally used to describe a fracture caused by a focal lesion which
has weakened the structure of the bone. A common cause is destructive bony metastatic disease
(Figure 2.10), but pathological fractures also occur in association with benign lesions which weaken
the bone structure.

What is not a fracture

There are a number of things which appear on X-rays which might resemble a fracture but are not, so it is
useful to be aware of some of the more common pitfalls.
Accessory ossicles are a common normal variant. Characteristically they are small, rounded and lie adjacent
to joints. They differ from fracture fragments in that they have a smooth surrounding cortex which covers all
sides, whereas on a fracture fragment it is usually possible to find an area where the margin has a sharp, rather
irregular appearance and lacks an overlying cortex which corresponds to where it was previously attached to its
site of origin (Figure 2.11).
A skin crease projected over a bone may be visible on X-ray as a black line, similar to a fracture. However,
following the line along its whole length will usually show that it extends beyond the margins of the bone,
which could not be the case with a fracture (Figure 2.12).
Figure 2.10 A pathological fracture of the right ischiopubic ramus. There are two fracture lines (orange) across the bone,
but the underlying bone texture is also abnormal, with ill‐defined lucency extending from the acetabulum to the inferior
pubic ramus, due to the presence of a lytic metastasis (green). Compare the bone texture in this area with the normal
appearance in the rest of the image.

Figure 2.11 An accessory ossicle (blue) lying adjacent to the medial malleolus. Note that the ossicle is smooth and rounded
and has a complete surrounding cortex.

Figure 2.12 A soft tissue crease causing a dark line (blue) across the intertrochanteric region of the left femoral neck.
Initially, this might be mistaken for a fracture, but the line can be followed into the soft tissues beyond the margins of
the bone.
30   Pathology

Describing fractures
To communicate a clear picture of a bony injury to a colleague, it helps to have a mental list of the relevant
features which need to be evaluated and described:

Which bone has fractured?

Name the bone and include whether this is on the right or left side of the patient.
A letter ‘R’ or ‘L’ should always appear in the periphery of an X-ray to indicate the right or left side of the
patient. For example, Figure 2.13 shows a fracture of the right middle finger metacarpal. (Note: In this book,
the side markers are mostly cropped off the original images for reasons of space.)

The site of the fracture within that bone

In Figure 2.13, the fracture involves the proximal shaft of the metacarpal.
It is also important to note whether the fracture involves the articular surface of the bone. Any loss of the
normal smooth articular surface may result in secondary osteoarthritis, and therefore these fractures may
require different treatment to ensure very accurate reduction (Figure 2.14).

The number of fragments

Is it a simple two‐part fracture or is it comminuted? When multiple fragments are present, the term
comminuted or multi‐fragmentary is used (Figure 2.15).

The orientation of the fracture

The metacarpal fracture shown in Figure 2.13 is transverse. The orientation of a fracture can also be
longitudinal, oblique or, when a twisting force has occurred, spiral (Figure 2.16a–c).

Figure 2.13 Fracture site: There is a fracture of the proximal shaft of the middle metacarpal of the right hand (orange).
Figure 2.14 Articular surface involvement: This middle phalanx fracture extends into the proximal interphalangeal joint.

Figure 2.15 There are more than two bone fragments in this distal femoral shaft fracture, and therefore it is described as
comminuted or multi‐fragmentary.
32   Pathology

(a) (b)

(c)

Figure 2.16 Fracture orientation: (a) Longitudinal fractures – proximal phalanx. (b) Oblique fracture – tibia. (c) Spiral
fracture – tibia.
 Trauma   33

Displacement
When describing displacement, the position of the fragment distal to the
fracture site is always described. Determine how the alignment of this
fragment has changed from where it was before the injury, that is how
has it moved away from the normal anatomical alignment. The
‘anatomical position’ (Figure 2.17) is the standard starting point from
which any displacement is described.
Displacement can take the form of angulation, shift or a combination of
these. Angulation and shift can both occur laterally, medially, anteriorly or
posteriorly. There may also be proximal or distal shift. It is essential to look
at two X‐ray views at 90° to one another to appreciate displacement
properly as it may be hidden on a single projection (Figure 2.18a and b).
See example in Figure 2.19.
Similarly with dislocations, the position of the more distal of the bones
forming the joint is stated and the bone proximal to the injury is used as
the reference point (Figure 2.20).
In the case of dislocations, the name of the distal bone is often omitted.
For example at the shoulder there may be an “anterior dislocation” or a
“posterior dislocation” based on the position of the humeral head.
The term dislocation refers to a joint injury in which the two articular
surfaces are no longer in contact, whereas in the case of subluxation there
is contact between some part of the joint surfaces but the alignment is
abnormal.
Rotational deformity cannot be accurately shown by X-rays and should Figure 2.17 The anatomical position.
be assessed clinically. Also when describing a fracture it is important to
note if a fracture is open or closed, but again this is part of the clinical,
rather than radiological, assessment.
34   Pathology

(a) (b)

Figure 2.18 (a and b) Two views at 90° to one another are needed to detect injuries and also to evaluate displacement.
This proximal interphalangeal joint injury is difficult to appreciate on the AP view, but the lateral film clearly demonstrates
dorsal subluxation, with loss of congruity of the articular surfaces (blue). It also reveals the presence of a small fracture
fragment (orange).
 Trauma   35

Figure 2.19 A fracture of the distal diaphysis of the radius. Evaluating the films for displacement of the distal fragment, the
lateral view shows dorsal shift and the ‘AP’ view shows lateral shift and lateral angulation.

