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Pediatric Neurosurgery - In Multiple-Choice Questions (Mar 25, 2024)_(3031495721)_(Springer) 1st Edition Samer S. Hoz

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Samer S. Hoz · Abdullah H. Al Ramadan · Ian Pople · Nada Mohammed · Waeel O. Hamouda · Ahmed El Damaty · Mustafa Ismail   Editors

Pediatric Neurosurgery

In Multiple-Choice Questions

Pediatric Neurosurgery

Samer S. Hoz • Abdullah H. Al Ramadan

Ian Pople • Nada Mohammed

Waeel O. Hamouda • Ahmed El Damaty • Mustafa Ismail

Editors

Pediatric Neurosurgery

In Multiple-Choice Questions

Editors

Samer S. Hoz

Department of Neurosurgery

University of Pittsburgh Pittsburgh, PA, USA

Ian Pople

Neurosurgery Department

Sidra Medicine

Doha, Qatar

Waeel O. Hamouda

Faculty of Medicine, Teaching, & Research Hospitals

Cairo University Cairo, Egypt

Mustafa Ismail Department of Neurosurgery

Neurosurgery Teaching Hospital Al-Risafa, Baghdad, Iraq

Abdullah H. Al Ramadan Dept of Neurosurgery and Spine Surgery

Qatif Central Hospital Al Qatif, Saudi Arabia

Nada Mohammed

Pediatric Neurosurgery Department Bristol Royal Hospital for Children Bristol, UK

Ahmed El Damaty Department of Neurosurgery, Faculty of Medicine

Heidelberg University Heidelberg, Baden-Württemberg, Germany

ISBN 978-3-031-49572-4

ISBN 978-3-031-49573-1 (eBook) https://doi.org/10.1007/978-3-031-49573-1

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023

This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifcally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microflms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed.

The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifc statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Paper in this product is recyclable.

Samer S. Hoz

To my lovely family: Sawsan, Saad, Arwa, Farah, Ward, Khawla, Samhar, Sanaa, Faris, and Luay. To the GYL team, Norberto, Kathi, and Paolo.

Abdullah H. Al Ramadan

To my Mom Layla (May Allah bless her soul) and my Dad Husain, To My love Rahmah, my daughters Sara and Sama and my supportive family: Ali, Mohammed, Ahmed, Zainab, Sara and Jawad.

Ian Pople

To my wonderful neurosurgical team and supporting staf at Sidra Medicine, Doha.

Nada Mohammed

To my parents, brothers and sister. To my friends Osilat, Ghada and Kholood for their unstoppable support.

Waeel O. Hamouda

To my patients who courageously endure the dismay and hardship of their diseases while trusting me with their lives and dreams. You are all my heroes.

Ahmed El Damaty

To my family and patients, whom their trust endeavored me on that long tedious way.

Mustafa Ismail

To my mom Khafa, to my dad Ismail (May Allah bless his soul), to my sister Noor, to brothers Osama and Qutaiba, my family.

Foreword 1

As someone whose postgraduate education started half a century ago and continues to this day, I am envious of the wide range of imaginative educational materials available to the present generation of trainees and consultants. I was fortunate in having some outstanding teachers who illuminated rote learning and dogma with scepticism, and who expected us to start to develop the ability to seek out and marshall evidence, recognise uncertainty and come up with workable solutions to problems for the beneft of our future patients.

Dr Hoz and his team are to be applauded for their use of the MCQ format to stimulate understanding of Paediatric Neurosurgery through a step-bystep concise overview of each disease from defnition, associated anatomy, pathology, clinical features and radiology through to surgical decisionmaking and surgical technique.

MCQs have a chequered reputation but have been widely adopted for examinations for their objectivity, ease of grading and validation, and the ability to cover as much material as possible. Much effort is required to construct sound MCQs. Trick questions are to be abhorred. Sadly, MCQs may have a short shelf life when the unscrupulous copy them in order to game the examination and certifcation process.

This book uses MCQs constructively as a way of encouraging the student at all ages to retrieve information from memory (if it ever existed!) and use it to answer clinically relevant questions. Potentially, this process should strengthen understanding and memory. The provision of key references for further reading is very welcome and should stimulate Departmental Chairpersons to ensure that their trainees have access to the necessary electronic library facilities.

This book is complimentary to existing international texts such as Youmans and Winn’s Neurological Surgery (4th edition 2016) and the Oxford Textbook of Neurological Surgery (Kirollos, Helmy, Thomson & Hutchinson, 2019). It will certainly fulfl its authors’ aim of helping readers from all countries, from trainee to established consultant and examiner, to identify the strengths and weaknesses in their knowledge of Paediatric Neurosurgery. It deserves a long life with further Editions as this fascinating feld advances.

University of Cambridge, Cambridge, UK

Foreword

2

Surgery, the most noble art, has been practised for millennia for the improvement of human suffering. Paediatric neurosurgery has the added dimension of treating the child, not just in the present but also the adult that this child may be destined to become. So it becomes paramount that the surgeon, deals with the pathology in a manner that keeps the morbidity of the treatment to an absolute minimum. Science gives us clues as to how we may achieve this, and it remains up to the surgeon to combine this science with the art to do our best for future generations.

Learning, seemingly ‘abstract’ facts, is rarely fun especially for the active surgical spirit yet often these ‘abstract’ facts give us vital clues into the pathology and its treatment. Prof Samer Hoz and his team of editors have done the most commendable job of picking out the most relevant facts and presenting them in a fashion that makes the tedious task of learning them more exciting and indeed more productive. The objective is to broaden the readers understanding of paediatric neurosurgery and to stimulate interest and further self-directed research and learning. The format ensures the facts become easily accessible which should serve to help with recall and board assessments. In this manner, entire topics are made more lucid and facts more relevant to the practice of surgery.

To the readers, I have little doubt you will fnd this book useful, I did. Know your facts, learn to use them in an unbiased fashion and answers hitherto unknown will become clear to you.

Noor ul Owase Jeelani

Great Ormond Street Hospital for Children, London, UK

Foreword 3

Basically, one of the main drawbacks a multi-authored book may have is the sense of unevenness in format and approach among the various chapters, that is why the editors of this book propend to offer a rigid scheme for their contributors to adhere to in order to make their book as uniform as possible. The readability of this book is further enhanced by the authors’ and editors’ shared understanding that an attitude of assured non-confusing knowledge must be prevailing.

The editors have chosen 20 subjects (chapters) that cover the large spectrum of pediatric neurosurgery, including those dealing with the commonly encountered disorders of cerebrospinal fuid dynamics and congenital malformations, while nevertheless dedicating other chapters to the less famous cases of spinal trauma and peripheral nerves disorders.

The questions and answers in each chapter cover almost all the topics attaining to a specifc disease; those might include mechanisms of disease, histopathology, medical management, diagnostic techniques, operative indications and contraindications, special points in the anesthetic technique, detailed description of related operations, and postoperative complications.

Over the years, controversy has arisen over the advantages and disadvantages of pursuing the specialty of pediatric neurosurgery in comparison with that of general neurosurgery, we come more and more to know that neurosurgical conditions within this vulnerable age group possess their specifc characteristics and challenges. As a pediatric neurosurgeon with more than 34 years of experience who has built his carrier in a developing country, I hope that my colleague neurosurgeons would fnd this reference of value in their pursue of knowledge related to and in their practice of pediatric neurosurgery as I have found it.

Dr. Juan Bruno Zayas

Alfonso General Hospital

Santiago de Cuba, Cuba

Southern Children's Hospital

Santiago de Cuba, Cuba

Hospital Infantil Sur

Santiago de Cuba, Cuba

Key Features

5 Pediatric Neurosurgery in Multiple Choice Questions, the frst review book to use the multiple-choice question format, is dedicated to neurosurgical pediatric neurosurgery.

5 The mission of the book is to help readers understand the content and maintain the knowledge, rather than merely fnding answers for tricky questions.

