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Andrea Poretti
Thierry A.G.M. Huisman
Editors
123
Neonatal Head and Spine
Ultrasonography
Andrea Poretti
Thierry A.G.M. Huisman
Editors
v
vi Preface
1 Introduction.................................................................. 1
References ............................................................................. 3
4 Seizures ......................................................................... 29
Differential Diagnosis of Brain Abnormalities
Associated with Neonatal Seizures That May Be
Detected by Neonatal Head Ultrasonography ............ 30
Arterial Ischemic Stroke (Figs. 4.1 and 4.2).................. 31
Herpes Encephalitis (Figs. 4.3, 4.4, and 4.5) .................. 34
Congenital Cytomegalovirus Infection
(Figs. 4.6, 4.7, 4.8, and 4.9) ........................................... 38
Intraventricular Hemorrhage with Periventricular
Venous Infarction (Figs. 4.10 and 4.11) ..................... 43
Periventricular Subependymal Heterotopia
(Figs. 4.12 and 4.13) ..................................................... 46
References ............................................................................. 49
5 Encephalopathy ........................................................... 51
Differential Diagnosis of Brain Abnormalities
Associated with Neonatal Encephalopathy That May
Be Detected by Neonatal Head Ultrasonography ...... 52
Hypoxic-ischemic Injury (Figs. 5.1, 5.2, and 5.3) .......... 53
vii
viii Contents
6 Muscular Hypotonia.................................................... 75
Differential Diagnosis of Brain Abnormalities
Associated with Muscular Hypotonia That May Be
Detected by Neonatal Head Ultrasonography ............ 76
Joubert Syndrome (Figs. 6.1, 6.2, and 6.3) ..................... 77
References ............................................................................. 81
7 Hemiparesis .................................................................. 83
Differential Diagnosis of Brain Abnormalities
Associated with Hemiparesis/Hemiplegia That May
Be Detected by Neonatal Head Ultrasonography ...... 84
Arterial Ischemic Stroke (Figs. 7.1 and 7.2).................. 85
Intraventricular Hemorrhage (Figs. 7.3, 7.4,
and 7.5).......................................................................... 88
Unilateral Periventricular Venous Infarction
(Fig. 7.6) ........................................................................ 92
References ............................................................................. 94
8 Apnea ............................................................................ 95
Differential Diagnosis of Brain Abnormalities
Associated with Apnea That May Be Detected
by Neonatal Head Ultrasonography.............................. 96
Cerebellar Hemorrhage (Figs. 8.1 and 8.2) ................... 97
Intraventricular Hemorrhage (Figs. 8.3 and 8.4) .......... 100
References ............................................................................. 103
Index...................................................................................... 169
Contributors
xi
Chapter 1
Introduction
References
Benson JE, Bischop MR, Cohen HL. Intracranial neonatal neuro-
sonography: an update. Ultrasound Q. 2002;18:89–114.
Daneman A, Epelman M, Blaser S, Jarrin JR. Imaging of the brain in
full-term neonates: does sonography still play a role? Pediatr
Radiol. 2006;36:636–46.
Di Salvo DN. A new view of the neonatal brain: clinical utility of
supplemental neurologic US imaging windows. Radiographics.
2001;21:943–55.
Govaert P, de Vries LS. An atlas of neonatal brain sonography.
London: Mac Keith Press; 2010.
Ladino Torres MF, DiPietro MA. Spine ultrasound imaging in the
newborn. Semin Ultrasound CT MR. 2014;35:652–61.
Leijser LM, de Vries LS, Cowan FM. Using cerebral ultrasound
effectively in the newborn infant. Early Hum Dev. 2006;82:
827–35.
Maalouf EF, Duggan PJ, Counsell SJ, Rutherford MA, Cowan F,
Azzopardi D, Edwards AD. Comparison of findings on cranial
ultrasound and magnetic resonance imaging in preterm infants.
Pediatrics. 2001;107:719–27.
Nwafor-Anene VN, DeCristofaro JD, Baumgart S. Serial head ultra-
sound studies in preterm infants: how many normal studies does
one infant need to exclude significant abnormalities? J Perinatol.
2003;23:104–10.
Orman G, Benson JE, Kweldam CF, Bosemani T, Tekes A, de Jong
MR, et al. Neonatal head ultrasonography today: a powerful
imaging tool! J Neuroimaging. 2015;25(1):31–55. doi:10.1111/
jon.12108.
Steggerda SJ, Leijser LM, Walther FJ, van Wezel-Meijler G. Neonatal
cranial ultrasonography: how to optimize its performance. Early
Hum Dev. 2009;85:93–9. doi:10.1016/j.earlhumdev.2008.11.008.
van Wezel-Meijler G, Steggerda SJ, Leijser LM. Cranial ultrasonog-
raphy in neonates: role and limitations. Semin Perinatol.
2010;34:28–38. doi:10.1053/j.semperi.2009.10.002.