Figure 2.20 Dislocation of the elbow. Predominantly, the distal bones of the joint (radius and ulna) have moved posteriorly
from their normal anatomical position. Articular surfaces of the trochlea and olecranon are in blue. The injury could be
described thus: ‘The radius and ulna have dislocated in a posterior direction’, but this is usually shortened to, ‘There is a
posterior dislocation of the elbow’.
Exploring the Variety of Random
Documents with Different Content
knew human nature well enough to be sure that with a man behind her
whom she loved, Joyce would have felt her bond to the man whom she did
not love to be still more impossible. In such a case fidelity was no longer a
virtue but a crime.
But Bellendean had gone, and had not spoken. Mrs. Hayward had been
both angry and disappointed by this failure. She had blamed Joyce for it,
and she had blamed the Colonel for it. That a man should afficher himself
and then go away was a thing not to be endured, according to her ideas. And
now she was really sorry for Joyce, in both these aspects of her case. If
Joyce had but known how much her stepmother divined, all her troubles
would have been increased tenfold. But fortunately she did not know,
although the additional kindness of Mrs. Hayward’s manner gave her now
and then a thrill of fear.
She was walking with her father in the park one morning, not long after
these events. Winter was coming on with great strides, and the leaves fell in
showers before every breath of wind. Some of the trees were already bare.
Some stood up all golden yellow against the background of bare boughs,
lighting up the landscape. The grass was all particoloured with the
sprinklings of the fallen leaves. Under the hill the river flowed down the
valley, coming out of distances unseen. The Colonel and his daughter
paused at a favourite point of theirs to look at the prospect. The wide vault
of firmament above and the great breadth of air and space beyond were
always a refreshment and consolation. ‘O Thames! flow softly while I sing
my song,’ Joyce said, under her breath.
‘Eh?—what were you saying, Joyce?’
‘Nothing,’ she said, with a smile; ‘only a line out of a poem.’
‘Ah! you know so much more about books, my dear, than I have ever
done. You must get that turn in your education early, or you never take it of
yourself. I have never asked you, Joyce, though it has often been on the tip
of my tongue. How do you like the place, now you know it? I hope you like
your home.’
‘It is very—bonnie. I use that word,’ said Joyce, ‘because it means the
most. Pretty would be impertinent to the Thames—and beautiful——’
‘Do you think beautiful’s too much? Well, my dear, tastes differ; but I
never saw anything that pleased me like the course of the river and the
splendid trees. You should have lived in a hot climate to appreciate fully
English trees.’
‘Oh, but I do,’ cried Joyce. ‘They are finer than we have—in Scotland,’
she said, after a pause. It had been on her lips to say ‘at home.’
‘Much finer,’ said the Colonel, with conviction; ‘but that is not exactly
an answer to my question. I asked if you liked it—as your home.’
Joyce raised her eyes to him, moist and shining. ‘Father,’ she said, ‘it is
you who are my home.’
‘My love!’ the Colonel stammered and faltered, in unexpected emotion.
The water came to his eyes and blotted out the landscape. ‘You make me
very happy and very proud, Joyce. This is more, much more than I had any
right to.’ He took her hand in his and drew it within his arm. ‘I have
wanted,’ he said, ‘to surround you with everything that your poor mother
did not have—to make you happy if I could, my dear: but I scarcely
expected such a return as this. God bless you, Joyce! Still,’ said the
pertinacious inquirer, caressing the hand upon his arm, ‘that’s not quite
what I asked, my dear.’
Joyce had twice avoided the direct response he demanded. She paused
before she replied. ‘Some,’ she said, ‘father, are happy enough never to
need to think, or ask such a question. I wish I had been always where you
were, and never to have had any life but yours; or else——’ Colonel
Hayward fortunately did not remark these two syllables, which were softly
said, and breathed off into a sigh.
‘My dear,’ he said, ‘under the best of circumstances that could never
have been, for you know the most of my life has been spent in India. The
worst of India is, that parents must part with their children. We should not
really have known very much more of each other if—if you had been born,
as you should have been, in your father’s house.’
‘Then there is little harm done,’ said Joyce, this time with a smile.
‘Not if you trust us fully, my dear, and love your home.’ He patted her
hand again, then moved on unsatisfied. ‘I think, however, you are beginning
to like the people, and feel at home among them. And they like you. I am
sure they like you—and admire you, Joyce, and feel that you are—— There
is Lady St. Clair, my dear, with all her bevy of girls. You will want to stop
and speak to them. My wife says they’re the best people, but I’m not myself
very fond—— How do you do?’ cried the Colonel cheerily, taking off his
hat with a flourish. ‘Lovely morning! How do you do?’
The old soldier stood the image of good-humour and cheerful courtesy,
holding his hat in his hand. There were so many ladies to share his bow that
it was longer than usual, and gave the wind time to blow about a little the
close curly locks, touched with gray, which covered the Colonel’s head with
all the vigour of youth. His countenance beamed with kindness and that
civility of the heart which made the fact that he was not himself very fond
of this group inoperative. But when Lady St. Clair, picking her steps to the
other side of the road, delivered in return the most chilling of faint bows,
while her daughters hurried like a flock of birds across the park to avoid the
encounter, Colonel Hayward stood dumb with consternation in the middle
of the path. His under lip dropped in his astonishment, he forgot to put on
his hat. He turned to Joyce, holding it in his hand, with dismay in his face.
‘What—what,’ he cried, ‘is the meaning of that?’
‘Indeed I don’t know,’ said Joyce. She was not aroused to the importance
of the action. Unfortunately she did not care, nor did it seem to her that so
slight a matter was worth noticing. ‘They were perhaps in a hurry,’ she said.
‘In a hurry! They meant to avoid us. They would rather not have seen us.
What does it mean, Joyce? They consulted together, and the girls rushed
off, and their mother—I am utterly astounded, Joyce.’
‘But,’ said Joyce, very calmly, ‘if they did not wish to speak to us, why
should they? I do not think I care.’
The Colonel put on his hat. He had grown a little pale. ‘Elizabeth will
not like it,’ he said. ‘She will not like it at all. For a long time she would not
go into society, because of—— But now that she does she likes to know all
the best people. I am not myself fond of those St. Clairs. But any
unpleasantness, I am sure, would make her unhappy. Can I have done
anything, I wonder? I am a blundering old fellow,—I may have neglected
some etiquette——’
‘Perhaps it would be better to say nothing about it,’ said Joyce.
‘Much better!’ cried the Colonel. ‘That’s the right way—take no notice. I
am glad you are of that opinion. But I’m very bad at keeping a secret,
Joyce. Probably I’ll blurt it out.’
‘No, father. I will look at you when I see you approaching the subject,’
said Joyce. She was quite unconscious of any seriousness in the matter.
Lady St. Clair and her girls seemed incapable of any influence on her fate.
She even laughed, looking up at him with a lightness quite unusual to her.
‘It will be a little secret between us,’ she said.
‘So it will,’ said the Colonel, brightening; ‘but you must keep your eyes
upon me, Joyce. I never could keep a thing to myself in my life, particularly
from Elizabeth. But this cannot be of any importance after all, can it? No, I
don’t think it can be of any importance. Lady St. Clair may be vexed with
me perhaps for the moment. I may have done some silly thing or other. I
would not for the world have a secret from Elizabeth—but such a trifle as
this.’
‘It cannot be of the least importance,’ said Joyce. She was more
confident of being right than he had ever known her before.
‘Well, my dear: but you must keep your eyes upon me,’ Colonel
Hayward said.
He came back to the subject several times as they went on, and worked
out the shock, so that by the time they reached home, he himself had come
to regard Lady St. Clair’s incivility as a matter of little importance. ‘Perhaps
she had something on her mind, my dear; their eldest boy, I believe, gives
them a great deal of trouble. And I know they are not rich—and with that
large family. People are not always in the mood for a conversation on the
roadside. You are quite right, Joyce. I daresay it meant just nothing at all but
the humour of the moment. It will be a little secret between you and me—
but you must keep your eyes upon me. Give a little cough, or put your hand
up to your brooch, or some sign I shall know—for I am an old goose, I
know it: I can keep nothing to myself.’
When they reached home, however, the incident and the secret were both
forgotten in the surprise which awaited them. They found Mrs. Hayward in
the drawing-room entertaining Mrs. Bellendean. Joyce, though she had
always been more shy of her dear lady since she had discovered how much
Mrs. Bellendean’s behaviour to herself was influenced by her change of
circumstances, was startled out of all her preventions by this unexpected
visit. But the sight of the woman to whom she had looked up with such
sincere reverence, and admired before everybody in the world, was not now
to her so simple a matter as it had once been: after the first burst of pleasure