5 The chapters of this book provide comprehensive coverage of the core concepts in pediatric neurosurgery.

5 This essential review mirrors the multiple-choice format adopted by the majority of shelf and board examinations.

5 This study companion provides more than 500 MCQs in a convenient format that is suitable for self-study.

5 The strategy and the format of the questions provide a step-by-step, thorough explanation of each disease from the defnition, associated anatomy, pathology, clinical features, radiology to surgical decision-making, and surgical tricks, providing a comprehensive and concise overview.

5 Answers and defnitions appear immediately below the questions to facilitate information retention.

5 This book is an adjunct to the existing texts and does not intend to be the primary source of information; it rather aims to help readers identify their relevant strengths and weaknesses in the area.

5 These questions are structured as a refresher course for both long and short study sessions.

5 Pediatric Neurosurgery in Multiple Choice Questions is an important asset for residents across neurosurgical disciplines as it includes much of the pediatric neurosurgery knowledge that neurosurgical residents need to prepare for their certifcation tests. It is also useful for those seeking ways to solidify their knowledge or maintain their current certifcation.

Preface

We are delighted to introduce pediatric neurosurgery in Multiple Choice Questions as your study companion. Navigating the complexities of pediatric neurosurgery demands precision, depth of knowledge, and a keen understanding of the delicate nuances that distinguish pediatric cases from adults.

The book Pediatric Neurosurgery in Multiple Choice Questions encapsulates the breadth of pediatric neurosurgery. The choice to present in an MCQ format promotes active engagement, facilitating both learning and selfassessment. We put this humble book as a guide to the mysterious vascular aspect of pediatric neurosurgery, trying to concentrate on the core, intended to help the reader via a systematic approach to diagnose and manage the common pediatric neurosurgical problems by applying scientifc knowledge to practice.

It is the frst review book to use the multiple-choice question format in pediatric neurosurgery, and it contains over 500 questions, and all are genuine (new). Each MCQ is designed to provide the reader with four correct facts and one false statement, as well as brief explanations to aid in consolidation. These questions are designed to provide a refresher course either in long or briefer study sessions as time permits during a busy day in the neurosurgical practice. As we journey together through these pages, they may not only inform but also inspire excellence in patient care.

We sincerely hope you enjoy and beneft from the book.

Pittsburgh, PA, USA

Al Qatif, Saudi Arabia

Samer S. Hoz

Abdullah H. Al Ramadan Doha, Qatar Ian Pople Bristol, UK Nada Mohammed Cairo, Egypt Waeel O. Hamouda Heidelberg, Baden-Württemberg, Germany Ahmed El Damaty Baghdad, Iraq Mustafa Ismail

Muffaq K. Lashhab, Oday Atallah, Ahmed Muthana, Mohammedbaqer A. Al-Ghuraibawi, Naba G. Husseini, and Samer S. Hoz

Aras F. Albarazanchi, Oday Atallah, Ahmed Muthana, Tabarek F. Mohammed, Sara A. Mohammad, and Samer S. Hoz

and Samer S. Hoz

Muthana, Fatimah O.

Oday Atallah, Laith T. Al-Ameri, Zinah A. Al-Araji, Zainab A. Alaraji, Huda Abdulrazaq, and Samer S. Hoz

Fatima A. Fakhroo, Mariam H. Allehaibi, Fatimah O. Ahmed, and Abdullah H.

Ahmed Adel Farag, Ahmed Abdelrahman Abdullah, Ali A. Dolachee, and Waeel O. Hamouda

Fehid Habalrih, Mashael Almarwani, Mustafa Ismail, and Abdullah H. Al Ramadan

Amna S. Hussein, Mohamed F. Alsawy, Mustafa Ismail, and Waeel O. Hamouda

Oday Atallah, Abdullah K. Al-Qaraghuli, Noor M. Shaker, Noor M. Akar, Alkawthar M. Abdulsada, and Samer S. Hoz

Honida A. Ibrahim, Nada Mohammed, Maliya Delawan, and Ian Pople

Ahmed K. Al-Kishawi, Mustafa

Ali Eltaj Osman, Nada Mohammed, Sadeem A. Albulaihed, and Ian Pople

Muhammad F. Khan, Abdulrahman R. Nazer, Ameer M. Aynona, and Waeel O. Hamouda

Muthana, Rokaya H. Abdalridha, Jaafer AbdulWahid, Sajjad G. Al-Badri, and Samer S. Hoz

Ruqaya A. Kassim, Muthanna N. Abdulqader, Alkawthar M. Abdulsada, Zahraa A. Alsubaihawi, Abrar A. Khoailed, Mustafa Ismail, and Samer S. Hoz

Sarah Basindwah, Abdulrahman R. Nazer, Ali A. Basalamah, Fatimh A. Alsaffar, Mahmood F. Alzaidy, and Abdullah H. Al Ramadan

Oday Atallah, Sarah F. Hassan, Mahmood F. Alzaidy, Ghazwan Hazem, Osamah M. Al-Shaikhli, Younus M. Al-Khazaali, and Samer S. Hoz

20 Pediatric Neuropathology.....................................................................................

Sadeq Wasil Al-Dandan, Mustafa Ismail, and Abdullah H. Al Ramadan

Contributors

Rokaya H. Abdalridha Babylon University, College of Medicine, Babylon, Iraq

Ahmed Abdelrahman Abdullah Kasr Al Ainy School of Medicine, Cairo University, Cairo, Egypt

Muthanna N. Abdulqader Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq

Huda Abdulrazaq College of Medicine, Alnahrain University, Baghdad, Iraq

Alkawthar M. Abdulsada Azerbaijan Medical University, Baku, Azerbaijan

Jaafer AbdulWahid University of Al-Nahrain, College of Medicine, Baghdad, Iraq

Fatimah O. Ahmed University of Mustansiriyah, College of Medicine, Baghdad, Iraq

Noor M. Akar College of Medicine, Al-Nahrain University, Baghdad, Iraq

Laith T. Al-Ameri Al-Kindy College of Medicine—University of Baghdad, Baghdad, Iraq

Zainab A. Alaraji University of Al-Nahrain, College of Medicine, Baghdad, Iraq

Zinah A. Al-Araji College of Medicine, Alnahrain University, Baghdad, Iraq

Sajjad G. Al-Badri Babylon University, College of Medicine, Iraq

University of Baghdad, College of Medicine, Baghdad, Iraq

Aras F. Albarazanchi Diana Princess of Wales Hospital, Grimsby, UK

Sadeem A. Albulaihed Department of Neurosurgery, Alfaisal University, College of Medicine, Riyadh, Saudi Arabia

Sadeq Wasil Al-Dandan King Fahad Hospital Hofuf, Al-Ahsa, Saudi Arabia

Contributors

Mostafa H. Algabri University of Baghdad, College of Medicine, Baghdad, Iraq

Mohammedbaqer A. Al-Ghuraibawi University of Warith Al-Anbiyaa, College of Medicine, Karbala, Iraq

Raghad O. Aljohani Al-Rayyan Medical Colleges, Madinah, Saudi Arabia

Younus M. Al-Khazaali College of Medicine, Al-Nahrain University, Baghdad, Iraq

Ahmed K. Al-Kishawi Al-Mustansiriyah University, College of Medicine, Baghdad, Iraq

Mariam H. Allehaibi Maternity and Children’s Hospital, Makkah, Saudi Arabia

Mashael Almarwani Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Abdullah K. Al-Qaraghuli MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, DC, USA

Abdullah H. Al Ramadan Department of Neurosurgery and Spine Surgery, Qatif Central Hospital, Eastern Health Cluster, Qatif, Saudi Arabia

Fatimh A. Alsafar Dammam Medical Complex, Dammam, Saudi Arabia

Mohamed F. Alsawy Faculty of Medicine, Cairo University, Cairo, Egypt

Osamah M. Al-Shaikhli Imam Ali General Hospital, Baghdad, Iraq

Zahraa A. Alsubaihawi University of Baghdad, College of Medicine, Baghdad, Iraq

Mahmood F. Alzaidy University of Baghdad, College of Medicine, Baghdad, Iraq

Oday Atallah Department of Neurosurgery, Hannover Medical School, Hannover, Germany