Chapter 2
How to Perform a Neonatal
Head Ultrasonography Study
Sinking gratefully upon the long chair, so restful in spite of its wooden
hardness, with the sun shining and the sea sparkling to the even movement
of the great turbine vessel as they caught the faint breeze of their motion,
Ermengarde would now have been happy, but for the fear of that dread
penalty the sea exacts from sensitive voyagers, and the impossibility in her
giddiness and weakness of opening the straps that held her rugs and shawls.
How exasperatingly, aggressively, comfortable people looked, chatting and
laughing in their cosy furs; some even shielded themselves from the mild
warmth of the wintry sun with parasols, though Ermengarde would have
welcomed the glare of a furnace, as she shivered in the sharp sea air.
But others were worse off than she. So much so that she was even
moved to offer her own hard-won chair to a pretty, slender French girl, pale
and tired-looking, who kept leaning against anything that came in her way
till she seemed to become chilled to the bone, when she would move a little
and come back to the best place she could find. Presently she leant against
an iron balk close to an inviting deck-lounge, which was occupied the
whole way across by a hard round hat, a man's fur coat, and some walking-
sticks and umbrellas. Ermengarde longed to send these properties flying—
especially the hat, which inspired her with peculiarly acute hatred—and lay
the pretty, tired French girl upon the comfortable lounge, if only till the
owner of the hard hat came to claim it, which he never did, till they went
ashore. Had she been certain of her ability to keep her feet, Ermengarde
would certainly have yielded her own chair to the girl, and annexed to her
own use that sequestrated by the owner of the detestable hat; it would have
been such a pleasure to kick and stamp on that hat and hear it boom like a
drum, and pop like a burst motor-tyre. But she was by no means certain of
her ability to do anything but shiver.
And now at last all fear of the dread penalty of the inexorable sea was at
an end, and Ermengarde rose to her feet in the proud consciousness of being
able to stand, and even walk, without sudden subsidences to the deck or into
the unwilling embraces of indignant fellow-voyagers. Helped by a sailor,
who unexpectedly appeared at her side as if from the clouds, and was easily
persuaded to carry her things, she got down to the level of the landing-
place, and enjoyed the first thrill of foreign parts at the sight of blue-
cloaked men in uniform, short and solid, with bristling moustache and
complacent strut. How good it is, the first sight of these dear, delightful
creatures, who never seem to have anything to do but enjoy dignified and
ornamental leisure for the benefit of admiring mankind! And how good,
Ermengarde thought, to see a gangway shot into a crowd of laughing,
gesticulating, blue-bloused porters—to see them hurl themselves upon the
gangway tumultuously, one over the other, in a solid mass, with shouts,
songs, and exclamations, and so board the vessel, leaping and laughing,
and, falling upon passenger after passenger, tear their precious misnamed
hand-baggage from them, strap it across their own shoulders, and, deaf to
all entreaties, fight their way back to the gangway, leap ashore, and fly from
sight.
She would have followed her own especial robber, but that he forbade
her with gay volubility, and bid her accompany the rest of the robbed and
find him again at the Custom-house.
"Numéro Quatre," he cried, tapping the brass plate on his cap, and
dancing off with the grin and gesture of a good-natured gnome.
Observing that all but a few sturdy and muscular men submitted to this
spoliation, and unhesitatingly obeyed the commands of the gnomes,
Ermengarde, feeling very lone and lorn, and suddenly forgetting for sheer
weariness the whole of the French language in a lump, gave herself up for
lost, and was borne passively in the tide of fellow-sufferers, who formed a
soft but shifting support, to the gangway, where the pleasing spectacle of a
nervous man dropping an open purse of gold into the sea just in front of her
in attempting to produce a ticket, showed that every depth has a lower deep,
and consoled her with the reflection that her own spare pence were safely
bestowed in various inaccessible portions of her attire.
But here she was at last, in the beau pays de France, within measurable
distance of the much-desired and artistically decorated sofa, etc., if stiff and
trembling limbs would but support her through the tourist's purgatory, the
Douane. Never again would she dread solitary travel; the sea trip in
retrospect grew to be absolutely delicious—if she had only known it at the
time—in the exaltation of having survived the awful ordeal of passing
through the chops of the Channel—not that she had noticed any chops—she
felt capable of penetrating to Central Africa. Actually penetrating only to
the centre of the Douane, which at first sight she supposed to be a large
stable or coach-house, our poor untravelled traveller sought the friendly
face of Numéro Quatre among the long lines of brass-plated gnomes, only
to find it, with its elfish grin and the whole of her travelling necessaries,
conspicuous by its absence.
It was then, after long and vain search and countless wild and polyglot
inquiries of unsympathizing foreigners, and endless courses up and down
and round the crowded, many-voiced Douane, that the hapless Ermengarde
began to ask herself why she had left the safe and comfortable precincts of
her native land, and braved cold and famine and the terrors of the deep,
only to become the prey of grinning brigands upon savage and inhospitable
shores. Poor little Charlie, unwilling victim of enforced football, but at least
happy in ignorance of his mother's fate! London was undoubtedly foggy;
but property there was comparatively safe. People there were at least not
compelled to part with the whole of their possessions at the bidding of
strange monsters. Nor were they obliged there to lose expensive Train de
Luxe by waiting for hours in places with nothing to sit upon for people who
never came.