it was impossible to forget how closely associated she was both with the old
life and the new. And Mrs. Bellendean herself was changed. There were
lines of anxiety and care in her face. She was no longer the calm queen in
her own circle, the centre of pleasure and promotion she had once appeared
to Joyce. The peace of the old life was gone from her, and something of its
largeness and dignity. She talked of her present plans and purposes in such a
way that Joyce, though little accustomed to the subtleties of conventional
life, slowly came to perceive that the object of Mrs. Bellendean’s visit was
not that which it professed to be. She explained to them that she was about
to leave England with her husband for Italy, and that she had come to take
leave of her friends—but this was not all. Joyce’s training in the net-work
of motives which lie under the surface was very imperfect. She wondered,
without at all divining, what the other object was.
‘Things have changed very much since Bellendean ceased to be our
headquarters,’ she said with a smile which was not a very cheerful one.
‘You remember how much I threw myself into it, Joyce. After having
nothing particular to do, to come into that full life with so many things to
look after was delightful to me. But my husband never liked it,’ she added
quickly. ‘He dislikes the worry and the responsibility. He thinks it worry:
you know I never did.’
‘My friend Norman,’ said the Colonel, ‘will be lost without you. It must
have been such a thing for him.’
‘Oh, Norman has been very good.’ Lines came out on Mrs. Bellendean’s
brow which had not been there before. ‘You saw something of him during
the summer?’
‘Something—oh, a great deal! We got quite used to see him appearing in
his flannels. Fine exercise for a young fellow: It helped him to support
London,’ said the guileless Colonel. ‘I think he found us very handy here.’
‘Old fellows, I suspect, think more of exercise than young fellows,’ said
Mrs. Hayward; ‘and London is very supportable in Captain Bellendean’s
circumstances—but we did see a little of him from time to time.’
Joyce said nothing at all. She kept a little behind, away from Mrs.
Bellendean’s anxious eyes. She could not prevent the colour from
deepening in her face, or her heart from beating high and loud in her breast
—so loud that she felt it must be heard by others as well as herself, the most
distinct sound in the room.
‘He has not been here very lately, I suppose?’ Mrs. Bellendean said.
‘Oh no, not since August—when he came to bid us good-bye.’
 ‘As I am doing now,’ said Mrs. Bellendean. She could not see Joyce,
who was behind her, but she was noting, with the intensest observation,
every movement and word. She was on a voyage of discovery, not quite
knowing what she expected, almost too eager to distinguish what she
imagined from what she saw.
‘Shooting, I suppose,’ said the Colonel. ‘I hope he has had good sport.
There was some talk of his coming back, but I never expected him for my
part, until the moors began to pall; and that doesn’t happen soon, your first
year at home. You preserved, of course, at Bellendean.’
‘There are always plenty of partridges—nothing more exciting. He has
been up in the Highlands, coming and going. I think he has thoroughly
enjoyed himself—as you say, the first year at home.’
These words were all very simple and natural; but there was a little
emphasis here and there, which betrayed a meaning more than met the ear.
Joyce felt them fall upon her heart like so many stones, thrown singly,
resolutely, with intention. It had never occurred to her before that any one
could wish to give her pain: and that her own lady should do it—her model
of all that was greatest and sweetest! The cruel boys throw stones at
wounded, helpless things. She remembered suddenly, with that quickness of
imagination which enhances every impression, a scene which detached
itself from the past—a boy in the village aiming steadily at a lame dog, and
how she had flung herself upon him in a blaze of indignation, to his
supreme astonishment. Why this should come into her head she could not
tell. The dog could yelp at least, but Joyce could not cry out. It seemed to
her that it was Mrs. Bellendean, in her mature, middle-aged beauty, tall,
dignified, and serene, who stood and took aim. It was all new to Joyce—the
covert blow, the deliberate intention, the strong necessity of keeping still,
uttering no sound, giving no look even of consciousness. Nothing in her
past experience had prepared her for this.
‘I have more sympathy with your plans than with Captain Bellendean’s
amusements,’ said Mrs. Hayward. ‘Sport’s monotonous, at least to women
who only look on. But to get away for the winter is always delightful. Oh,
not to you, Henry, I know! You like your walks. And he tells me it is so
English, so like home. Very English indeed, and pleasant, for girls who
skate, and all that; but when one begins to get old and go about in a shawl!’
 ‘I would willingly compound for the shawl,’ said the visitor. ‘It is cold
enough at Bellendean; but there one had both duties and pleasures. I hate to
be one of a useless crowd, drifting about pleasure-places. When it’s health it
is dismal enough; but at least there is some meaning in that.’
‘Oh, there is a great deal of meaning in being warm,’ cried Mrs.
Hayward, with a little shiver, ‘in seeing sunshine and the blue sky instead of
universal greyness and fogs. The Colonel takes a pleasure in it, even in east
wind; but so do not I.’
‘My dear,’ cried Colonel Hayward anxiously, ‘if you really do feel so
strongly about it, you don’t think that I would ever object? I like my own
country, I confess; and to understand what everybody’s saying—but if you
feel the cold so much——’
It was not much wonder that he should not understand; but Joyce, for
whom the thing was done, knew almost as little as he did that this diversion
was for her benefit. A half-forlorn wonder arose in her mind that so much
useless, aimless talk should mingle with the torture through which she was
going. Better that the stones should all be thrown, and the victim left in
peace. But this was not how it was to be. The gong sounded, beaten by
Baker’s powerful hand, and the little procession went in to luncheon. Joyce
had to expose her face, with all its clouds, the burning red which she felt on
her cheek, the heavy shadow about her eyes, to the full daylight and Mrs.
Bellendean’s searching gaze. Nobody could help her now.
 CHAPTER XXXIX
‘At last I can get a word with yourself, Joyce!’
Mrs. Bellendean led her out under the verandah to the garden path
beyond with an anxiety and eagerness which startled Joyce. She half
enveloped the girl in the warmth of her cloak and of the caressing arm
which held hers. It was a caressing hold, but very firm, not leaving any
possibility of escape. More than an hour had passed slowly in the usual
vague interchanges of drawing-room conversation, when there is nothing
particular to talk about on either side; but the visitor had said nothing about
going—had not even mentioned, as such visitors are bound to do, the train
by which she intended to leave. She had kept a furtive watch upon Joyce,
following all her movements, but she had not transgressed against decorum
and domestic rule by asking to speak with her alone. Accident, however,
had done what Mrs. Bellendean did not venture to do. Mrs. Hayward had
been called away for some domestic consultation, the Colonel had gone out,
and Joyce was left with her visitor alone.
‘Are you afraid of the cold?—but it isn’t cold—and I do want to say a
dozen words where no one can possibly hear. Joyce, my dear girl, do let me
speak to you while there is time. Joyce—I don’t know how to open the
subject—I would not venture if I were less anxious. Joyce, you heard what I
was saying about Norman, my stepson?’
‘Yes.’ Joyce did not look up, nor did she feel herself able to say more.
‘You used to be—devoted to me, Joyce; as I always was very fond of
you. A little cloud has come between us somehow—I can’t tell how—but it
has made no difference to my feelings.’ Mrs. Bellendean was a little short
of breath. She paused, pressing Joyce’s arm with hers, leaning over her,
with anxious eyes upon her face. But something prevented Joyce from
making any response—that cloud was still between them, whatever it was.
‘You know very well the interest I have always taken in you from the
very beginning, before any one suspected—— And Greta—Greta was
always fond of you. You have not met much lately.’
‘No.’ Nothing would come but monosyllables.
 ‘I want to speak to you of Greta, Joyce. She is younger than you are,
though you are young enough. She has never been crossed or disappointed
in her life. I can’t think of that for her without a shudder. She would die. It
would break her heart.’
‘What?’ said Joyce.
‘Joyce, I am going to take you into our confidence—to tell you our
secret; you will never betray us. If things should happen so that what we
wish never came to pass, you would not betray us?’
For the first time Joyce raised her eyes to Mrs. Bellendean’s face.
‘I know—I know—I never doubted for a moment. It will rest with you to
decide. Joyce, you have got Greta’s life in your hands.’
‘I! in my hands.’ She looked up again into the face which was bending
so closely with such an anxious look over hers. The lace of Mrs.
Bellendean’s veil swept her forehead. The breath, which came so quick,
breathed upon her cheek.
‘Joyce,’ said the lady again, ‘I know that it was not a little that you saw
Norman. I know that he was here day after day. I know that he was—in love
with you.’
Joyce detached herself suddenly from that close enlacement. She drew
her arm away, shook off the draperies which half enveloped her. ‘I do not
think you have any right—to say that to me,’ she said.
‘If I did not know it to be true—and you know it’s true. He came here