Ameer M. Aynona University of Babylon, College of Medicine, Babylon, Iraq

Leen R. Azzam Royal College of Surgeons in Ireland-Bahrain, School of Medicine, Adliya, Kingdom of Bahrain

Ali A. Basalamah King Saud University Medical City, Riyadh, Saudi Arabia

Sarah Basindwah King Saud University Medical City, Riyadh, Saudi Arabia

Maliya Delawan Gulf Medical University, College of Medicine, Ajman, United Arab Emirates

Ali A. Dolachee Department of Surgery, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq

Osman Elamin Department of Neurosurgery, Jordan Hospital and Medical Center, Amman, Jordan

Ahmed El Damaty Pediatric Neurosurgery Division, Heidelberg University, Heidelberg, Germany

Ahmed M. ElGhamry Department of Neurosurgery, St George’s University Hospital, London, UK

Fatima A. Fakhroo Bahrain Defense Force Hospital—Royal Medical Services, Riffa, Kingdom of Bahrain

Ahmed Adel Farag King Abdullah Medical City Makkah, Makkah, Saudi Arabia

Fehid Habalrih Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Waeel O. Hamouda Neurological & Spinal Surgery Department, Cairo University Faculty of Medicine, Teaching & Research Hospitals, Cairo, Egypt

Sarah F. Hassan University of Baghdad, College of Medicine, Baghdad, Iraq

Ghazwan Hazem Al-Wasitey Teaching Hospital, Baghdad, Iraq

Samer S. Hoz Department of Neurosurgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA

Amna S. Hussein Banner University Medical Center, University of Arizona, Phoenix, AZ, USA

Naba G. Husseini College of Medicine, University of Mosul, Mosul, Iraq

Contributors

Honida A. Ibrahim Department of Neurosurgery, Ribat University Hospital, Khartoum, Sudan

Mustafa Ismail Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq

Ruqaya A. Kassim University of Baghdad, College of Medicine, Baghdad, Iraq

Muhammad F. Khan Security Forces Hospital—Dammam, Dammam, Saudi Arabia

Abrar A. Khoailed University of Baghdad, College of Medicine, Baghdad, Iraq

Mufaq K. Lashhab Ali Omar Askar Neurosurgery Hospital, Tripoli University, Tripoli, Libya

Sara A. Mohammad University of Baghdad, College of Medicine, Baghdad, Iraq

Nada Mohammed Senior Clinical Fellow, Pediatric Neurosurgey, Bristol Royal Hospital for Children, Bristol, UK

Tabarek F. Mohammed University of Baghdad, College of Medicine, Baghdad, Iraq

Ahmed Muthana University of Baghdad, College of Medicine, Baghdad, Iraq

Abdulrahman R. Nazer Prince Sultan Military Medical City, Riyadh, Saudi Arabia

Ali Eltaj Osman Armed Forces Hospital, Wadi Aldawasir, Saudi Arabia

Military School Dist., Wadi Aldawasir, KSA

Ian Pople Division Chief of Neurosurgery, Department of Surgery, Sidra Medical & Research Center, Doha, Qatar

Noor M. Shaker University of AL-Ameed, College of Medicine, Karbala, Iraq

Eleni Tsianaka Neurosurgery Department, Kuwait Hospital, Sabah Al Salem, Kuwait

Abbreviations

ACA Anterior cerebral arteries

AChE Acetylcholinesterase

ADC Apparent diffusion coeffcient

AFP Alpha-fetoprotein

AKA Also known as

AVM Arteriovenous malformations

BBB Blood–brain barrier

bSSFP MRI Balanced steady-state free precession MRI

CBC Complete blood count

cGy Centigray

CN Cranial nerve

CNS Central nervous system

CRP C-Reactive protein

CRPS Complex regional pain syndrome

CSF Cerebrospinal fuid

CT Computed tomography

DSA Digital subtraction angiography

DWI Diffusion weighted imaging

EEG Electroencephalogram

ESR Erythrocyte sedimentation rate

ETV Endoscopic third ventriculostomy

FGFR Fibroblast growth factor receptor

FLAIR Fluid-attenuated inversion recovery

GCS Glasgow Coma Scale

GMFCS Gross motor function classifcation system

GRE Gradient echo

HGB Hemangioblastoma

HHT Hereditary hemorrhagic telangiectasia

ICH Intracerebral hemorrhage

ICP Intracranial pressure

Abbreviations

ICU Intensive care unit

IV Intravenous

IVH Intraventricular hemorrhage

LOC Level of consciousness

LP Lumbar puncture

MAP Mean arterial pressure

MB Medulloblastoma

MCA Middle cerebral arteries

MMD Moyamoya disease

MRI Magnetic resonance imaging

MRV Magnetic resonance venography

NAI Non-accidental injury

NCD Neurocutaneous disorders

NF1 Neurofbromatosis type 1

NF2 Neurofbromatosis type 2

NPO Nothing by mouth

NTD Neural tube defects

OAD Occipital atlantal dislocation

PCA Pilocytic astrocytoma

PET Positron emission tomography

PFD Posterior fossa decompression

PTS Posttraumatic seizures

RARE MRI Rapid acceleration with relaxation enhancement MRI

RCC Renal-cell carcinoma

SAH Subarachnoid hemorrhage

SBP Systolic blood pressure

SDE Subdural empyema

SEGA Subependymal giant cell astrocytoma

SWS Sturge–Weber syndrome

TBI Traumatic brain injury

TIA Transient ischemic attack

TP53 Tumor protein 53

VGAM Vein of Galen aneurysmal malformation

VHL Von Hippel-Lindau disease

VP Ventriculoperitoneal

WHO World Health Organization

WI Weighted imaging

yrs Years

Neuroanatomy

Muffaq K. Lashhab, Oday Atallah, Ahmed Muthana, Mohammedbaqer A. Al-Ghuraibawi, Naba G. Husseini, and Samer S. Hoz

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. S. Hoz et al. (eds.), Pediatric Neurosurgery, https://doi. org/10.1007/978-3-031-49573-1_1

