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CLINICAL REASONING
FOR MEDICAL STUDENTS
Bridge the Gap
Lasith Ranasinghe

World Scientific
Published by
World Scientific Publishing Europe Ltd.
57 Shelton Street, Covent Garden, London WC2H 9HE
Head office: 5 Toh Tuck Link, Singapore 596224
USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601

Library of Congress Cataloging-in-Publication Data

Names: Ranasinghe, Lasith, author.
Title: Clinical reasoning for medical students : bridge the gap /
Lasith Ranasinghe, Imperial College Healthcare NHS Trust, UK.
Description: New Jersey : World Scientific, [2024] | Includes index.
Identifiers: LCCN 2023031769 | ISBN 9781800614567 (hardcover) |
ISBN 9781800614659 (paperback) | ISBN 9781800614574 (ebook) |
ISBN 9781800614581 (ebook other)
Subjects: MESH: Clinical Reasoning | Diagnosis, Differential | Handbook
Classification: LCC RC71.3 | NLM WB 39 | DDC 616.07/5--dc23/eng/20230929
LC record available at https://lccn.loc.gov/2023031769

British Library Cataloguing-in-Publication Data

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

Copyright © 2024 by World Scientific Publishing Europe Ltd.

All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means,
electronic or mechanical, including photocopying, recording or any information storage and retrieval
system now known or to be invented, without written permission from the Publisher.

For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance
Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy
is not required from the publisher.

For any available supplementary material, please visit

https://www.worldscientific.com/worldscibooks/10.1142/Q0430#t=suppl

Desk Editors: Balasubramanian Shanmugam/Rosie Williamson/Shi Ying Koe

Typeset by Stallion Press

Email: [email protected]

Printed in Singapore
 Foreword

Even as a relatively new doctor, I’ve seen first-hand the incredible

relationship we can have with our patients. The deeply personal
moments we share, the conversations that bring you to tears and
the lasting impact that we can have when treating debilitating
health issues. We are more than a service provider, more than an
algorithm and more than a cog in a machine. We really do make a
difference and we do truly leave an impression on patients that will
often last a lifetime.
Being in a position of such privilege comes with responsibility.
The responsibility to advocate for our patients, provide them with
up-to-date information and empower them to make decisions about
their health. We can only do this because of the vast knowledge
we’ve acquired through hundreds of hours spent sitting at a desk,
in cadaver labs, in lecture halls, in hospital corridors, in operating
rooms and by the patient’s bedside. It is this time, this labour and
this sacrifice we have made that puts us in a unique position to be
able to call ourselves Doctors.
Remember that every moment you spend studying is a moment
spent honing your knowledge and preparing yourself for future sce-
narios that you can scarcely imagine as a medical student. All so
that, when you show up on the day and someone’s life is in your
hands, you’re able to think clearly and make the right decisions to
improve their outcomes.
Becoming a doctor has lived up to every expectation that I had
of it and more. Every day I’m surrounded by incredibly intelligent

v
vi  Clinical Reasoning for Medical Students: Bridge the Gap

people, all pushing each other to do better. No two days are the
same, and every patient brings with them a sense of excitement
and intrigue as we gain a small yet valuable insight into their lives.
Resources, like this book, help lay the foundation upon which
our clinical practice is built. Case studies, treatment algorithms,
acronyms and questions are essential in retaining all the informa-
tion doctors use on a daily basis. Lasith is a wonderful teacher,
inspired and practical with his knowledge and deeply caring about
his students. I have no doubt this resource will be irreplaceable to
any aspiring doctor and will be a staple on their bookshelves for
years to come.

Dr. Nasir Kharma

Junior Doctor & Content Creator
 About the Author

Lasith Ranasinghe is a junior doctor based in

London who has a keen interest in Anaesthetics
and Intensive Care Medicine. Since medical
school, he has maintained an exceptional aca-
demic standard having frequently ranked in the
top 3 in his cohort at Imperial College London,
received 25 prizes for academic excellence
and ranked within the top 3% and 1% of candi-
dates in the MRCP Part 1 and Part 2 exams,
respectively. In his spare time, he runs a char-
ity called Make a Medic that produces high-quality medical educa-
tional resources for students and uses the funds raised to create
grants for education and public health initiatives in low- and middle-
income countries. Before this publication, he authored the highly
rated RevMED series.

vii
 The Contributors

Dr. Syra Dhillon

University Hospitals Sussex NHS Foundation Trust
Dr. Adam Graham
Lewisham and Greenwich NHS Trust
Aleksandra Dunin-Borkowska
Imperial College School of Medicine
Ghavin Kuganesan
Imperial College School of Medicine
Alexandra M. Cardoso Pinto
Imperial College School of Medicine
Justyna Gromala
Imperial College School of Medicine

ix
 Acknowledgements

The author and illustrators would like to express their gratitude to

several individuals who reviewed our content and helped shape it
into the book that you are holding with your hands in front of you. We
collected feedback from both junior doctors and medical students to
ensure that the resource is both user-friendly and clinically sound.