"Surely this carriage faces the sea?" she cried in tones of horror.
Then followed a deadly battle with the conductor, compared with which
the skirmish in the Douane ranked as a polite difference of opinion.
Gallantly facing this awful gold-braided personage, who at first was to busy
to be spoken to, and, on the advice of her fellow victim, bombarding him
with reproaches in such scattered remnants of French as an extreme effort
of will could summon from the recesses of an exhausted brain, and vainly
looking meanwhile in every direction for the civil and paternal Cooks'
Interpreter of advertisements and letters, Ermengarde told how she had
booked through the perfidious Cook a seat facing the engine, and could not
by any means travel in any other way and must have another carriage. A
civil flow of idiomatic provincial French, upon which the words Marseilles
and Paris floated at intervals, in reply, conveyed nothing but distraction to
her mind. Finally she demanded an exchange of seats with some traveller
who liked going backwards, in three separate languages, and heard in two
that madame had better monter vite, as the train was off.
During this engagement she was much annoyed by the efforts of a man
in a furred coat, of whose observation she had been indignantly conscious
before, to divert the official's attention to himself, in which he at last
succeeded by some mystic sign (probably Masonic) conveyed by a touch of
the hand in which something glittered in the sunshine. At this juncture the
other lady appeared on the car steps, and drawing her inside, explained that
it would be all right if she would only wait till the people were settled in the
now moving train, and found her a slip seat in the corridor, with which the
hapless Ermengarde was obliged to content herself, facing forward, and
cherishing deep resentment against the man in the fur collar, whose
mysterious and insistent gaze from behind coloured spectacles had
continually followed her since her arrival at the train. She felt that in some
vague way her misfortunes were owing to this creature's malevolence.
"Always, when they get out of Russia, unless they are diplomatists. He
was hiding a box under his coat. Filled with dynamite, no doubt."
"To blow us all up? Oh! I don't think we are worth that. No celebrities
on board to-day. Are you going all the way to the Riviera? You look so
tired. Recovering from influenza? So tedious. Pray let me help you all I
can."
The man of mystery might as well let off his infernal machine at once,
and have done with it; the slip-seat was narrow, the train rocked as it flew,
and Ermengarde, aching wherever it is possible for humanity to ache, felt as
if she was breaking in halves at the waist. But what was her surprise and
pleasure in the misery of this dark moment to hear a respectful voice at her
ear requesting madame to be kind enough to take possession of a forward
compartment to Paris in the next carriage, and to find herself at last, as if by
enchantment, in the identical state-room of her dreams and the International
Sleeping Car Company's pictured advertisement, with its private dressing-
room, its airy space, its slip-seat under the window—"should the passenger
desire to change position"—and, better still, the whole compartment to
herself, but jusqu' à Paris only. What bliss to sink upon the deep, springy
seat, to cast aside heavy coat, furs, and hat; and close tired eyes for a
moment, and then open them and see the flying foreign landscape, chill,
bleak, powdered with snow, and bounded by sea, as they drew near
Boulogne!
But what gave the country that unlikeness to English chalk and heath-
lands, that charming unlikeness, so dear to new travellers, that gives the
feeling of being somewhere else, the true foreign touch? To this pleasure
she surrendered herself with drowsy content, forgetful of recent sufferings,
forgetful of the superb ragout peculiar to Calais somebody had solemnly
charged her to take at lunch in the long wait between train and boat,
forgetful of lunch to be had on the car, till the spectacle of a waiter carrying
tea past the door reminded her that "perfect meals are served," and that none
approaching that description had fallen to her lot since that far-off
yesterday, when the luxuries of travel had still been a dream. After many
and vain requests to the "civil attendants" to bring tea, she staggered to the
dining-car, wondering why the waiters all looked so absurdly drunk, and the
tables behaved as if they were at spirit-rapping séances, and wondering still
more when the modest cup of tea "for about tenpence" took a couple of
francs to pacify the staggering, taciturn waiter's demand. It was evident that
foreigners, civil and talkative when sober, are surly and taciturn when
drunk, just as Britons, surly and taciturn by nature, become over-civil and
garrulous in liquor.
Snow lay here and there on the bleak levels flying past the windows.
How small the cottages were! Cottages? No—huts—cottage was too cosy a
word for these poor cabins. What a poverty-stricken country; the very trees
lopped and starved of branch, starved houses, starved peasants ploughing
with horse-ploughs, no comfort, no prosperity anywhere; all like a pinched,
starved England, till after Boulogne, where sand blowing about from the
great dunes was a distinct foreign note. What if the train was over-hot?
Cold, cold it was outside, and, if the windows were opened, the wind cut in
like a sword. A city of a splendid tower lay in the cold light after a pale pink
sunset; the rushing, rocking train came to a stop by a dusky, empty
platform, where a solitary, starved-looking boy stood motionless, cold in the
cold twilight, his arms rolled in his apron, listless, benumbed. This must be
Amiens, or else some dim city of twilit dreamland; mortal railway station it
could hardly be, so dim, so chill, so empty, so silent, with no passengers, no
officials, only that one ghostly train, whence none descended and whither
none climbed, hissing furtively in the greyness, while vague figures in
blouses passed silently by, tapping thoughtfully at the wheels now and then,
and the thin, hunger-pinched boy looked listlessly about him, his bare arms
rolled in his apron. Evidently nobody ever goes to French cathedral cities
except to stay there; perhaps even the boy was only a statue, the latest
triumph of realistic art.