1. Circumventricular organs. The FALSE answer is:

A. The subfornical organ is a circumventricular organ.

B. The subcommisural organ lacks a blood–brain barrier.

C. The area postrema is the only paired circumventricular organ.

D. The pineal gland has a role in maintaining the circadian rhythm.

E. Organum vasculosum is an outlet for hypothalamic peptides.

v Answer B

5 The subcommisural organ is the only circumventricular organ with an intact blood–brain barrier.

2. The climbing fbers of the cerebellum. The FALSE answer is:

A. They are excitatory fbers.

B. They travel through the inferior cerebellar peduncle.

C. They arise from the contralateral inferior olivary nucleus.

D. They secrete aspartate.

E. They synapse with both purkinje and granule cells.

v Answer D

5 They secrete glutamate.

3. The hypothalamic nuclei. The FALSE answer is:

A. The posterior nucleus is responsible for arousal.

B. The medial nucleus is concerned with satiety.

C. The anterior and medial nuclei have a role in the parasympathetic response.

D. The posterior and lateral nuclei are important in the sympathetic response.

E. The anterior nucleus increases body temperature.

v Answer E

5 The anterior nucleus decreases body temperature, while the posterior nucleus increases body temperature.

4. Visual feld defects. The FALSE answer is:

A. Left nasal hemianopia is due to a lesion involving the left perichiasmal area.

B. Left homonymous hemianopia is due to a lesion involving the right optic tract.

C. Left homonymous superior quadranopia is due to a lesion involving the lower right optic radiation.

D. Left homonymous superior quadranopia is due to a lesion involving the upper right optic radiation.

E. Left homonymous hemianopia is due to a lesion involving the right occipital lobe.

v Answer C

5 Left homonymous inferior quadranopia is due to a lesion involving the lower right optic radiation.

5. The deep peroneal nerve, innervation. The FALSE answer is:

A. Extensor digitorum brevis muscle.

B. Extensor hallucis longus muscle.

C. Extensor digitorum longus muscle.

D. Peroneus longus muscle.

E. Tibialis anterior muscle.

v Answer D

5 The superfcial peroneal nerve innervates the peroneus longus.

6. The corticospinal tract. The FALSE answer is:

A. Ninety percent of the descending fbers travel in the lateral corticospinal tracts.

B. Uncrossed fbers travel in the anterior corticospinal tracts.

C. Divides into three tracts at the spinomedullary junction.

D. Passes through the anterior limb of the internal capsule.

E. The sacral fbers occupy the most lateral aspect.

v Answer D

5 The corticospinal tract fbers pass through the posterior limb of the internal capsule.

7. Papez circuit. The FALSE answer is:

A. It’s known as the medial limbic circuit.

B. The amygdala is part of the circuit.

C. The anterior thalamic nuclei constitute a key component of the hippocampal system for episodic memory.

D. The circuit includes the mammillary bodies.

E. The fornix is the major output tract of the hippocampus.

v Answer B

5 The amygdala is not part of the circuit.

8. Benedikt’s syndrome. The FALSE answer is:

A. It’s known as the paramedian part of midbrain syndrome.

B. It includes cranial nerve (CN) III palsy.

C. It involves the red nucleus.

D. It is associated with hemiataxia.

E. It can result from a superior cerebellar artery occlusion.

v Answer E

5 It can result from a posterior cerebral artery occlusion.

9. Cerebral venous system. The FALSE answer is:

A. Internal cerebral veins are formed by the union of thalamostriate, choroidal, septal, epithalamic, and lateral ventricular veins.

B. The basal vein of Rosenthal drains the anterior and medial temporal lobes.

C. The vein of Galen merges with the inferior sagittal sinus to form the straight sinus.

D. The vein of Trolard drains into the sigmoid sinus.

E. The vein of Labbe drains into the transverse sinus.

v Answer D

5 The vein of Trolard drains into the superior sagittal sinus.

10. The innervation of the refexes. The FALSE answer is:

A. CN V2 mediates the sneeze refex.

B. CN 7 mediates the pectoral refex.

C. CN 10 mediates the cough refex.

D. CN 7 mediates the jaw-jerk refex.

E. CN 9 mediates the gag refex.

v Answer D

5 CN V mediates the jaw-jerk refex.

11. The contents of the tarsal tunnel. The FALSE answer is:

A. Tibial nerve.

B. Flexor hallicus longus tendon.

C. Tibialis posterior tendon.

D. Flexor digitorum brevis tendon.

E. Flexor digitorum longus tendon.

v Answer D

5 The fexor digitorm brevis is a broad muscle found deep in the sole of the foot, and its tendon is not part of the tarsal tunnel.

12. The musculocutaneous nerve, innervation. The FALSE answer is:

A. Coracobrachialis muscle.

B. Biceps brachii muscle.

C. Brachioradialis muscle.

D. Brachialis muscle.

E. Lateral forearm muscle.

v Answer C

5 The brachioradialis muscle is innervated by c6 through the radial nerve.

13. The axillary nerve, innervation. The FALSE answer is:

A. Teres minor muscle.

B. Teres major muscle.

C. Deltoid muscle.

D. The long head of the triceps muscle.

E. Skin over the shoulder.

v Answer B

5 The teres major muscle is supplied by the subscapular nerve from the C 5 to C 6 roots.

14. The nucleus pulposus of the intervertebral disc. The FALSE answer is:

A. It’s composed of collagen and a proteoglycan matrix.

B. It’s abneural and avascular.

C. It acts as a shock absorber.

D. It is derived from the neural tube.

E. It is made of 66% to 86% water.

v Answer D

5 It is an embryological remnant of the notochord.

15. The contiguous ligaments of the spine. The FALSE answer is:

A. Supraspinous ligament.

B. Ligamentum favum.

C. Posterior longitudinal ligament.

D. Anterior longitudinal ligament.

E. Interspinous ligament.

v Answer B

5 The ligamentum favum is noncontiguous and connects laminae between segments.

16. The collagen fbers of the intervertebral disc. The FALSE answer is:

A. Type I is found in the normal anulus fbrosus.

B. Type II is found in the nucleus pulposus.

C. Type III is increased in areas of minor to advanced degeneration.

D. Type VI is increased in areas of minor to advanced degeneration.

E. Type III staining is enhanced in the degenerated endplate.

v Answer E

5 Type II staining is enhanced in the degenerated endplate.

17. The contributors of spinal cord blood supply. The FALSE answer is:

A. Anterior radicular arteries.

B. Posterior radicular arteries.

C. Ascending cervical arteries.

D. Carotid arteries.

E. Deep cervical arteries.

v Answer E

5 The carotid arteries are responsible for the blood supply to the brain, neck, and face but not the spinal cord.

18. Artery of Adamkiewicz. The FALSE answer is:

A. It supplies the anterior spinal cord.

B. It is a large lower thoracic and upper lumber region blood supplier.

C. It originates as a branch of the left posterior intercostal artery.

D. It originates as a branch of the right posterior intercostal artery.

E. It is known as a great anterior radicular artery.

v Answer D

5 It typically arises from a left posterior intercostal artery at the level of the ninth to 12th intercostal artery.

19. Spinal cord tracts, functions. The FALSE answer is:

A. Anterior spinothalamic tract: crude touch and pressure.

B. Lateral spinothalamic tract: pain and temperature.

C. Dorsal spinocerebellar tract: muscle and joints unconscious information.

D. Lateral corticospinal tract: voluntary movements.

E. Rubrospinal tract: refex head turning.

v Answer E

5 The tectospinal tract is responsible for controlling the movement of the head in response to auditory and visual stimuli.

20. Clarke’s nucleus. The FALSE answer is:

A. It is mainly located from C7 to 13–14 levels.

B. It is found in the medial part of lamina VII.

C. It is an important structure for motor function.

D. It is located in the base of the posterior gray column.

E. It’s known as nucleus dorsalis.

v Answer C

5 The Clarke’s nucleus is involved in unconscious proprioception.

21. Rexed lamina, correspondence. The FALSE answer is:

A. Lamina II: substantia gelatinosa.

B. Lamina IV: nucleus proprius.

C. Lamina VII: dorsal nucleus of Clarke.

D. Lamina I: marginal zone.

E. Lamina V: Renshaw cells.

v Answer E

5 Renshaw cells are mainly located in rexed laminae VII and VIII.

22. Spinal ligaments, extensions. The FALSE answer is:

A. The apical ligament extends from the tip of the dens to the basion.

B. The posterior longitudinal ligament extends from C1 to S1.

C. The transverse atlantal ligament extends between the tubercles of the lateral masses of the atlas.

D. The anterior longitudinal ligament extends from the basioocciput to S1.

E. Alar ligaments extend from the dens to the lateral margins of C1.

v Answer E

5 Alar ligaments extend from the dens to the lateral margins of the foramen magnum.

23. Muscles that are innervated by the recurrent branch of the laryngeal nerve. The FALSE answer is:

A. Transverse arytenoid muscle.

B. Thyroepiglottic muscle.

C. Posterior cricoarytenoid muscle.

D. Cricothyroid muscle.

E. Anterior cricoarytenoid muscle.

v Answer D

5 The recurrent laryngeal nerve innervates all intrinsic laryngeal muscles except the cricothyroid, which is supplied by the external branch of the superior laryngeal nerve.