Dr. Sarah Kelly

Guy’s and St Thomas’ NHS Foundation Trust
Dr. Jessica Muirhead
London Northwest University Healthcare NHS Trust
Dr. Katharine Alder
Imperial College Healthcare NHS Trust
Dr. Nicholas Ubhi
University Hospitals Sussex NHS Foundation Trust
Dr. Jaya Chawla
London Northwest University Healthcare NHS Trust
Sujil James
University of Cambridge School of Clinical Medicine
Muhammad Aniq
University of Cambridge School of Clinical Medicine
Shubham Gupta
Imperial College School of Medicine

xi
xii  Clinical Reasoning for Medical Students: Bridge the Gap

Abhishek Viswanath
King’s College London School of Medical Education
Eu Fang Foo
Cardiff University School of Medicine
Aroosa Malik
Medical University of Sofia
Max Fogelman
University of St Andrews School of Medicine
Rhea E Patel
Imperial College School of Medicine
Abigail Merison
Imperial College School of Medicine
Ioanna Voyatzaki
King’s College London School of Medical Education
Pippa Whitaker
Bart’s and the London School of Medicine and Dentistry
 Contents

Forewordv
About the Authorvii
The Contributorsix
Acknowledgementsxi
Introductionxv
How to Use This Bookxvii

Chapter 1 Headache 1
Chapter 2 Confusion 13
Chapter 3 Collapse 23
Chapter 4 Dysphagia 35
Chapter 5 Nausea and Vomiting 43
Chapter 6 Haematemesis 55
Chapter 7 Chest Pain 65
Chapter 8 Cough 75
Chapter 9 Shortness of Breath 85
Chapter 10 Epigastric Pain 97

xiii
xiv  Clinical Reasoning for Medical Students: Bridge the Gap

Chapter 11 Jaundice 109

Chapter 12 Right Upper Quadrant Pain 119
Chapter 13 Iliac Fossa Pain 131
Chapter 14 Dysuria 143
Chapter 15 Polyuria 151
Chapter 16 Constipation 159
Chapter 17 Diarrhoea 169
Chapter 18 Rectal Bleeding 179
Chapter 19 Scrotal Mass 191
Chapter 20 Back Pain 199
Chapter 21 Joint Pain 211
Chapter 22 Leg Pain 221
Chapter 23 Weight Loss 233
Chapter 24 Fatigue 243
Chapter 25 Differentials in Detail 255

Index363
 Introduction

The worst advice I ever got as a young doctor readying myself to

start my career was

Working is nothing like medical school. The things you learnt at

medical school will not help you.

My initial reaction to hearing such a daring statement was one

of bewilderment. Why had I just sat through dozens of medical
school exams over the course of 6 years if none of it is going to be
useful?
Three years and several rotations later, I feel that I have accu-
mulated enough experience at this early stage in my career to
confidently declare that the statement could not be further from the
truth. There are, of course, plenty of aspects of working as a doctor
that cannot be simulated or tested under controlled conditions,
however, medical schools have existed for hundreds of years and
have constantly been iterating through curricula to prepare us as
best as possible.
We have a pretty good idea of how the body works and main-
taining a decent understanding of preclinical subjects (anatomy,
physiology and biochemistry) will undoubtedly help you in your
career. As you begin your clinical training at medical school, you
are brimming with knowledge that you may not quite know how to
apply. This gap between the preclinical and clinical realms is what
this book aims to bridge.

xv
xvi  Clinical Reasoning for Medical Students: Bridge the Gap

This book will take you through the thought processes that
should be going through your head as you have a conversation
with a patient about whatever is bothering them. It will teach you
how to think both critically and clinically, in order to arrive at a sen-
sible diagnosis and management plan. We sincerely hope that this
book will aid you in your clinical development and help smoothen
the transition into your clinical career!
 How to Use This Book

The main flow chart at the start of the chapter will provide an
overview of the thought processes that should be going through
your mind when you assess a patient with a given presentation.
The Patient Background box allows you to build an image of
the patient in your mind’s eye. It will contain important demographic
information and details about their past medical, drug, social and
family histories. The boxes in the midline follow the main compo-
nents of a conversation between the doctor (red circle) and patient
(blue circle). To conserve space, we have sometimes included
multiple questions though it is worth noting that this is generally
advised against in the context of OSCEs!
The arrows extending to the side demonstrate the additional
questions that you should ask at that point in a history (e.g. red
flags and SOCRATES). In clinical practice, a history is often fol-
lowed by an assessment which will be listed in the form of
Observations and Examination findings. The information pro-
vided will culminate in a diagnosis, shown at the bottom of the
page. Each chapter will go through each of these sections in turn
to ensure that you have a robust understanding of why certain
questions are asked.
Once you have made a diagnosis, you will likely have to explain
what the condition is, any additional investigations that are required
to facilitate the diagnosis and the subsequent management plan.
To keep the information concise, we have only listed the key inves-
tigations and aspects of management — it is by no means an