This grey, starved country, so different from rich, cosy England, would
have been depressing but for the swift rush of the rocking train, the warm,
downy comfort of the carriage, and the fairy-like strangeness that gave
everything an air of unreality. If only Charlie were there, his clear eyes wide
with pleasure, sharing the fascination, enjoying the motion, asking
impossible questions, and making bewildering comments! Monstrous to
send such a baby to a school of rough boys. She was not spoiling him, as
his father declared; he was not getting womanish ways; children need
tenderness, and a boy may have charming manners and be a delightful
companion without being unmanly. At Easter he would come home, steeped
in savagery, inarticulate and slangy, full of the surly self-consciousness that
dreads to be thought anything but brutal, or to vary by a pin's head from
"other fellows." Arthur would be delighted, and say he liked boys to be
boys. Arthur, whose one aim in life appeared to be to avoid showing the
least sign of emotion or humanity, or anything comforting and pleasant.
When it came to saying good-bye, at his sudden departure on the eve of
hers, she had choked miserably and said nothing, her eyes brimming over;
but he—
He was off before the last word, and had banged the door, and sprung
into his cab by the time her choke was overcome. If only he had not said
"dear," that commonplace symbol of conjugal indifference; "Ermengarde,"
with the faintest inflection of tenderness, would have made all the
difference—she could even have borne the reference to hats had he said
something nicer than "dear."
The twilight deepened, and the train became a flying meteor of linked
lights; she grew more and more inclined to accept the rift in the lute and
make the best of it. Her man had his good points, and all men seemed to be
made of hard, unloving stuff; why seek sympathy in the impossible region
of rocky male hearts? As for the scene in the study, she may have put a
wrong interpretation upon it; she would not admit that she had ever given it
the worst; it might mean some passing infatuation, resisted, perhaps
overcome, at the utmost—or some harmless mystery, that five words would
have made clear. Of course, men should not have secrets from their wives;
but equally of course, men did. It was well to be away for a time; new
experiences would put all this trouble in the background and show it in true
perspective; she would wipe it clean off her memory and begin again,
harden her heart, take all cheerfully, without show of feeling, answering
chaff with chaff; weakness had made her over-sensitive, returning health
would harden her, and, perhaps, who could tell? the man himself might
soften, and miss and long for her. She hoped he would be very
uncomfortable and mislay everything and have no one to find it, and no one
to protect him from the zeal of housemaids, the carelessness of cooks, and
the importunity of men of business.
But what was this cry of the man with the napkin? "Diner est servi!"
Blissful announcement, if one could only stagger through the rocking
corridor without serious mishap. How excellent a thing is dinner—at the
proper time. There was the Anarchist, whose grim visage had more than
once startled her meditations as he passed her door—"Tramping up and
down like a wild beast," she confided to her fellow traveller in the dining-
car, while enjoying the really "perfect meal" for which the long fast had
prepared her.
How deft the staggering waiters were, dancing with their dancing dishes
to the dancing tables, and always contriving to land the portions safely in
the plates! How delightful this flying repast through the flying night—
providing one faced the engine. Even the Anarchist was judged with
lenience; if he did send furtive glances in her direction, her back hair and
hat were unconscious of them. Timbale de Paris on the menu had an
attractive look, the same, sliding about the dish balanced unsteadily over
her head, was even more fascinating, lodged triumphantly on her plate after
five abortive attempts, it was beyond words delicious, when—was it an
earthquake or a collision?—a series of bumps and crashes, and passengers
tumbling together and apart like nuts shaken in a bag, and the darkened
outside world, starred with the lights of Paris, beginning to run away
backwards. Farewell, exquisite iced Timbale! The only safety is in instant
flight. The train has turned.
The true inwardness of the phrase "jusqu' à Paris" was now realized,
when Ermengarde found herself in great peace, though only half fed, facing
the engine in her own compartment, while the lights of Paris twinkled past
for some twenty minutes. Then another convulsion of nature seemed to take
place, and the world again began to run away backwards from her dizzied
sight. "It will turn again at Marseilles," her fellow traveller said cheerily,
and at this terrible news there was nothing for it—since the other
compartment was now occupied by two men—but to stand, facing the seat,
and occasionally fall hither and thither in the rocking of the train, until her
companion piled their two bundles of rugs together against the wooden
partition and she sat on them, her back stiffened miserably against the
straight wooden partition, and her legs jammed between knee and ankle
hard against the edge of the seat, and her feet hanging (the space between
wall and seat being about fifteen inches, and she a full-sized and shapely
lass) in a position to which St. Lawrence's gridiron was luxury, and which
soon produced such faintness as had to be treated with brandy.
"And if this," said Ermengarde, when the spirit ran through her veins
and restored her speech, "if this is a Train de Luxe, give me the commonest
third-class carriage, with at least a floor to sit and fall upon!"