day after day till he imagined—he was in love with you. And then he came
to Bellendean. All this time he has been seeing Greta every day. He has
made her believe that it is she whom he loves.’
The heart of Joyce gave one bound as if it would have burst out of her
breast.
‘And she believes it,’ said Mrs. Bellendean. ‘She is a tender little flower;
she has never been crossed in her life. She believes that it is she whom he
loves—and she loves him.’
There was a momentary silence, complete and terrible. A little gust of
wind burst forth suddenly, and sent a small shower of leaves at their feet.
They both started, as if these had been the footsteps of some intruder.
‘It has always been our desire:’—the visitor began again in a low voice,
as if she were afraid of being overheard—‘everybody has wished and
expected it. They suit each other in every way. She has been brought up for
him. She has always thought of Norman all her life. Poor little Greta! she is
so young—not strong either; her mother died quite young. And she doesn’t
know what disappointment is. We are all to blame; we have petted her and
made her think there was nothing but happiness before her. And she was
always fond of you, Joyce. You, too’—Mrs. Bellendean added, after a pause
—‘you were devoted to her.’
Joyce’s voice sounded harsh and hoarse. After the silence it came out
quite suddenly, all the music and softness gone out of it: ‘What have I to do
with all this? What has it to say to me?’
‘Joyce! do you think I would come to you without strong reason—
betraying Greta?’
‘This has nothing to do with me,’ said Joyce again.
‘It has everything to do with you. So long as he has been at home all has
been well. He has seen her every day. He has got to appreciate her, and to
see that she is the right wife for him, his own class, his own kind, fit to take
her place in the county, and help him to his right position. But he is coming
up to town. He will be coming here,’ said Mrs. Bellendean, putting her hand
again upon the girl’s arm. ‘Oh, Joyce, Joyce——’
‘I have nothing to do with it,’ said Joyce. ‘What—what do you think I
can do?’
‘He—can be nothing to you,’ said the visitor tremulously. ‘You—you’re
engaged already. You’ve given your word to a—good respectable man.
Norman is only a stranger to you.’
Joyce did not reply. She drew herself away a little, but could not escape
the pressure of that eager, persuasive hand.
‘I understand it all,’ said Mrs. Bellendean. ‘He is not clever, but he has
the manners of a man that knows the world, and he has been very much
struck with you. And you have been—flattered. You have liked to have him
come, even though he could never be anything to you.’
She had got Joyce’s arm again in her close clasp, and she felt the strong
pulsations, the resistance, the movements of agitation, which, with all her
power of self-control, the girl could not restrain.
‘Oh, think, Joyce, before it goes any further! Will you for simple vanity
—or like one of the flirts that would have every one at their feet—will you
break Greta’s heart, and make a desert of both their lives? All for what?—
for a brag,—for a little pleasure to your pride,—for it can be nothing else,
seeing you’re engaged to another man!’
The woman was cruel, remorseless,—for she felt Joyce’s arm vibrate in
her clasp, which she could not loosen,—and thus commanded her secrets,
and forced her to betray herself. The girl felt herself driven to bay.
‘I don’t understand—the things you say,’ she answered slowly at last.
‘You speak as if I had a power—a power—that I know nothing about. And
oh, you’re cruel, cruel! to put all that in my mind. What—do you think I can
do?’
‘Oh, Joyce, I knew you would never fail me. You have such a generous
heart. Let him see, only let him see, that between him and you there can be
nothing. He will accept it quickly enough. A man’s pride is soon up in arms.
It has only been a passing fancy, and he will soon see that everything is
against it; while everything is in favour of the other. If you will only be
firm, and let him see—oh, Joyce, you who are so clever! dear Joyce!’
Joyce’s heart swelled almost to bursting. ‘You call me clever, and dear,’
she cried; ‘and you tell me I must save Greta’s heart from breaking; but
what if I were to break mine,—and what if I were to hurt his,—and what if I
were to make three miserable instead of one? You never think of that.’
‘No,’ cried Mrs. Bellendean, with a tone of indignation; ‘because I
would never do you that wrong, Joyce,—you that are honour itself and the
soul of truth,—to believe that you had even a thought of Norman, being
engaged to another man.’
Joyce shrank as if she had received a blow. ‘Oh,’ she cried, in a broken
voice, ‘you never ceased to say that I had done wrong—that it was not a fit
thing for me—that I would change, that I would find it not possible to keep
my word. You said so—not I.’
‘My dear! my dear!’ cried Mrs. Bellendean.
‘No,’ said Joyce, ‘don’t call me so. I am not dear any more. You know
that there was a time when Joyce would do what you said, if it was small or
great, if it was to give you a flower or to give you her heart; and then you
changed, and that ceased to be; and we got all wrong because I was Colonel
Hayward’s daughter. And now you come and put me back again in my old
place, but far, far lower—the girl engaged to Andrew Halliday, whom you
never could bear to hear of—and bid me do what may be, perhaps, for all
you know, a heartbreak to me——’
‘No, Joyce—no, dear Joyce!’
‘For what?’ she said sadly—‘that you may call me that—you that raised
me up to your arms, for being not myself but my father’s daughter—and
now drop me down, down again, for fear I should come in your way. And
why should I break my heart more than Greta? why should I be
disappointed and not she? why should I give up my hope to save her—if it
was so?’
‘But, Joyce, Joyce!—it is not so!’
Joyce made no reply.
The two figures moved on together slowly in silence, with the autumn
leaves dropping over them, and the afternoon growing grey. Mrs.
Bellendean felt upon her arm the strong beating of the girl’s heart, and the
tremor that went through her; and her own heart smote her for what she was
doing: but not for so little as that did she give up the work which was
already more than half done. She followed all the movements of the girl’s
mind with an extraordinary sympathy, even while she set herself to the task
of overcoming them; for she was not the less fond of Joyce, and scarcely
felt with her less, for this determination to subdue her. She was conscious of
the commotion, the revolt, the sense of personal wrong, yet underneath all
the strong fidelity and loyalty of the spirit over which she was exercising a
tyrannical power. She let her own influence work in the silence, without
saying a word, with an assurance of victory. The only thing that lessened
the cruelty of the undertaking was that she did not really know whether
Joyce’s heart was or was not engaged—even now she could not fathom that
—but was able to persuade herself that the girl’s protest was one of
indignation only, not of outraged love; and that the sacrifice, if she made it,
would only be a sacrifice of her pleasure in a conquest and of her vanity,
not of any real happiness or hope.
Mrs. Bellendean’s confidence was justified. After a minute or two, which
had seemed hours, Joyce spoke again. ‘There is no need to tell you,’ she
said, very low, so that the lady had to stoop to hear her—for Joyce’s head
was bent, and her voice scarcely audible—‘there is no need to tell you—
that as far as in me lies I will do what you say.’
‘My dearest, kind girl—my own Joyce!’
 ‘No,’ she said, with a shudder, drawing away her arm, ‘not that—never
that. It is all changed and different, Mrs. Bellendean. I am not even Joyce,
your schoolmistress, that was so proud to please you; but in another parish,
with another name—as you think best for me.’
‘Oh, Joyce,’ said Mrs. Bellendean, with real pain, ‘don’t say that! I only
think so because you yourself thought so; and with your father’s help and
that of your friends, it need not be another parish, nor any parish. He is a
most respectable, clever man. We will find him something far better,
something more worthy of you.’
Joyce said nothing more. She turned round and led the way back to the
house, keeping apart from her companion, walking with a new-born dignity
and pride. There was not another word said as they returned to the
verandah, from which Mrs. Hayward was looking out, looking for them.
She had a shawl wrapped close round her, yet shivered a little in the early
falling twilight. ‘You will both get your death of cold,’ she cried. ‘Come in,
come in, and have some tea. Joyce, you really carry rashness too far: you
must be chilled to death.’
‘I am afraid it is my fault,’ said Mrs. Bellendean. ‘I forgot she had no
wrap. It was such a pleasure to have a little talk with her’—the lady
hesitated for a moment, then added with a tremble in her voice—‘as in the
old days.’
As in the old days!—a pleasure to talk! ‘Yes, it is very cold,’ said Joyce,
holding her hands to the fire. She stood up there, a dark shadow against the
warm glow. A strange fascination kept her in the presence of the woman
whom she had so loved, who had turned her love to such account. She stood
there without moving, trembling with the cold, and something more than
the cold. So long as these entreaties were not repeated here! so long as her
step-mother was not taken into the lady’s confidence too. Nothing was
further from Mrs. Bellendean’s mind. She took with pleasure the warm cup
of tea, which, and the warm air of the fire-lighted room, brought back a
genial heat all over her. She was a little tremulous, yet satisfied, feeling that
she had done all for which she had come. And no harm had been done to