24. The inferior division of the oculomotor nerve. The FALSE answer is:

A. It innervates the levator palpebrae muscle.

B. It innervates the inferior oblique muscle.

C. It innervates the medial rectus muscle.

D. It innervates the inferior rectus muscle.

E. It passes through the anuulus of Zinn.

v Answer A

5 The levator palpebrae muscle is innervated by the superior division of the oculomotor nerve.

25. The hypoglossal nerve, innervation. The FALSE answer is:

A. Palatoglossus muscle.

B. Styloglossus muscle.

C. Genioglossus muscle.

D. Hypoglossus muscle.

E. Intrinsic muscles of the tongue.

v Answer A

5 The vagus nerve innervates the palatoglossus muscle.

26. The CN contains special visceral aferent fbers. The FALSE answer is:

A. Facial nerve.

B. Glossopharyngeal nerve.

C. Olfactory nerve.

D. Trigeminal nerve.

E. Vagus nerve.

v Answer D

5 The trigeminal nerve doesn’t contain special visceral afferent fbers.

27. Skull base triangles and borders. The FALSE answer is:

A. Glasscock’s triangle: third division of trigeminal + grater petrosal nerve + foramen spinosum/arcuate eminence.

B. Kawase’s triangle: third division of trigeminal nerve + GSPN + arcuate eminent + superfcial petrosal sinus.

C. Parkinson’s triangle: oculomotor nerve + second division of trigeminal nerve + tentorial edge.

D. Clinoidal triangle: optic nerve + oculomotor nerve + tentorial edge.

E. Supratrochlear triangle: oculomotor nerve + trochlear nerve + dura of petrosal edge.

v Answer C

5 Parkinson’s triangle is bound by the trochlear nerve, the frst division of the trigeminal nerve, and the tentorial edge.

28. Structures pass through the annulus of Zinn. The FALSE answer is:

A. Frontal nerve.

B. Oculomotor Nerve.

C. Roots of the ciliary ganglion.

D. Nasociliary nerve.

E. Abducens nerve.

v Answer A

5 The frontal nerve passes outside the annulus of Zinn.

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would have thought him a paragon of perfection if he only would be less attentive to Christie.

And Christie, the sly little child-wife, had gone on dreaming "Love's young dream," and never thinking how terrible one day would be her waking.

Since their bridal-night, the mysterious phantom had never been seen; and both were beginning to hope it had been only an illusion of a heated imagination. Mr. Drummond had accounted for the terrifying shriek and Christie's fainting fit in some ingenious way of his own, that quite satisfied the old lady, and lulled to sleep any suspicions she might have conceived.

One evening, as Willard set out to keep an appointment with Christie, he observed Lem standing, or rather sitting perched up on a limb of a giant pine tree, shading his eyes with his hands, and looking anxiously out to sea.

"Well, my boy, what has caught your attention in that direction—wild geese?"

"No, master," said Lem, solemnly; "I see a sail."

"Well, and what of that?" said Mr. Drummond. "A sail is not such an unusual sight here, is it?"

"Bur dare's a storm brewing an' if de Lord ain't took 'special charge ob dat vessel, de fust lan' it makes will be Davy Jones' locker," said Lem.

"A storm, you blockhead!" exclaimed Drummond, "There is not a cloud in the sky."

"Jes' look ober dar, massa, and see dat black cloud, 'bout de size o' your hand."

"Well?" said Willard.

"Pretty soon dat will be all ober the sky, and den we'll hab a taring squall. De trees tell de wind's risin' already, and you needn't be s'prised ef

to-morrow mornin' you sees de ruins o' dat wessel spread all over the shore."

And Lem, with a doleful shake of his head, descended from his perch and sought the house.

Ere the hour had passed, Lem's prognostications proved true. The heavens rapidly darkened, as dense, black, threatening clouds rolled over it; the sea became of an inky hue, crested with white, ghastly-looking foam, as it heaved and groaned like a "strong heart in strong agony," The wind rose and crashed with terrific force through the woods, bending strong trees like reeds before its might.

"Lor' sakes, how it blows!" said Mrs. Tom, as she blustered in and out. "I 'clare to man, it 'most took me right off my feet. I ain't heerd sich a wind these five year come Christmas, and them two ships were wrecked right out from the shore, and every soul perished. Dear, dear! what a sight it was next day, when all the drowned corpses was washed ashore. It was the most awfulest sight I ever seed. Carl, don't sit layin' there in the corner all night, toastin' your shins like a singed cat. Get up and pick the pen-feathers out of that fowl."

"I heard Lem saying there was a ship in view about an hour ago," said Drummond, rising.

"Lord a' massy upon them, then!" said Mrs. Tom; "for, if they touch the shore, they'll every one go to the bottom.'"

"Oh, dreadful!" said Christie, turning pale with pity and horror.

"It's goin' to be an awful night! Just listen to the wind roarin' through the trees, and that rain! I never heard the waves boomin' on the beach as they're doin' now, that a wreck didn't foller. It's a blessin' Captain Guy and Miss Sibyl ain't on the sea this dreadful night. When they were away, I used to think of them in every storm. Lord preserve us! look at that." And, with a piercing shriek, the startled Mrs. Tom sprang back.

A fierce gust of wind, threatening to bring down the roof about their heads; a tempestuous dash of rain, as if the flood-gates of heaven had opened for a second deluge; a blaze of blue, livid lightning, as though the whole firmament was one sheet of flame; a crash of thunder, as though heaven and earth were rending asunder!

With a wild cry of terror, Christie sprang up pale, trembling, horrorstruck. Carl crouched into a ball in a remote corner. Neither dared to speak or move.

Mrs. Tom, forgetting her first involuntary alarm, sprang to close the shutters, and make fast the doors. And Willard, amazed at the suddenness with which the storm had arisen, buttoned up his coat, preparatory to starting for the lodge, ere it should further increase in violence.

"Oh, do not go—do not leave us!" cried Christie, springing forward, and pale, wild, terror-stricken, clinging to him, scarcely conscious of what she did.

"Dearest love, do not tremble so; there is no danger," he whispered, encouragingly, encircling her slight waist with his arm.

But Mrs. Tom, turning suddenly around, and beholding them in this position, in spite of her panic, was shocked and indignant.

"Lor' a' massy 'pon us, child, sit down—no, kneel down, and say your prayers. You ought to be ashamed of yourself to do sich a thing. Mr. Drummond, I'd be 'bliged to you not to keep your arm 'round her that way; it doesn't look right, nor, likewise, respectable."

But here, Mrs. Tom's words were abruptly cut short; for, across the stormy, raging sea, high above the roar and shrieking of the storm, pealed a minute-gun of a ship in distress, like an agonized cry for help.

"Heaven be merciful! Listen to that!" exclaimed Mrs. Tom, turning pale.

Another fierce, tempestuous burst of wind and rain another blinding glare of sulphurous lightning; another appalling peal of deafening thunder

rent the air. And then again boomed the minute-gun over the sea.

"Something must be done; something shall be done!" cried Willard, excited beyond endurance, at the thought of so many perishing almost within a dozen rods of where he stood. "Carl, my boy, come with me; and, with the assistance of Lem, we may be able to save some of those perishing wretches."

"It's too wet!" said a terrified voice, from the corner, as its owner crouched into a still smaller ball.

But Mrs. Tom—who never forgot the practical no matter what her alarm might be—went over, and taking the unfortunate youth by both ears, lifted him, with a jerk, to his feet.

With a howl of pain, Carl extricated himself from her hands, and clapped both his own palms over the injured members.

"Now, go this minute, and get your hat and overcoat, and go out with Mr. Drummond, and do whatever you can. And if he goes laying around, just give him a blow 'long side of the head, and make him know he's got to mind you. Come, be quick!"

Carl, whose dread of the storm was far inferior to his dread of Mrs. Tom, donned his coat and hat with amazing alacrity—having tied the former under his chin, with a red handkerchief, to keep it on—stood ready to depart, wiping the tears from his eyes, first with the cuff of one sleeve, and then with the other.

Willard cast one look at Christie, who had sunk on the floor, her face hidden in her lap; and then turned to depart, followed by the unwilling Carl. The blinding gust of wind and rain that met them in the face nearly drove them back; but, bending to the storm, they resolutely plunged on; and it required all the strength of Mrs. Tom to close the door after them.

The storm seemed increasing in fury. The wind howled, raged and shrieked; the waves thundered with terrific force over the rocks; the thunder roared, peal upon peal, shaking the very island to its center; the lightning

alone lit up for an instant, with its blue, livid glare, the pitchy darkness; and then the crash of the strong trees in the neighboring forest, as they were violently torn up by the roots, all mingled together in awful discord.