Chapter IV
Was it a dream, or had she really seen the Anarchist's bearded, goggled
face bending over her in close proximity to her fellow-traveller's? Who
could say? These two were shrouded in mystery, and permeated with
intrigue, phantasmic, unreal. The woman professed not to have observed the
man, and when asked to notice him as he passed their door in the corridor,
had stared blankly in every other direction, looked at the conductor,
attendants, other passengers, but always failed to perceive a man with beard
and goggles.
Yet, when sitting on the jolting little seat in the corridor, while the
attendant made up the beds, at her fellow-traveller's kind suggestion, so that
she might lie facing the engine, Ermengarde, now wide awake and sensible,
could have taken her oath that she saw these intriguers talking together, in
the little lobby at the entrance end of the corridor.
"Talking to whom?" the woman of mystery replied, with that baffling,
stony-blank look that she put on like a mask at times. "Yes, I asked the man
to make up the beds at once, that you might face the engine. See what nice
bedding they give us; sheets, pillow-cases, all complete, and snowy white—
so different from London-washed linen. I shall be glad to go to bed myself,
after all the shaking and rattling. Which man did you say? I see nobody
with a beard. Let us smile at the bed-maker as if we meant tips—five-franc
smiles. He's very civil. No; he's clean-shaven. So sorry going backwards
upsets you."
That was all to be got out of this woman of mystery, who seemed so
impersonal and so much above all feminine, not to say human, infirmity.
Yet there was a curious attractiveness about her. The eyes, that were at
times so blankly impervious to expression from within or impression from
without, were beautiful in shape and colour, of the dark blue that varies
from grey to purple, and shaded by long sweeping lashes on finely curved
lids. Her mouth shut firmly in the true bow shape, with full lips, that, in
repose, had a sort of voluptuous sadness. She was slender and rather tall,
moved well, and had in her figure and bearing a sort of melancholy
distinction. A woman with a past, undoubtedly, and, by all appearances,
with a present of precarious tenure and painful interest as well. The kind of
woman men can never pass without taking note of, though nothing in her
bearing, look, or dress challenges observation, unless it be an accentuated
quietness and reserve. Such women, it occurred to Ermengarde, when not
absolute saints, are eminently fit for "treasons, stratagems, and spoils."
What if she were in league with the Anarchist, whose anarchism might be,
after all, of the common-place type that indiscriminately relieves fellow-
creatures of the burden of personal property? A distinctly unpleasant idea to
entertain of one who shared sleeping-quarters and was so ready to have
beds made up and lights covered.
In cases like this, the only comfort is to carry nothing worth stealing.
But few travellers are without a watch and at least some little money.
Ermengarde's was safely sewn up in some inaccessible portion of her attire,
and when her companion plausibly suggested the comfort of undressing
before going to bed, and volunteered to help her out of her clothes, she was
glad to be able to point out that there was not room enough to undress
oneself in, much less anyone else. Then she wondered, did she look rich?
and when they found her so little worth robbing, would they murder her in
revenge afterwards?—or beforehand to prevent a disturbance—charming
reflections to sleep upon. Of course, Arthur had been right—the man had an
exasperating way of always being right, especially about unpleasant
contingencies—in saying that she ought not to travel alone. How many tales
and newspaper records there had been lately of passengers robbed and
murdered by unknown hands, especially in Southern France and Italy! It
would be a judgment on her for taking things into her own hands, and
flaunting in her husband's face a certain small hoard they both knew of—to
be used only in great emergency, such as conjugal desertion, or personal
violence, or bankruptcy, their jest had been. That had been coarsely done,
she owned now with flaming cheeks; he had felt, perhaps resented, the
indelicacy of the revolt. Let them rob her, then, but let them spare her life.
The thought of a motherless Charlie, screwing his precious fists into his
darling eyes, was too moving.
It was his bedtime; perhaps he was just saying his little prayers for
"fahver and muvver," or nestling his curly head contentedly into his pillow,
and falling into that instant, happy sleep that made him look like a little
angel, at the very moment when she laid her own head, uncomfortably full
of hairpins—perilous to remove with no chance of replacing them in that
jolting, swinging little bunk—upon the train-pillow, expectant of midnight
robbery and assassination, but too glad to lay it anywhere to care much
about anything.
"Won't you at least let me take off your boots?" the woman of mystery
murmured drowsily from the top berth; and Ermengarde would have given
all she possessed to do so, had she discerned the remotest possibility of ever
being able to put them on again, having now reached that stage of anguish
when one seems to have somebody else's feet on, and those several sizes
too large.
As she lay face forward on a wide, springy bed, the swaying train soon
became a cradle of rest, and the rhythmic rattle and crash of its wheels and
engine a soft lullaby, or the gallop of giant steeds, bearing one swiftly away
to regions of elysian slumber and soothing dreams. Let the Anarchist rob or
murder her, or both, if he would; but let him do it gently, so as not to disturb
that exquisite combination of motion and repose, or break the rhythm of
that musical gallop of winged steeds, yoked to flying cars, flashing swifter
and ever swifter across France, across Europe, across the night, from North
to South, from sea to sea, from evening to morning, from darkness to dawn,
from earth to fairyland, when—— Bang! crash! jolt! rumble! and
everything falling together and coming to a dead stop, at the weird repeated
cry of some lost spirit, that pierced the startled night in prolonged
reverberations.