Joyce—no harm. She wished the girl would not stand there, cold,
reproaching her by the silent shiver with which she held her hands to the
fire. But that was all. What is a little cold at her age?—no more than the
little puncture of her vanity, the little salutary wound which was all, Mrs.
Bellendean persuaded herself, that she had given.
‘It was foolish of me to forget that Joyce had no shawl. She has always
been so hardy, I hope it will not matter. It is such a long time since I have
seen her.’ It seemed impossible to change the subject, to get out of these
banalités which meant so much worse than nothing, which conveyed so
false a sense to Joyce’s keen ear. Mrs. Bellendean was embarrassed, but she
was not conscious of being false. She added, ‘And it will be a long time
before we meet again. I shall have to try and dismiss all my anxieties about
my friends from my mind. Joyce is one whom I can always trust not to
misunderstand me, not to forget anything,’ Mrs. Bellendean said.
Joyce heard everything, even the rustle of Mrs. Bellendean’s gown, the
movement of her arm as she lifted her teacup to her lips, but could not
move or say a word. She stood still, warming herself, while the two ladies
carried out the usual little interchange of nothings. All they said entered into
her brain, and remained in her memory like something of importance. But it
was of no importance. Presently Mrs. Bellendean remembered that she must
go by a certain train, and a cab had to be sent for. There was a little bustle of
leave-taking. Joyce felt herself enclosed in a warm embrace, tenderly
kissed, still more tenderly said farewell to. ‘I don’t say, Remember, for I am
sure you will not forget me, Joyce,’ were Mrs. Bellendean’s last words, ‘nor
what I have said.’ But to this also Joyce replied nothing.
‘I thought she was never going away,’ said Mrs. Hayward. ‘She must
have had something very particular to say to you, Joyce.’
Joyce was walking across the hall towards the stair without any
response. Mrs. Hayward stood still under the light and cried impatiently,
‘You don’t seem to have heard me. You look dazed. What had she to say to
you, Joyce?’
Joyce turned half round, holding by the banister of the stair. She said,
‘Nothing—it was I myself——’ then paused. ‘She was telling me about
Greta. Greta—has never been disappointed—not like—like other folk.’
‘Never disappointed!’ cried Mrs. Hayward. ‘Do they think she can get
through life like that? And was this all Mrs. Bellendean came to say? I think
she might have saved herself the trouble. I would let Miss Greta look after
her own affairs.’
 CHAPTER XL
Never had been disappointed—never crossed!
Perhaps that is as real a claim upon human compassion as is the claim of
the long-suffering and much-tried. Perhaps it is even a stronger claim. It is
the claim of a child. Who would be the one to open the doors of human
trouble to a child?—to give the first blow?—to begin the disenchantment
which is the rule of life? People get used to disappointments as to the other
burdens of human existence; but to snatch the first light away and replace it
by darkness, who would do that willingly? to change the firmament and
eclipse the sunshine, where all had been brightness and hope! There had
been a sombre anger roused in Joyce’s heart by that appeal. She had said,
Why should one be spared by the pain of another? Why should her heart
break, that Greta’s should be saved from aching? But she no longer asked
herself that question. She said to herself that it was just. There are some that
must be saved while the others go bleeding. It is the rule of life—not
justice, perhaps, but something that is above justice. Some must have
flowers strewn upon their path, while others walk across the burning
ploughshares. There was no reason in it, perhaps, no logic, but only truth:
for some object unknown, which God had made a law of life. Greta had
been the idol of her family all her life. Everybody had loved her, and cared
for her. She had been sheltered from every wind that blew. Joyce was only a
little older, but already had passed through so many experiences. She knew
what it was to be disappointed, to have all her dreams cut short, and the
current of her being changed. Another pang to her, who was accustomed to
it, would not be half so much as the first pang of wounding misery to Greta.
Poor little Greta! fed on the roses, and laid in the lilies of life, to give her all
at once the apples of Gomorrah, to wrap her in the poisoned robe. Oh no!
oh no! It was a just plea. Let the heart that is used to it go on breaking; let
the child’s heart go free.
Joyce’s room was the one full of thoughts in the middle of that peaceful
house. In all the others was the regular breathing of quiet sleepers—the rest
of the undisturbed. She alone waked, with her little light burning, throwing
a faint gleam across the invisible river-banks, on the dark stream floating
unseen. Had there been any wayfarer belated, any boat floating down-
stream, the gleam from that window would have given cheer in the middle
of the darkness and night. But there was not much cheer in it. The room it
lighted was full of thoughts and cares, and sheltered a human creature
facing a sea of troubles, doing her best to keep afloat—sometimes almost
submerged by these rising waves: and there is this additional pang in the
troubles of a woman—of a girl like Joyce—that there is no motive to strive
against them. The Hamlets of existence have a great life and great
possibilities before them; but what profit is there to the world in one poor
girl the more or less? If she is glad or sad—a victim or a conqueror—what
matter? Her poor old people were separated from her. They would never
know. Her father would not suffer, and no one else in the world would care.
There was no mother, no sister, to wish her woes their own—not even a
friend—not a friend! for Mrs. Bellendean and Greta were those who had
been most dear. There would be some use in her suffering, but none in her
happiness—none at all: rather evil to all concerned. A selfish good
purchased by others’ disadvantage. No good—no good to any one in the
world.
Joyce said to herself, in her profound discouragement, that after all Mrs.
Bellendean’s prayer had made no change in anything. She had already made
up her mind. Happiness was a very doubtful thing in any case, everybody
said. It was not the end of existence, it was a chimera that flew from you the
more you sought it. But your honour was your life. To be faithful and true,
to be worthy of trust, to stand to your word whatever happened, that was the
best thing in the world, the only thing worth living and dying for. Even if
you could not keep your word to the letter, she said to herself with a
shudder, at least to do nothing against it, not to contradict it before earth and
heaven! No human creature but can do that. She would never, never turn her
back upon her pledge. What was the need of invoking another motive, of
adjuring her by Greta’s happiness, by Norman’s advantage? This was only
to irritate, to import into the question a sense of injustice and wrong. It had
been decided before there was a word of all that. Everything that Mrs.
Bellendean had said had been an irritation to Joyce. To take it for granted
that her happiness should yield to that of Greta,—that Norman’s interests
should be considered before hers,—that she would be a burden, a
disadvantage to Norman, while Greta would be nothing but good and
happiness:—and finally to thrust her back to what they considered her own
place, into the arms of the man whom they all had thought unworthy of
Joyce in Joyce’s humblest days,—to thrust her back into his arms, to speak
of promotion for him, of humble advancement, comfort which would make
him a match for her!
Mrs. Bellendean’s appeal had only brought a succession of irritations,
one more keen than the other. Joyce felt herself angered, wounded, driven
to bay. She had not needed any inducement to do what she felt to be right;
but now it required an effort to return to the state in which she had been
when she had renewed her pledge and promised to keep to her word. She
would stand by that resolution whatever might be said; but she was angry,
offended, wounded, in her deepest heart. Her friends, her own friends, those
who were most dear, had torn away all veils from the helpless and shrinking
soul. She had been Joyce, their handmaiden—oh, eager to do their will;
ready to spend her life for them, in proud yet perfect humility. And then
they had lifted her up, called her their equal, pretended to treat her as such,
because of the change—though there was no change in her. And yet again,
last phase of all, they had flung her down from that fictitious position, and
shown her that to them in truth she never had been more than a
handmaiden, a being without rights or feelings, born only to yield to them.
And these were her dearest friends, the friends of her whole life, whose
affection had elevated her above herself! Joyce hid her face, that she might
not see the thoughts that rent her heart. Her friends, her familiar friends, in
whom she had trusted; her dear lady, who had been to her like the saints in
heaven; her Greta, whom she had thought like an angel. They had betrayed
her, and after this, what did it matter what man or woman could do?
The night was half over before the little light in the window disappeared
from the darkling world through which the Thames flowed unseen. It
disappeared, and all was black and invisible, the dark sky and the darker
earth lost in the night and the blackness of the night and its silence. No such
watch had ever been kept in that peaceful house before.
Next morning, when Joyce came downstairs, looking very pale and
sleepless, with dark lines under her eyes, she found her stepmother standing