But, above all, the minute-gun came wailing once more over the sea.

The two, plunging so blindly through the storm, hastened on as if winged at the saddest of sounds. And, after tumbling, slipping, falling, rising, and hurrying on again, they reached the old lodge at last.

A light was burning in the kitchen. Both rushed in there—wet, dripping, and half-blinded by the storm. Aunt Moll was on her knees in the middle of the floor rocking back and forward, and praying aloud in an agony of terror and apprehension; and Lem was walking up and down, groaning and praying, at intervals, with his mother.

"Oh, good Lor'! I's been a drefful sinner, I is; but if you'll only spare me jes' a little while longer, I tends to do better. Oh, do spare me! I ain't ready to go 'deed and 'deed I ain't. Please do, good Lor', an' I'll nebber do nothin' sinful again. Oh, what a streak o' lightnin' dat 'ar was! O, Lemuel, kneel down, or yer ole mammy'll be took away in a flash o' lightnin' like 'Lijah was."

And in an agony of fear Lem tramped up and down the long kitchen, quaking at every fresh clap of thunder.

"Come, cease that caterwauling!" said Drummond, as he burst in upon them, dripping like a sea-god; "and you, Lem, get your coat, and come with us down to the beach, and see if we cannot save some poor unfortunates from death and destruction."

"'Deed, Master Drummin', honey, I dassent, I's 'feared to go out," said Lem, his teeth chattering like a pair of castanets.

"You black villain, if you are not ready in ten minutes, I'll thrash you till you are not able to stir!" exclaimed Willard, catching and shaking him furiously.

Too terrified by the young man's fierce tone to resist, Lem drew on his hat and coat, and, shaking like one in an ague-fit, followed them out into the night, and darkness, and storm.

Once more over the tempest-tossed waves rolled the mournful voice of the minute-gun, like a dying cry.

"Oh, Heaven, this is maddening!" exclaimed Willard, rushing to the beach like one demented; "to think they should perish thus, within reach of us almost, while we are here in safety. Carl, where is your boat? I will venture out, and see if I cannot save some one, at least."

"Oh, Marse Drummin'! for de dear Lord's sake, don't risk it!" cried Lem, in an agony of terror. "No boat could live two minutes in dem waves."

"You couldn't launch the boat in these breakers," said Carl, "much less pull, if you were into her."

"And they must perish before our very eyes! Oh, heavens, this is awful!"

Again he listened for the gun, but it came no more. Its voice was silenced in storm and death.

"They have gone down!" said Carl; "the signal gun will fire no more."

"Heaven have mercy on their souls!" said Willard, solemnly, lifting his hat.

"Amen!" said Lem, whose fears seemed swallowed up in awe.

"We may soon look out for the bodies," said Carl, straining his eyes over the black, seething waves.

Even as he spoke, by the blinding light of a glare of lightning they beheld two bodies, lashed to a spar, thrown violently on the sands near them. All sprang forward, and drew them up beyond the reach of the waves.

"Unfasten this rope," said Carl, "and we will bring them up to the house. Perhaps they may not be drowned yet."

"One's a woman," said Lem, as he cut the lashing. "I can carry her, I reckon, while you two tote the man along."

"Go on, then," said Willard, "up to Mrs. Tom's. Be quick!"

Bearing, with the utmost difficulty, their wet and apparently lifeless burdens in their arms, they reached the cottage of the widow, and deposited the senseless forms before the fire. Then, leaving them to her charge and that of Christie, they descended once more to the beach to rescue any other unfortunate who might providentially be washed ashore.

Toward midnight the storm abated, and the king of the tempest sullenly began to call off his hosts. The dense thick clouds slowly rolled back, the lightning ceased to flash, and the thunder only growled in the distance. The wind abated, and the rain fell more slowly; but, though they waited until morning dawned, no more bodies were wafted to their feet.

The next day's light showed a scene of ruin and death. The beach was strewn in every direction with fragments of the broken ship, and some halfdozen dead bodies lay scattered on the sands. All were cold and dead; and sad and disappointed, our tired and drenched watchers turned a way.

Before going to the lodge Willard visited the cottage, and learned that the rescued ones were both alive, and might recover. And, grateful to have been the means of saving even two of the unfortunates, he sought his own couch, to dream of wrecks and drowned men till noon-day.

CHAPTER XII.

SIBYL'S RETURN TO THE ISLE

"There is a shadow in her eye, A languor in her frame; Yet rouse her spirit and she'll glow With passion's fiercest flame." T.W.H.

It was late in the afternoon of the following day when Willard Drummond left the lodge for Mrs. Tom's cottage. Curiosity to see the rescued ones prompted the visit as much as any other feeling; and he walked along rapidly, viewing the scene of desolation which the preceding night's tempest had left.

The cottage door was open to admit the pleasant sunshine, and Willard paused for a moment to view the scene before he entered.

Mrs. Tom went bustling about the room in her usual breezy, chirruping way, talking incessantly, but in a subdued tone, as though afraid of disturbing some one. Christie sat near the window, bending over her sewing, looking pale still, after the terror and excitement of the previous night. But Willard's eyes did not linger a moment on her; they were fixed, as if fascinated, on another, who lay back in Mrs. Tom's arm-chair, propped up with pillows.

It was the woman, or rather the girl, he had saved, What was there in that pale young face to make him start so vehemently, while the blood rushed in a crimson torrent to his very temples? He only saw a small, slight figure; short, crisp, golden curls clustering over a round, white, polished forehead; bright, saucy gray eyes, half veiled now under the long, silken eyelashes, resting on the pearly cheek; a little rosebud mouth, and a nose decidedly retrousse. It was not a wonderfully pretty face; but there was something bright, piquant, original, and charming about it—something

daring, defiant, and high-spirited, as you could see even in its pallor and languor. She might have been sixteen, though she scarcely looked so old as that.

She lay back now with her little white hands folded listlessly on her lap, her veiled eyes fixed upon them with a dreamy, abstracted look, as of one whose thoughts are far away—replying low and languidly to Mrs. Tom's ceaseless questioning. And Willard Drummond, pale and excited, leaned against the door-post, gazing upon her like one who cannot believe his senses.

Suddenly Christie raised her eyes from her work, and uttered an ejaculation as she espied him. He could linger no longer, and like one who walks in his sleep, he passed in.

The clear, dark eyes of the little lady in the chair were raised as he entered, and fixed with a look of complete amazement on his face. Her dark eyes dilated—her lips parted in surprise, as she made an effort to rise from her chair, and then sank back exhausted.

"Willard Drummond!" broke in surprise from her lips.

"Laura!" he exclaimed.

And he was by her side in an instant, holding her hands in his, and gazing in her eyes with a look that would have aroused Sibyl's jealousy, had she been present, but which only puzzled Christie, who, with Mrs. Tom, looked on in astonishment.

"Who in the world would have expected to meet you here!" said the lady, recovering first from a moment's embarrassed silence; "certainly the last spot on earth I should ever look for the gay, pleasure-loving Willard Drummond. So, sir, I presume you have been 'taking the world easy,' here in this Enchanted Isle, while your poor, deluded friends were laboring under the conviction you were improving your mind—-which needed improving, goodness knows—by foreign travel? Pretty conduct, Mr. Drummond, I must say!"

"Oh, Laura! Laura! how little did I dream, last night, you were in that fatal ship!" he exclaimed, passionately.

"Ugh! yes; wasn't it awful?" said the young girl, with a shudder. "I'll never get the horrid sight and sounds of that dreadful night out of my mind while I live. Oh! to have heard the screams, and cries, and prayers, and blasphemies of the drowning crew, mingling with the fearful storm, was appalling. Holy saints! I hear them yet!"

With a convulsive shudder, she hid her face in her hands.

"Thank Heaven your life was saved, at least," said Drummond, with fervor.

"Yes, our escape was little less than miraculous. I remember some one making me fast to a floating spar, as the ship struck; then the waves swept furiously over me, and I remember no more, until I awoke and found kind friends chafing my hands and temples. Was it you who saved me, Willard?"