No, not a lost spirit, after all; only a sleepy man in a blouse, crying the
name of some town—was it Dijon?—through the echoing emptiness of a
dimly lighted station, and through the window a glimpse of sky full of stars
looking down in peace. They had come to somewhere else, whither they had
flown during the delicious sleep into which she had fallen. There is nothing
more delightful than that feeling of having come to somewhere else without
effort and without thought, in the stillness of night and sleep.
If only one had on one's own legs and feet, and no hairpins and no
close-fitting day clothes, pinching in wrong places, or if only one could find
a pocket-handkerchief or a smelling-bottle, or look at one's watch, without
fear of waking the woman of mystery, and so hastening the hour of
assassination by turning on the light; the presence of which, the latter had
averred, was absolutely destructive of her chances of sleep.
But the winged steeds begin to snort and pant, stamping, and clashing
their harness, and, with a sudden clatter of trampling hoofs, are off again
into the waste places of midnight, through which a star glances
intermittently and kindly, and Ermengarde remembers that she has not yet
been murdered, but is almost too drowsy to hope she has not been robbed,
feeling blindly for the gold sewn into her clothes and not finding it, and not
knowing that an excruciating pain under the ribs is what she vainly seeks
and is lying upon, or that acute discomfort in other regions means that her
hat, a really becoming one, has tumbled off its hook and constituted itself a
portion of her couch, which is no longer a bed of roses.
Surely the winged steeds are now tearing away at increasing, headlong
speed, and their way is rougher, up hill and down dale, over crag and
boulder and chasm; the cradle is rocked less gently, and the rhythm of the
rapid gallop is not so smooth, else it would be heavenly to fly thus between
the pinions of the fiery coursers through centuries of calm content, unvexed
by thought or care; and surely the cadence that seemed, now music, now the
burden of some sweet, old ballad of forgotten days, had declined to the
double knock of civilization and hourly postal deliveries; to file-firing, to
the racket of the housemaid's morning broom and furniture destruction, to
summer thunder, to Portsmouth guns? No; silence on a sudden, and
stillness, and once more the drowsy cry of some place-name through the
echoing emptiness of a dim-lighted building. Again she had arrived
somewhere else in sleep—could it be Valence, or Vence, enchanted names?
Or rather some city of faery, beleaguered by visions, or dumbed by spells of
sweet strong magic; it could be no earthly town; it must be the place of all
men's longing, the land of Somewhere Else, of somewhere
"afar
From the sphere of our sorrow—"
Oddly enough, Arthur was there and Charlie; the woman of mystery had
disappeared, and the man with her, and the wild, winged horses were
galloping faster and faster through the night, which was no longer black,
but pale grey, shot with faint lemon; and there, through the window, glanced
and quivered one large, lustrous white star—and—of course, it was
fairyland again or some region of old romance, because, where the star had
been faintly traced upon the luminous twilight sky, was strange oriental
foliage, palm-tops, olive-boughs, fading and passing.
"Shall we switch off the light?" asked a clear cold voice from above;
and Ermengarde, springing up with a start, realized that day was breaking
and the fear of assassination past.
"Poor old Arthur! She made a wrong shot that time," thought
Ermengarde, who was inclined to consider her husband's essays in literature
as so much waste of hours more legitimately and profitably given to
journalism. Had she not been overcome by train nausea, she would have
asked what was the woman of mystery's favourite among her husband's
works, which she believed she had never read. Few people had.
As it was, she could only cling miserably on to the little hinged seat in
the couloir, whither the ladies had been compelled to take refuge while their
two sleeping-bunks were being transformed into one sofa. There she clung,
jostled by fellow-passengers staggering past in various stages of disarray
and dishevelment—where, by the way, were all the smart owners of huge
trunks, tall flunkeys, and reluctantly prim maids of Victoria platform?—
jolted by the swaying of the rushing train, and dimly conscious that this
young woman never ceased to keep an eye upon her lightest motion, under
pretence of sympathy with her discomfort, even when apparently absorbed
in thought—sad thought, to judge by her drooping mouth and wistful gaze,
clouded more than once by tears, furtively dashed away. Had Ermengarde
dreamed of suppressed sobs above her once or twice during the night? Was
the Anarchist her husband, and did he beat her? But there was no wedding-
ring on the slender hand, that had more than once ministered to ungrateful
Ermengarde's needs. For this absence there might be reason good.
Ermengarde had already seen, and, as the sorrow and perplexity had
vanished from her companion's face at the sight, the weariness and physical
discomfort went out of hers, while both gazed and gazed in a silent passion
of joyous admiration, with moistened eyes and trembling lips, absorbed,
rapt, caught up and away into the very shrine and inmost heart of beauty.
So these two untravelled travellers saw it, and so they would see it
never again, because first things come only once. But a deep strong
certainty that after all some things are real and abidingly good even in this
stained world of shifting shadows, took hold of these women at sight of this
deep, sweet purity of colour.