in the hall, turning over a letter, with great surprise in her face. ‘It is
inconceivable,’ she was saying.
‘It must be a mistake,’ said the Colonel; ‘depend upon it, it must be a
mistake.’
 ‘To ask you and me and not Joyce,—I cannot understand it. Can Joyce
have done anything to offend them? Why should I be asked to a ball but for
Joyce? We are not dancing people, you and I. I might have gone for Joyce,
and Joyce is left out. What can it mean? She must have done something to
offend them.’
‘That reminds me, my dear.’ said the Colonel, ‘of something that
happened yesterday. We met the St. Clairs, that huge regiment. I took off
my hat—oh!’ said the Colonel suddenly, beholding Joyce with her finger
up, standing behind Mrs. Hayward.
‘What do you mean by breaking off like this?’ What happened?’ cried his
wife.
‘Oh, nothing, nothing, my dear,’ said the veteran, with confusion and
dismay.
‘Nothing, Henry? you change your tone very quickly. You spoke as if it
had some bearing upon this strange invitation, which wants explanation
very much.’
‘No, my dear, no. I was mistaken; it couldn’t have anything to do with
that. In short, it was nothing—nothing—only a piece of nonsense—one of
my mistakes.’ He looked piteously at Joyce, standing behind, who had
dropped her hand, as if abandoning the warning which she had given him.
Joyce, in the extremity of her trouble, had fallen into that quiescence which
comes with the failure of hope. She remembered the bargain that had been
made between them at the instant, but that and everything else seemed of
too little importance now to move her beyond a moment. Mrs. Hayward,
however, turned round, following her husband’s look.
‘Oh, it is you, Joyce! You wish your father not to tell me.’
‘The fact is,’ said the Colonel, eager to speak, ‘we thought it might
annoy you, Elizabeth.’
‘You are taking the best way to annoy me,’ she cried. ‘What is this you
have been making up between you? Henry, I have a right at least to the truth
from you.’
‘The truth!’ he said; ‘surely, my dear, the truth, if it was of any
consequence. Joyce will tell you what happened. It was of no importance.
Most likely Lady St. Clair is short-sighted. Many ladies are, you know.
Most likely she didn’t make out who we were. That was your opinion,
Joyce, wasn’t it?’ The Colonel felt that the best thing he could do, as Joyce
did not help him out in safety, was to drag her into her share of the danger.
‘There might be many reasons. I did not think it mattered at all,’ said
Joyce.
‘Reasons for what?’ said Mrs. Hayward, stamping her foot on the
ground. ‘I think between you you will drive me mad.’
‘My dear! for nothing at all, Elizabeth. She scarcely returned my
salutation. The girls all scuttled off across the park like so many rabbits.
They are not unlike rabbits,’ the Colonel said, with an ingratiating smile.
‘But we agreed it was of no importance, and that it was useless to speak to
you of it, as it might annoy you: we agreed——’
‘You agreed!’ Mrs. Hayward gave Joyce an angry look. ‘I wish in such
matters, Henry, you would act from your own impulse, and never mind any
one else.’ She swept in before the others into the dining-room, where it was
the wont of the household that the Colonel every morning should read
prayers. But it is to be feared that these prayers were not so composing to
the soul of the mistress of the house as might have been wished. ‘We
agreed’—these words kept ringing through the devotions of the family, as if
some sprite of mischief had thrown them, a sort of demoniac squib or
cracker through the quiet air. To have her husband consult with his daughter
as to what should or should not be told to her was more than she could bear.
Mrs. Hayward went out in the afternoon alone to make a call at a much
frequented house, where she hoped to discover what was the cause of Lady
St. Clair’s rudeness and Mrs. Morton’s strange invitation. She met a great
many acquaintances, as was natural in a small place, where all ‘the best
people’ knew each other. Among them was Lady St. Clair, who, instead of
avoiding her as she had done the Colonel, came forward with empressment,
showing the most sympathetic civility. ‘How are you, dear Mrs. Hayward? I
hope you are well. I do hope you are bearing—the beginning of the severe
weather,’ that lady said, shaking her hand warmly, and looking with tender
meaning in her eyes.
‘I don’t pay much attention to the weather, thank you,’ said Mrs.
Hayward, ‘and we can’t complain of it so far. I am glad to see you so well.
My husband thought he saw you yesterday, and that you were put out about
something.’
 ‘Put out! I did see Colonel Hayward,’ said Lady St. Clair, with dignity;
‘but I am sure you will understand, dear Mrs. Hayward, that charming as he
is, and much as we all like him, there are circumstances——’
‘Circumstances!’ cried Mrs. Hayward. ‘I don’t know indeed any
circumstances which can possibly affect my husband. None, certainly, that
don’t affect me.’
‘Oh, we all feel for you,’ said the leader of society, pressing Mrs.
Hayward’s hand.
She had to pass on, fuming with indignation and astonishment, and next
minute it was her fortune to meet the lady who had sent her the invitation of
the morning: for Mrs. Hayward had by chance stumbled into a tea-party
specially convoked for the purpose of talking over the last great piece of
news. Though she had as yet no clue to what it was, she felt there was
something in the air, and that both in the salutations and the silence of those
about her, and the evidently startling effect of her unexpected appearance,
there was a secret meaning which was at once perplexing and exasperating.
The mere fact of a tea-party of which she knew nothing, in a house so
familiar, was startling in the highest degree. She went up eagerly to Mrs.
Morton, with a belligerent gaiety. ‘How kind of you,’ she said, ‘to ask me to
your ball, the Colonel and me! It is very flattering that you should think me
the young person—unless it was all a mistake, as I am obliged to believe.’
‘Oh, no mistake,’ said the lady, a little tremulous. ‘I hope you can come.’
‘I—come? But you must be laughing at me,’ cried Mrs. Hayward, with a
little burst of gaiety. ‘Of course I go everywhere as Joyce’s chaperon: but to
ask me, at my age, to a dance! My dear Mrs. Morton, you must think me an
old fool.’
‘Oh, indeed, I should have liked to ask—indeed, if it hadn’t been for
what was said,—but I hope, I do hope you will come. I am sure I did not
mean any—any disrespect——’
‘Disrespect! oh, flattery I call it! to think a dance was just the thing for
me. My step-daughter will be asked to the dinner-parties, I suppose, now
that it is evident the balls are for a young creature like me.’
This lady, who could not conduct matters with so high a hand as Lady
St. Clair, slid away behind backs, and concealed herself from those severe
yet laughing looks. She had thought it would please Mrs. Hayward to be the
one chosen, while the other was left out. Presently Mrs. Hayward fell into
the hands of the lady of the house, who led her aside a little. ‘I am so glad,’
said this friendly person, ‘to see you here by yourself. It is so lucky. Of
course I should have asked you to come if it had not been—many of us, you
know, don’t think we would be doing right if we were to countenance——’
‘To countenance—what?’ Mrs. Hayward grew pale with astonishment
and wrath.
‘But I assure you,’ cried this lady, ‘no one blames you. We quite
understand how you have been led to do it to please him and for the sake of
peace. We don’t think one bit the less of you, dear.’
‘The less—of me!’
‘Rather the more,’ said the mistress of the house, giving her bewildered
guest a hasty kiss; and then she was hurried off to receive some new-
comers. Mrs. Hayward stood and stared round her for a minute or two,
neglecting several kind advances that were made to her, and then, without
any leave-taking, she walked out of the room and out of the house. She was
in a whirl of anger and astonishment. ‘Don’t blame—me! don’t think the
less—of me!’ This was the most astounding deliverance that had ever come
to Elizabeth’s ear. She was not in the habit of supposing that any one could
think less than the highest of her. The assertion was the profoundest
offence. And what could it mean? What was the cause?
Coming down the hill she was met by the Thompsons’ big resplendent
carriage, which stopped as she drew near, and Lady Thompson leant out,
holding forth both hands. ‘Oh, how is the poor dear?’ said Lady Thompson,
beginning to cry: ‘I am sure you ’ave too much heart to forsake ’er
whatever happens. Oh, how is the poor dear?’
‘I don’t know whom you mean, Lady Thompson. I never forsake
anybody I am interested in—but I don’t know what you mean.’
‘Oh, I’m sure you’re a good woman. I’m sure you’re a real lady,’ Lady
Thompson cried.
Mrs. Hayward walked away from the side of the carriage. Her head
seemed turning round. What did it mean? She? Who was she? Utter
perplexity took possession of her. She was so angry she could scarcely
think: and Lady Thompson, notwithstanding that warm unnecessary
expression of confidence, was, with her blurred eyes and eager tone, almost
more incomprehensible than the rest. She walked quickly home to avoid
any further insinuated confidence, to think it over, to make out what it
meant. Who could tell her what it meant? She saw Mrs. Sitwell at a little
distance, and concluded that she would be the most fit interpreter; but the
parson’s wife saw her too, and quickened her steps, hurrying away. ‘It is her
doing,’ Mrs. Hayward said to herself. At last she came to her own door.
Some one was there before her, standing in the porch waiting till the door
should be opened. He turned round at the sound of her step, and stood aside
to let her pass, holding out at the same time his hand.
‘Captain Bellendean! it is a long time since we have seen you.’