"Not exactly. The waves washed you ashore, and my part of it was merely to have you conveyed up here. But how little did I dream then, that Laura Britton was so near!"

"Laura Courtney, if you please, Mr. Drummond," she said, quietly. "I have had the honor of changing my name since I saw you last."

"And you have married Edgar Courtney! Oh, Laura, Laura?" he said, reproachfully.

Her eyes flashed as she faced suddenly round, and said, sharply:

"Yes, I have married him; and, Mr. Drummond, don't you dare to speak of him in that tone again. I will not endure it. No, not if you had saved my life a dozen times."

The angry blood flushed to her pale cheek, and she jerked her hand angrily away from his grasp.

Willard bit his lip till it bled, to keep down his rising anger; while Christie and Mrs. Tom still sat staring in increasing amazement.

There was a long, disagreeable pause, broken at last by Mrs. Courtney saying, in her usual quick, abrupt way:

"There! you need not get mad, now, Willard; have you forgotten that no one used ever to get angry at anything said by 'Madcap Laura?' Come, don't speak so of Mr. Courtney again, and I'll forgive you; there's my hand on it. I cannot forget that we are old friends."

A shadow crossed Willard's face, as he bent over the little hand she extended.

"Has your—has Mr. Courtney been saved?" he asked, in a subdued tone.

"Yes, the waves washed us ashore together, but something struck him on the head, and he is unable to rise. I suppose you are puzzling your brains now to know what brought us to this quarter of the globe?"

"I confess I have some curiosity on that point."

"Well, you see," said little Mrs. Courtney, adjusting herself more comfortably in her chair, "we went on a bridal-tour to New York, and on our way home Edgar thought he would call at Westport, where he had business of some kind. All the way we had fine weather until the journey was at its end, and then the storm arose in which we nearly perished. But, Willard, what under the sun can have driven you here?"

Willard colored as he met her keen, bright glance.

"Well, I came with a friend of mine, a certain Captain Campbell, who owns a residence here, and I am for the present his guest, though unexpected business, for a time, called him away. Anything for a change, you know," he added, laughing, "and this island is not quite devoid of attraction."

"By no means," said Mrs. Courtney, glancing demurely at Christie. "I certainly admire your good taste in saying so. Once here, with such a divinity as this, I can easily account for the attraction that binds you, most fickle of men, here," she added, in a lower tone.

"Pshaw, Laura!" he said, striving to hide by a laugh the guilty flush that lingered still on his face, "you surely do not think I have forgotten you so soon?"

"If it were any one else I would not, but you—oh, you never would be true to any one longer than a month. Talk about woman's fickleness! I'm sure the wind never was half so changeable as you."

"Yes, you gave me great encouragement to be true to you," he answered, with some bitterness.

"Did I," said Mrs. Courtney, with a yawn. "Well, I know I was a horrid little simpleton once, but I've grown old and wise now. And, if it's all the same to you, Mr. Drummond, I'll leave you now. I feel tired and half sick yet, after last night."

She rose and went into the room with a weary, tired air.

"So, you know her?" said Mrs. Tom. "Who'd ever thought it? So that tall, dark-looking fellow, with all the whiskers and mustaches, is her husband? I declare if it ain't scandalous the way gals will get married afore they're out o' short frocks. I jist wish I had a darter—no, I mean if I had a darter—I'd like to see her tryin' to get married at such an unchristian age!"

Christie turned scarlet, and bent lower over her work.

Willard stood leaning with one arm on the mantel-piece, gazing thoughtfully into the fire.

"What did you say her name was?" inquired Mrs. Tom, sitting down, and beginning to reel off yarn.

"Mrs. Edgar Courtney, now; she was Laura Britton when I last met her," he said, as if half speaking to himself.

"S'pose you've known her a long time?" continued Mrs. Tom.

"Yes, we were children together," he replied, in the same dreamy tone.

"And her husband—known him long?" pursued Mrs. Tom.

"Yes, I know him for a cruel, jealous, passionate tyrant!" said Willard, starting up so suddenly and fiercely that Mrs. Tom dropped the ball she was winding, and sprang back.

"Well, you needn't make such a fuss about it!" she exclaimed, recovering herself, and indignantly resuming her work. "Scaring a body out o' their wits for nothin'. I s'pose she knowed all that afore she took him."

"Pray, pardon my vehemence, Mrs. Tom," said Willard, recovering himself by an effort, as he saw Christie's troubled gaze fixed on his face; "I forgot myself for a moment. But this patient of yours, this Mr. Courtney, may need a doctor. I am going over to Westport to-night, and if you wish, I will bring one to-morrow."

"It would be better," said Mrs. Tom, thoughtfully. "He's got a temenjous cut right in his head. I did what I could for him; but, of course, a body would feel more satisfied if they had a reg'lar doctor.'

"If I were ill, Mrs. Tom, I should trust to you in preference to any doctor ever warranted to kill or cure," said Willard, as he took his hat to go.

Mrs. Tom smiled benignly at the compliment, quite delighted at this tacit acknowledgment of her skill.

And an hour after, Willard and Lem were on their way to Westport.

What were Willard Drummond's thoughts, as, sitting silently in the stern of the boat, he watched the dancing waves flash and sparkle in the sunlight? Very different from those he had indulged not long since, when, on one eventful night, he and Christie had crossed it together. This Laura Courtney,

with her pretty, piquant face, and pert, saucy manners, had first won his boyish heart. He had raved, and vowed, and implored at her feet, but she only laughed at him and his passion, and now she had no more power over his heart than if she never existed. Might it not be the same with those he had loved since? Was not his passion for Christie beginning to grow cold already? Would it not grow colder every day? And in the hot ardor of his love he had made this little obscure, uneducated, shy child, his wife. Why, oh, why, had he not waited? And now that the deed was irreparable, where was this to end?

They reached Westport before dark; and Lem, having landed him, set off for the island again, promising to return for him in the morning. The moon was just rising above the pine trees when he reached home; and, on entering the house, the first object he beheld was his young mistress, in close conversation with his mother.

"Lor' sakes, Miss Sibyl! you here!" was Lem's first ejaculation.

"Yes, Lem; and glad to be home again," she answered, gayly. "Aunt Moll tells me you have just been taking Mr. Drummond over to Westport."

"So I hev; but I'm to go for him early to-morrow-mornin.' 'Spect, ef he'd know you was a comin,' he'd staid here."

"Humph!" said Aunt Moll, dubiously.

"Did he seem lonely during my—during our absence?" asked Sibyl.

"Lonesome? 'Deed he didn't, honey; he was in fust rate spirits all the time."

"Ah!" said Sibyl, a shadow falling over her face; "he spent his time in fishing and shooting, I suppose, and snaring birds?"

"Snarin' birds? Yes; an' caught one, too," said Aunt Moll, in a tone that spoke volumes.

"Caught one! What do you mean, Aunt Moll? I don't understand," said Sibyl, anxiously.

"Miss Sibyl, don't listen to her. She's allers got some nonsense to tell," interrupted Lem, casting an angry and warning glance toward his mother.

But now that the opportunity she had so long waited for had come, the old woman's tongue was not to be stopped.

"It's all fur yer good, child, 'deed it is; an' I 'siders it my duty to warn you, honey, dat Massa Drummond ain't to be 'pended on. Dar!"

"Aunt Moll, what do you mean? Speak, and tell me what you are hinting at. What has Mr. Drummond done?" asked Sibyl, growing very pale.

"Well, chile, 'stead o' stayin' here, and thinking ob you, as he'd orter, he's been prowlin', all hours o' de night, round de island, wid dat 'ar Miss Chrissy—making lub to her, I'll be bound."

"What?" cried Sibyl, in a tone that made the old woman leap to her feet, as she sprang forward, and caught her by the arm. "Dare you insinuate such a thing? I tell you he could not, and he would not—he dare not prove false to me!"

"Miss Sibyl, honey! for de Lord's sake, don't look at me wid such wild eyes. I 'spec's she's witched him. I can't 'count for it no other way," said Aunt Moll, trembling before the awful wrath of those blazing eyes. "I on'y says what I knows. He's all the time talkin' 'bout her to hisself, when he's 'lone."