"I judge that's Hyères," they heard, as not hearing, from a nasal voice
passing along the corridor.
The winged steeds were no longer yoked to the cars; they must have
vanished long since with the darkness; the train moved more and more
slowly. That it should gradually slacken speed to a crawl through all this
magical beauty was natural; but that it should actually stop, like common
trains in regions of prose, for people to get out, claim luggage and pay
porters, was amazing, especially as that first superb colonnade of date-
palms was seen to rise behind one of these stations—perhaps Cannes? True,
they were not stations in the ordinary sense, but rather pleasant places of
pause, where leisurely persons of distinguished bearing and immaculate
attire, gold-braided, button-booted, and black-kid-gloved, enjoyed the
amenities of a life devoid of care, incidentally remembering from time to
time to bestow a kindly and condescending courtesy upon wanderers
descending casually from the train of luxury, that was now enjoying a
beautiful calm in singular contrast to its wild stir at starting and headlong
rush through the night.
All the glamour of Shelley's ethereal poetry seemed to breathe and sing
from that glorious sea, which Homer compared to wine in its depth of
colour. All Shelley's seas are Mediterranean, and most of Byron's, while
Keats and Tennyson, Coleridge and Matthew Arnold, for the most part love
the paler grey-blue and more frequent foam of Northern shores.
Vainly did the woman of mystery remind Ermengarde that she had not
breakfasted; she was feasting with gods; she needed no meaner sustenance;
even the shadow of the man of mystery passing her door, and glaring
insolently through his detestable goggles upon her rapt face, scarcely
annoyed her, except as a momentary eclipse of some lofty headland running
out into the happy morning sea. She had even forgotten that she had slept,
not only in, but upon, her hat, a really successful creation from Bond Street.
Bright-eyed and lazily smiling, the youth strode slowly along the quiet
platform, carelessly glancing at the windows, when a sudden thrill of
sympathy made Ermengarde turn to see the woman of mystery, who was
standing leaning against their door and looking across her at the people
passing, start with a crimson face and eyes of flame, and crush herself
suddenly far back in the corner of her seat, holding a paper of far-off
yesterday before her eyes, with a quick, deep sigh.
The youth passed on and came back again, stopping to speak to a
Parisian costume in lemon hair and bistred eyes; left her, joyously laughing
with his head thrown back, and cannoned against a brother Briton in an
agony of misunderstanding with a porter, who was replying to impossible
English-French in equally impossible French-English.
"Riviera Palace, vite!" cried the English youth, cutting the Gordian knot
and calming the troubled waters by those simple words in three different
tongues; then, gripping the bewildered Briton by the arm, he steered him
placidly out of sight.
The mountains soared higher, and drew back from the land with ever
greater majesty, and the headlands became more magically lovely as they
stretched into the shining sea, the villas, the gardens, and groves ever richer;
and, after having seemed to spend a brief but happy lifetime in traversing a
beautiful dream, glorious with palm and olive and mimosa, the train again
paused, and the woman of mystery suggested to Ermengarde that she had
better get out.
"You have arrived," she explained, finding her unwilling to stir. They
had done nothing but arrive at intervals during the last twenty-four hours,
and how should this mysterious creature know that this was her final
destination?
Still, the woman had been exceedingly kind, and Ermengarde thanked
her graciously as she bowed her farewell, suddenly remembering that the
dread ordeal of the Douane had once more to be faced, and her property,
unseen since somebody had taken it to be registered at Victoria, had to be
rescued from the barbarians—probably at high ransom.
Chapter V
On the Ridge
The moving palace of luxury that had conveyed her in so few hours
through so many dreams of magic and visions of faery, rumbled slowly out
of the spacious hall of idleness commonly known as Mentone Station, but
more nearly resembling a Home of Rest for railway officials. There it left
Ermengarde, dizzy, bewildered, and solitary, planted by the luggage, that in
some magical and mysterious way had suddenly been restored to her, and
looking vacantly across the rails at a group of sturdy palms and a purple rim
of sea.
She would see the woman of mystery no more—so forlorn were her
feelings that it was grief to part even with this probably suspicious character
and possible assassinator of her nocturnal imaginings—she was going all
alone to an unknown foreign house full of strangers, with not a soul to meet
her or speak to her; perhaps to one of those hostelries so often met with on
lonely moors in historic romance, that exist only as traps to rob and murder
wayfarers.
"But, one at a time, not all at once," the driver explained with gestures
of deprecation.
"This is infamous!" thundered the fair-sized man, recovering from
partial suffocation and upon the verge of apoplexy. "My wife's minimum
weight is fourteen stone! Infamous! Besides, she can't ride. Atrocious!"
"Mais," replied the driver, with a large circular sweep of both arms,
obviously intended as a conclusive and satisfactory settlement of all
difficulties.