‘Yes, a long time. I have been a fool. I mean I have been—busy. I hope
you are all well, Mrs. Hayward. My dear old Colonel, and——’
‘He is quite well—but I fear you will not find him at home. This is not
his hour for being at home.’ She stood between him and the open door,
barring his passage, as it seemed. It was a way of working off the
disturbance and trouble in her mind.
‘I hope you will let me in,’ he said humbly. ‘It is not a mere call. I could
wait till he came back. I—I have something important to say to him: and—
and—I hope you will let me come in and wait.’
‘That is a modest prayer. I cannot refuse it,’ she said, leading the way.
 CHAPTER XLI
Joyce had to come to a resolution at which she herself wondered, in forlorn
helplessness, as if some other being within her had decided upon it and not
she. That she, all shy, shrinking, reticent as she was, with the limitations of
her peasant pride and incapacity for self-revelation, should attach a last
desperate hope to the possibility of enlightenment from some one else’s
judgment, was wonderful to herself. For how could she lay that tangled
question before any one, or unfold her soul? how could any stranger know
what her perplexity was, between the claims of the old tranquil yet
enthusiastic affections of her youth, and the strange unconfessed dream of
absorbing feeling which had swept her soul of late—between the pledges of
her tender ignorance, and the fulfilments of a life to which fuller knowledge
had come? She did not herself understand how she had come to stand at this
terrible turning-point, or why she should thus be summoned to decide not
only her own fate, but that of others; and how could she explain it to
strangers who knew nothing, neither how she was bound, nor wherein she
was free? And yet there came a longing over her which could not be
silenced—to ask some one—to make a tribunal for herself, and plead her
cause before it, and hear what the oracle would say. Perhaps it was because
all her lights had failed her, and all her faculties contradicted each other,
that this despairing thought suggested itself—to discover an oracle, and to
find out what it would say.
Of whom could she ask, and who could fill this place to her? Not her
father. Joyce did not say to herself that the good Colonel was not a wise
man, though he was so kind. Had he been the wisest of men, she would
have shrunk from placing her heart unveiled in his hand. For to the father
everything must be said. He is no oracle; he is a sovereign judge: that was
not the help her case required. Her step-mother was more impossible still. If
not to him, still less to her, could the girl, so cruelly wounded, so torn in
divers directions, lay open her misery and difficulty. Not to any one could
she lay them open. It was an oracle she wanted—something to which a half-
revelation, an enigmatical confession would suffice—who would
understand before anything was spoken, and give a deliverance which,
perhaps, would be capable of various interpretations, which should not
approach too closely to the facts. This was what she wanted without
knowing what she wanted, with only a strong longing to have light—light
such as was not in her own troubled self-questionings and thoughts.
Joyce had not many friends among the people who surrounded Mrs.
Hayward with a flutter of society and social obligations. Indeed Mrs.
Hayward herself had not many friends, and it is doubtful whether she would
have found one to whose judgment she could resort for advice, as Joyce
meant to do. But, the girl was perhaps more discriminating by a natural
instinct as to who was to be trusted—perhaps in her far higher ideality more
trustful. At all events, there were two very different persons to whom, after
much tossing about on the dark sea of her distress, her thoughts turned. A
little light might come from them; she might unfold herself to them
partially, fancifully, leaving them to guess the word of the enigma, finding
some comfort in what they said, even if it should fall wide of the mark.
When Mrs. Hayward set out to pay her visits in the afternoon, Joyce stole
forth almost furtively, though all the world might have seen her going upon
her innocent search after wisdom; but the world, even as represented in a
comparatively innocent suburban place, would have been at once startled
and amused to note at what shrine it was that Joyce sought wisdom and the
teaching of the oracle. She went not to any of the notable people, not to the
clergy, or even to Mrs. Sitwell, who was supposed to be her friend, and who
was known to be so clever. Joyce did not at all know that the parson’s wife
had played her false, and she had seen more of that lady than of any one
else in the place. But this was not because of any innate sympathy, but
because of the pertinacity with which Mrs. Sitwell had seized upon Joyce as
a useful auxiliary in the carrying out of her own ends—and the girl’s
instinct rejected that artificial bond, and put no faith in the cleverness which
she acknowledged, nor even in the goodness after its kind, which Joyce’s
mind was large enough to acknowledge too. She went not to Mrs. Sitwell,
nor to the parson, Mrs. Sitwell’s husband, but she threaded through many
lanes and devious ways until she came to a door in a wall with a little bright
brass knocker, and a grating, and great thorny branches of a bare rose-tree
straggling over. Within was a small neat green garden, and a little house
looking out upon it with shining windows. And within that, coming hastily
to the door to meet her, was Miss Marsham, whom everybody knew to be as
good as gold, but nobody imagined to be wise or instructive in any way.
Joyce had come to find her oracle here.
 The room was small and low, full of old china, old pictures, a little
collection of relics, in the midst of which their gentle mistress, a mild spirit
clad with only as much body as was strictly essential, and with an old gown
constructed on the same principles, with just as much old and somewhat
faded silk as was strictly necessary, appeared in perfect harmony, the soul of
the little dainty place. She received Joyce with the tenderest welcome, in
which there was something more than her usual kindness, and an anxiety
which Joyce, full of her own thoughts, never perceived. Miss Marsham was
ready and prepared to be confided in. She was prepared for the story of
Joyce’s youth, for the revelation of her peasant parents, and how for their
good she had sacrificed herself to Colonel Hayward’s fancy—ready to
understand at half a word, to condone and to condole, to give praise for the
noble motive, the self-sacrifice, and only gently—very gently—to touch
upon the deception, which the severest critic could not consider to be
Joyce’s fault. She kissed her and said, ‘My dear child, my poor Joyce,’ with
a tender pity which forestalled every explanation. Did she then already
know Joyce’s trouble and sore perplexity? but how was it possible that she
should know?
‘You must not think I have come just to call,’ Joyce said.
‘No, dear? but why shouldn’t you come just to call? There will never,
never be any circumstances in which I shall not be glad to have you come.
My dear, circumstances don’t matter at all to me when I know any one as I
know you!’
Joyce was a little bewildered by this effusion. She said, with a faint
smile, ‘And yet you don’t know me well. I have been here just five months,
and part of that away——’
‘My love, when you understand a person and love a person, as I do you,
the time does not count by months.’
‘That is what I feel: and I have nobody—nobody to look to:—you will
say my father, Miss Marsham. He is kind, kind—but oh, I have not been
brought up with him nor used to open my heart,—and in some things he
knows only one language and me another—and besides, if I were to tell him
everything, he would say what I was to do, and I would have to obey. And
Mrs. Hayward with him, they would settle it all,—and I am not used to it,
and I cannot——’
 ‘No, Joyce, I understand—it is they who have led you into it—you can’t
ask advice from them.’
‘They did not lead me into it,’ said Joyce. ‘It was just nature led me into
it, and the perversity of things. Will you ever have noticed in your life how
things go wrong? Nobody means any harm, and all you do is innocent; and
even if you were very prudent and weighed everything beforehand, there
would not be one step that you could say afterwards—This was wrong. And
yet things all turn wrong, and your heart is broken, and nothing is to blame.’
‘Oh, Joyce, words cannot say how sorry I am! There was one thing
perhaps, my dear, a little wrong—for to deceive in any way, even if it seems
to do no harm and is with the best motive—the highest motive, to help
those you love——’
Joyce sighed softly to herself, no longer asking how Miss Marsham
could know, then shook her head. ‘I wish it had been for that motive; but
there was no love, no love,—I,’ with a sudden blush, ‘did not know what
love meant.’
Miss Marsham looked up with an exclamation of astonishment on her
lips, but stopped with her mouth open, wondering. Joyce, whose eyes were
cast down, did not see the impulse at all.
‘He had read a great deal—a great deal,’ said the girl. ‘I have never met
any one—oh, not here nor anywhere—so well instructed. I thought then that
there was nothing so grand as that. He had read a great deal more than I!—
he was my—superior in that. It is true, I always knew all the time that I was
not—what seemed—— But that might never have come to anything, and
besides, I would have thought shame. For I thought that to know the poets,
and all that has been written—that was what made a gentleman. Oh, I think
shame to say such a thing,—it doesn’t—— how can I say it? It seems there
must be something more.’
Miss Marsham remained silent in simple bewilderment. Joyce was now