"It cannot be true; he dare not deceive me!" almost shrieked Sibyl. "What proof have you of this? Speak! speak!"

"Miss Sibyl, honey! you may 'sassinate me ef you's a mind to; but I's tellin' de trufe. Sence eber you left, dey ain't a minute apart. Dey've sailed in de riber after night, an' gone trampin' in de woods in de day time; an' I's heered him callin' her his 'dear Chrissy,' when he's 'lone. I knows, chile,

'taint pleasant, nor likewise 'greeable for you to hear dis; but I talks for your good, honey—'deed I does."

But now the first fierce gust of passion was over, and pale and tottering, Sibyl leaned against the chimney-piece—her arm on the mantel, her head bowed upon it, shuddering, sinking, collapsed. All his neglect, that had puzzled her so long, was accounted for now. She was forgotten—deserted, for this island girl!

So long she remained in that fixed, rigid attitude, that Aunt Moll began to grow alarmed; and she was on the point of commencing a consoling speech, beginning with: "Miss Sibyl, honey," when the young girl lifted her head, and, asked in a hollow voice:

"Is this—this girl on the island still?"

"Yes, chile, ob course she is—down to Miss Tom's."

For a moment longer Sibyl stood, gazing steadily before her, with those wild, fierce, burning eyes; her face perfectly colorless, save that two darkpurple spots blazed in and out upon it like burning coals; her teeth set; her hands clenched. All the humiliation, the shame, the agony of being deserted, rushed, like a burning torrent, through her mind. And with it came a fierce, demoniacal hatred of her idol, and a deadly wish to be revenged.

Starting suddenly up, she fled up the stairs, through the long, unlighted hall, out of the front door, and took the path leading to Mrs. Tom's.

The bright moonlight lit all around with a pale, radiant glory. And, standing near a rock, commanding an extensive view of the sea, Christie stood, enjoying the beauty of the night, when suddenly a fierce grasp was laid on her shoulder, and she looked up. Her vision was realized. Sibyl Campbell stood glaring upon her, with her fierce, wild, black eyes, her long hair streaming down her back, like an aroused tigress preparing to spring.

CHAPTER XIII. THE MEETING.

"Thou mayest hold a serpent by the tongue, A chafed lion by the mortal paw, A fasting tiger safer by the tooth, Than cross this love of mine "

Trembling, paralyzed, shrinking with terror and superstitious awe, as she recollected her vision, Christie stood quailing before that dark, passionate glance.

And, glaring upon her with a hatred and jealousy that for the time "swept her soul in tempests," and inspired her with a momentary frenzy, Sibyl stood, transfixing her with those wild, fierce eyes. With one glance she took in all her rival's extraordinary beauty, far surpassing even what she feared; and the sight, to her passionate heart, was like oil poured upon flame.

"So," she hissed, at length, through her closed teeth, "pretty Miss Christie has found a lover during my absence. Girl, take care! You have begun a dangerous game, but the end has not come!"

Her words broke the spell of terror that held Christie dumb. And now, noticing her disordered attire, and wild, disheveled hair, she said, in surprise and entreaty:

"Miss Sibyl, what has happened? What have I done? I did not know you were on the island."

"No; I am aware of that," said Sibyl, with a hard, bitter laugh. "Oh, it is a wondrous pity I should have come so soon to spoil the sport! You and your dainty lover thought yourselves secure—thought Sibyl Campbell far away. But again I say to you, beware! for 'twere better for you to tamper

with a lioness robbed of her young than with the passions of this beating, throbbing heart!"

She looked like some priestess of doom denouncing all mankind as she stood there, with her long, black, streaming hair, her wild, burning, passionate eyes, her face white, rigid, and ghastly, save where the two purple spots still blazed in and out on either cheek.

"Oh, Miss Sibyl—dear Miss Sibyl! what have I done? Oh, I never, never meant to offend you, or stand in your path; as Heaven hears me, I did not! Tell me, only tell me in what I have offended, and I will never do it again," said Christie, clasping her hands in increasing terror and childlike simplicity.

"What have you done? Have you really the effrontery to stand there and ask me such a question?"

"Miss Sibyl, I do not know—indeed, indeed, I do not know!" exclaimed Christie, earnestly.

In all the storm of anger and jealousy that raged in her soul, a look of superb scorn curled the lips of Sibyl.

"You do not know! Oh, wondrous innocence! angelic simplicity! Must I despise as well as hate you? Listen, then, since I must speak my shame, and answer me truly, as you hope for salvation. Promise."

"I promise!"

"Swear to answer me truly, by all you hold dear on earth! by your hopes of heaven!"

"I swear! Oh, Sibyl, speak!" cried Christie, wrought up to an agony of terror and excitement by her wild words.

"Then, and may Heaven's heaviest curse fall upon him if I conjecture truly—has Willard Drummond dared to speak of love to you?"

Pale, trembling, terror-stricken, Christie's tongue clove to the roof of her mouth; had her life depended on it, no sound could have escaped her quivering lips.

"Speak, and tell me! Speak, for I must know—I have a right to know?" cried Sibyl, grasping her arm, and setting her teeth hard to keep down the tempest of passion that was sweeping through her soul.

"Oh, spare me—spare me!" wailed Christie, lifting up her pleading hands.

"Death, girl! Must I tear the truth from your false heart! Tell me, truly, has he dared to speak of love, and have you dared to listen to him? Heavens! will you speak before I am tempted to murder you!"

"Oh, do not ask me—do not ask me!" cried Christie, in a dying voice, as trembling, fainting, she sank at the feet of her terrible foe.

With her hands clenched until the nails sank into the quivering flesh, her teeth set hard, her deep, labored breathing, her passion-convulsed face, she looked more like an enraged pythoness than a frail girl learning for the first time her lover's infidelity.

She required no further proof now. He whom she would have trusted with her soul's salvation was false. And, oh! what is there more terrible in this world than to learn that one whom we love and trust has proven untrue?

Sibyl had loved as she had done everything else—madly; had trusted blindly; had worshipped idolatrously, adoring man instead of God; and now this awakening was doubly terrible. Had Christie been in her place, she would have wept and sobbed in the utter abandon of sorrow; but her grief would have been nothing compared with the dry, burning despair in those wild black eyes.

Now that Sibyl had learned the worst, her fiery, tempestuous fierceness passed away, and there fell a great calm—a calm all the more terrific after her late storm of passion.

"And so I am forsaken," she said, in a deep, hollow voice, "and for her —this pretty, blue-eyed baby. I, whom he promised to love through life and beyond death. Saints in heaven! shall he do this and live?"

"You?" said Christie, lifting her pale, terrified face. "And did he promise to love you, too?"

"Yes, learn it, and let it whelm your soul in shame. Before he saw you, before he knew you, he loved me; and I was to be his wife. Yes, weep, and wail, and sob; your tears shall not soon dry. You have caused him to forget his vows, his honor, his plighted faith, his promised love to me, and you must pay the penalty."

"Oh, I never knew it—I never knew it!" wailed Christie, wringing her hands.

"And, as he has been false to me, so, likewise, will he be false you. You are the cause of his treachery, of his broken vows, his perjured soul; you are the cause of all; and, think you such love can be blessed?"

"Forgive me! Oh, Sibyl, forgive me!" still wailed Christie.

"May Heaven never forgive me if I do!" cried Sibyl, with impassioned vehemence. "Think you, girl, I am one to be won by tears and protestations? Faugh! you should have thought of all this when you listened to his unlawful love."

"Oh, I did not know! As Heaven hears me, I did not know. I would have died sooner than have listened to him, had I known!"

"Prove it," said Sibyl, with a sudden gleam in her dark eyes.

"How—how? Only say how I shall redeem my error! Let me know how I may atone!"

"Atone!—you?", said Sibyl, with a withering sneer. "I tell you, girl, if your life could be prolonged for a thousand years, and every second of that time spent in torture, you could not atone for the wrong you have done me.

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