At this the owner of the dark eyes, moustache and engaging smile
looked with an expressive twinkle and shrug at Ermengarde (who was
sufficiently refreshed and gladdened by the sight of the stout lady's
difficulties to renounce her intention of lying down and dying for the
present), and came forward with the explanation that the little climb was
nothing; the animals were strong and accustomed to heavy burdens; the
luggage would be carried by pack-mules, and the heavier passengers by the
strongest of the saddle-mules; that no horsemanship was necessary; both
donkeys and mules were to be regarded simply as ambulant easy-chairs, on
which it was possible to doze and dream, to compose poetry, and evolve
philosophic systems and scientific theories, "as Monsieur does," he added,
gracefully indicating the thin man, who was lame, and having been hoisted
on to the largest and most handsome of the engaging, soft-eyed donkeys,
was reclining wearily with one arm on the velvet back of the saddle.
"Na, Hedwig," growled the tranquil German in the fly, "disturb thyself
not! There are many hotels in Menton, Zuruck! Geschwindt!"
And back they went straightway, impervious to the pleading of the dark-
eyed man, who too late discovered that the senior partner in that domestic
firm was not of the persuadable female sex. Then, recognizing Mrs. Allonby
to be of more ductile material than the other two, he devoted his persuasive
powers to the woman of substance and the British matron, whose stern
brows soon relaxed beneath his sunny smile and pleading glances; the
woman of substance finding herself in a trice, she hardly knew how,
accommodated with an improvised chaise à porteurs, consisting of a
perilously aged basket-chair and two hoe-handles borne on the shoulders of
two handsome Italian workmen, whose teeth glistened with fun and the
prospect of five-franc pieces to come, while the fair-sized man and the other
matron were mounted each on a strong mule, and before they could utter a
syllable of remonstrance, the mystic word "jay" came from the mule-driver,
and they found themselves bumped out of sight up the narrow path, which,
consisting of steep steps made of huge cobbles, or, rather, small crags,
compelled them to devote their whole energies to avoid being shot over the
mules' tails, as the animals reared on end with a jerk at each stony stair.
It was during this ascent that the fold of Ermengarde's brain in which
the French language was located suddenly became accessible, and she
implored them in choicest Parisian to stop, to take her off, to allow her to
fall in some soft place, anywhere, with the sole result of bringing a fresh
shower of twig-blows and jays from these harmless people, who only
understood the Italian patois of the district, and supposed from her agonized
voice and gestures that she was anxious to ascend more quickly, whereas
her one consuming desire was to get off her ambulant armchair at any price.
It was some years since the unfortunate Ermengarde had ridden at all, and
then it had been upon an average Christian horse, and only those who have
been borne unwillingly by a series of bone-dislocating rears and jerks up
endless staircases enclosed in rock-walls, and along knife-edged ledges
overhanging abysmal nothingness, upon animals that understand no
civilized language, and answer to no bit or bridle, and whose sole form of
obedience is to run away from whoever pronounces the word "jay" in their
rear, can imagine the complicated anguish of such riding. Nothing but the
delight inherent to fallen nature at the spectacle of the misfortunes of others
enabled Ermengarde to endure this singular form of torture; but when she
witnessed the spluttering indignation of the British matron of majestic girth
at being constantly, either crushed between the thin man and the adjacent
rock-wall, or edged perilously over the precipice by his donkey, and his
agonized attempts to avoid this unseemly proximity, with his wild and
ineffectual endeavours to explain his own innocence and the friendly
relations existing between their respective beasts, who could by no human
means be induced to travel apart, she became uplifted in spirit and capable
of enduring anything. Especially when the thin man weakly tried to
apologize in French, of which he was hopelessly incapable, thus
exasperating the woman of majestic girth to madness at the idea of being
taken for a foreigner.
It was not until the handsome and stalwart donkey that bore the tortured
form of Ermengarde took advantage of some mischance to the driver's
apparel to dart up a side staircase, bordered by succulent grasses, with a
suddenness that extracted an involuntary shriek from his hapless burden,
that her woes came to pause, and, like Balaam's, her donkey found the path
between the vineyards barred by the sudden apparition, not, indeed, of an
angel with a sword, but of a comfortably real figure, with a walking-stick
and two laughing dark eyes. He had dropped from heaven knew whence,
and understood Parisian French even on English lips.
Then it was that this man of infinite resource came to the rescue. He
took the donkey's short bridle—too short to be used by the rider—in one
hand, and passing his other arm behind the saddle brought the lawless
animal into subjection, and diverted the rider's attention from her
misadventures to the splendour of the prospect, which was unfolding
beneath them with every step they mounted, but which she had been totally
unable to see because it was all behind. Then, after a short rest and
rearrangement of the Bond Street hat, which, besides having been slept
upon, was obviously not intended to ride donkeys up precipices in, he
personally conducted donkey and rider for the remainder of the ascent,
making Ermengarde's hair stand on end by disputing edges of precipices
with the animal, and preserving her in violent and unexpected jerks by the
support of his arm.
"But how will you ever face the miserable people you have fastened
upon wild animals against their will, when we get to the top—that is, if
there is any top, and we ever get there?" she asked.
"Ah, Madame," he replied with twinkling eyes and a small shrug, "I am
discreet. I do not face them, especially the fat lady, till they have been fed.
But—she is a drôlesse, that stout one. Imagine to yourself, her porters have