talking her own language, which nobody understood.
‘You may say it was deceiving to let him think I cared for him, but that
was never what I intended. He said at first, it was enough for him to care for
me. Oh, but that is nothing, nothing!’ cried Joyce suddenly, ‘that is only the
beginning. Though I cannot keep my word to him, I need not break it,—that
would have been easy. It is far, far worse what is to come.’
 Miss Marsham took Joyce’s hands into hers. She was lost in amazement,
and felt herself swimming, floating wildly, at sea, among things altogether
strange and incomprehensible. She could not reply, but there is always
sympathy in a pressure of the hands.
‘There was nothing wrong in meeting another man that was my father’s
friend, that was my dear lady’s son,’ said Joyce, very low; ‘how was I to
know that he and me would see each other different from—common folk?
How was I to know that they had made it up for him to be the love of—of
another girl? And now here I stand,’ she cried, rising up holding out her
hands in piteous explanation, ‘pledged to one, and caring nothing for him,
harming another that but for me would do what was meant for him, would
do—would do well—with a lady bred like himself, born like himself, not
one that had been abandoned like me. Tell me what you would do if you
were me! The lady comes and asks me—she has no right. She says that I
know trouble and sorrow, but Greta never a disappointment, never a thing
that was not happy—and that she’ll break her heart; and nobody cares for
mine. And she says I should keep my word, though she was the first to say
he was not the one for me. And oh, what am I to do—what am I to do?’
Joyce sank down again upon the seat, and covered her face with her
hands.
‘Oh, my poor Joyce—my dear Joyce!’ Miss Marsham cried.
Her head was not very clear at any time—it was apt to get confused with
a very small matter. And Joyce’s story was confusion worse confounded to
the anxious hearer. Even what she thought to be her knowledge of the
circumstances deepened Miss Marsham’s bewilderment. She knew of the
man to whom Joyce was engaged, from whom all the information came; but
the after episode—half told, hurried over, which Joyce had no mind to
explain fully, which she addressed to the oracle—was as a veil thrown over
poor Miss Marsham’s understanding. She knew none of these people; the
name of Greta brought no enlightenment to her, nor did she know who the
lady was, nor who the man was who was mixed up inextricably in this
strange imbroglio. She drew Joyce’s hands from her face, and laid that
hidden face upon her own kind breast, kneeling down to caress and to
soothe the poor girl in her trouble. But what to say or what to do Miss
Marsham knew not. She did not understand the delicate case upon which
her advice was required. And the oracle was mute. There was no response
to give. ‘Oh, my poor child, my dear child, my poor dear love!’ Miss
Marsham cried.
After a minute Joyce raised her head and looked at her friend in whom
she trusted. She was very pale, her eyes were wet with tears, and looked
large and liquid in caves of trouble,—her mouth quivered a little, like the
mouth of a child when its passion-fit is over, and there was a pathetic little
break in her voice. ‘Tell me,’ she said, with a look that searched the very
soul, ‘tell me what you would do—if you were me.’
‘Oh, my pretty Joyce—my poor dear!’
‘Tell me,’ the girl said, ‘would you break her heart and wound him, all
for yourself? Would you break your word and your pledge that you gave
when you were poor, all for yourself? as if you had to be happy whatever
happened—you! And what right had you to be happy, any more than Greta
—or Greta more than you?’
The question, heaven knows, was vague enough—but the oracle was no
longer mute. The pilgrim at the shrine had touched the true chord, and at
last the priestess spoke. She had a moment of that ecstasy, of that semi-
trance of mingled reluctance and eagerness, which makes those pause who
have the response of the unseen to give forth to feeble men. Her gentle eyes
lit up, then dimmed again; a brightness came over her faded face, giving it a
momentary gleam of eternal youth, then disappeared. She trembled a little
as she held the votary to her breast.
‘Oh Joyce! my darling Joyce! I don’t know that I quite understand you,
dear. It is all so mixed up. Things that I have heard and that you tell me are
so different. I don’t know what to think—but if it’s a question between you
and another, which is to take the happiness and let the other suffer—oh, my
child, my dear! do I need to say it to you—do I need to tell you? Joyce,
your heart tells you—it’s like a, b, c, to a woman. You know——’
‘I thought,’ said Joyce, with that sob in her throat, following with intent
eyes every little movement of her agitated instructor— ‘I thought that was
what you would say.’
‘Yes,’ said the vestal, the priestess of this new Dodona, ‘it is not in our
will to choose or to change. You can’t leave the heartbreak to another. You
have to take it, though your spirit may cry out and refuse. I am not wise to
give you advice, oh my darling! but I know this, and every woman knows
it. Oh, it isn’t all that do it, I know, for it’s not an easy thing. But when you
have strength from above, you can do it. And what is more, it is not in your
nature to do anything else. So don’t ask me what I would do. You could not
—do—any other thing: being you and nobody else: Joyce that I know.’
‘No,’ said Joyce, stumbling, rising to her feet, meeting with a solemn
look the wet and weeping eyes of her oracle, ‘no, not any other thing.’
‘Not any other thing.’ Miss Marsham would have kept her in her arms,
would have wooed her to further speech, would have wept over her and
caressed her, and expended all the treasures of her heart in soothing the
martyr whom she had thus consecrated. But of this Joyce was not capable.
She had got her oracle, and it was clear. It was what she had wanted, not
advice, but that divine and vague enigma which corresponded with the
enigma of her confession. She resisted gently the softness of her friend’s
clinging embrace. Her eyes were full of the awe of the victim who consents
and accepts, and is restrained by every solemnity of her religion from any
struggle—but who already feels herself to be outside this world of
secondary consolations, face to face with the awful realities of the sacrifice.
‘Don’t keep me,’ she said faintly, putting away the thin kind hands that
would have held her, ‘I must go—I must go.’
‘Oh Joyce,’ cried Miss Marsham, stricken with a secret terror, ‘I hope I
have said right!’
‘I am sure you have said right; it is what I knew. I could not—do—any
other thing. Let me go, Miss Marsham, let me go, for more I cannot bear.’
‘Oh, my dearest, I hope I have done right! Oh, stay a little and tell me
more! Oh Joyce, God bless you, God bless you, my dear, if you must go!’
She followed the girl to the little door, so flowery and embowered in
summer, now overshadowed by those straggling bare branches of the rose-
tree, which were good for nothing but to make, had that been wanted, a
sharp garland of thorns. Joyce scarcely turned to answer her blessings and
good-byes, but went on straight from the door as if hurrying to the place of
sacrifice. The thought was folly, Miss Marsham said to herself, and yet it
went with a chill to her heart and would not be chased away.
 CHAPTER XLII
You could not do—any other thing. If there could be a proof of the divinity
of the oracle it was this. It addressed that something within which is more
than any external hearing. ‘When thou wast under the fig-tree.’ Who could
tell what was in the spirit in secret but the perfect Teacher, who saw all?
Joyce received in something of the same way the utterance which had been
given in such darkness on the part of its exponent, as is the way of oracles.
She felt that it was the true and only revelation. She hurried along in the
wintry twilight, her head bent down, avoiding the cold night wind; her heart
beating loudly; her eyes hot and suffused with scalding tears, which did not
fall; her feet cold, stumbling over every little stone. The certainty which had
replaced her doubts and conflicts of mind was scarcely less confusing than
they: it did not inspire her as in the procession to the place of sacrifice. Ah!
had she to do that boldly in the face of man for a great cause, Joyce knew
how high she could have carried her head, and marched with what steady
force and triumph. But the way was dark and tortuous, and full of fears,—
the wind in her face so cold, the sensation in her heart so full of misery. The
oracle had spoken right. It had been what she wanted. It had made her see
clearly, driving from her eyes those films of weakness that come up upon
the wind and obscure the vision, even when it is most clear. She
remembered now that there never could have been any doubt, that she was
even pledged to that sole course. Had she not said, ‘I will do as you wish?’
and had not she been blessed and thanked for her resolution? and yet it had
failed, and she had sought the oracle—to have it confirmed, as it was right
it should be.
Ah! but the oracle is pitiless too. It has no regard for the weakness of—
common folk. Joyce was one who had held her head very high, who never
in her consciousness had been one of the common folk. But now, in her
despair, consenting to the sacrifice demanded of her, yet with partial
revulsions of her mind against it, she took refuge in that common strain of
humanity. Those oracles which spoke out of the veiled heights, from which
the votaries with bleeding hearts, all torn with special wounds, received
such stern and abstract answers—they were right, but they were
remorseless. They took nothing into consideration, not the weakness of the