xvii
xviii  Clinical Reasoning for Medical Students: Bridge the Gap

exhaustive list but should be more than enough to enable you to

answer viva questions.
We would also like to draw your attention to the Classical
Presentations tables that are available in each chapter. It can
sometimes be difficult to tease apart various differentials as, in list
form, the associated symptoms can be very similar. We have,
therefore, written a ‘classical presentation’ of each condition so that
you can visualise how it typically presents. This will be useful for
both your OSCEs and for interpreting single-best-answer questions
in your written exams.
Given that you are likely early on in your clinical development,
some of the differentials may be unfamiliar to you and it may seem
as though there are a lot of differentials to keep in mind for a single
presenting complaint. To address this, we have designed Bridge
Boxes which illustrate an important concept that features in the
chapter or provide a visual summary of the differentials.
If you want to learn more about the key differentials for each
presentation, please refer to the Differentials in Detail section
towards the back of this book.
 Chapter 1

Headache

Most people will experience headaches at some point in their lives

and, most of the time, it can be managed effectively with simple
analgesia and lifestyle changes. A headache, however, could also be
the presenting symptom of several sinister underlying conditions.

1
2  Clinical Reasoning for Medical Students: Bridge the Gap
 Headache 3

Patient Background
The age of a patient presenting for the
first time with a headache can help point
you towards the likely causes. Tension
headaches and migraines are more likely
to present for the first time in younger
patients, whereas intracranial bleeds and
giant cell arteritis (GCA) typically present
in older patients. Venous sinus thrombo-
sis is a serious cause of a headache that
is associated with hypercoagulability,
so the patient’s background should be
4  Clinical Reasoning for Medical Students: Bridge the Gap

screened to determine if there are any factors that may make their
blood hypercoagulable (e.g. combined oral contraceptive pill, preg-
nancy and cancer). It is also important to consider the patient’s
body habitus — idiopathic intracranial hypertension (IIH) is a rare
but important cause of a persistent headache that responds poorly
to analgesia and is about 20 times more common in obese patients.

Differential Diagnosis

Common causes of headaches, such as migraines, tension head-

aches and medication overuse headaches, can be managed effec-
tively in primary care with careful counselling and appropriate use
of medication. These headaches can be severe, but they tend to
have a chronic history. There are some features of migraine (e.g.
neck stiffness and photophobia) that can be difficult to distinguish
from more serious causes of a headache.

Uncommon causes of a headache that are not usually an acute

cause for concern include cluster headaches and IIH. These head-
aches can be severe and are known to respond poorly to conven-
tional analgesia.

Dangerous causes of headaches include intracranial bleeds, cen-

tral nervous system (CNS) inflammation (e.g. encephalitis and
meningitis), brain tumours, GCA and venous sinus thrombosis.
Brain tumours are likely to present with a chronic history, whereas
GCA and CNS inflammation are likely to present with a subacute
 Headache 5

history of a headache developing over the course of several days.

Intracranial bleeds and venous sinus thrombosis tend to present
acutely, though it is worth noting that subdural haemorrhages can
present with worsening confusion and neurological sequelae over
days and weeks following a head injury.

SOCRATES

There are a few patterns of symptoms that are worth keeping at the
back of your mind while you explore SOCRATES in a patient pre-
senting with a headache:

· Site
 Unilateral: Migraine, GCA, venous sinus thrombosis and

cluster headache
 Generalised: Tension headache, medication overuse head-

ache, sinusitis, CNS inflammation, brain tumour, IIH and intrac-

ranial bleeds
· Onset
 Rapid Onset: Migraine, venous sinus thrombosis, cluster

headache and intracranial bleed

 Gradual Onset: Tension headache, medication overuse

headache, sinusitis, GCA, CNS inflammation, brain tumours

and subdural haemorrhage
· Character
 Intense and Throbbing: Cluster headache, migraine and

venous sinus thrombosis. A subarachnoid haemorrhage will

cause a sudden onset worst headache ever that reaches
maximum intensity within seconds of onset.
6  Clinical Reasoning for Medical Students: Bridge the Gap

 Aching and Persistent: Tension headache, medication over-

use headache, sinusitis, brain tumours, CNS inflammation
and IIH
· Radiation
 Neck Stiffness: Migraine, subarachnoid haemorrhage and

CNS inflammation
 Eye: Cluster headache and venous sinus thrombosis

· Associated Symptoms
 Photophobia: Migraine and meningitis

 Seizures: CNS inflammation, intracranial bleeds and brain

tumour
 Lacrimation: Cluster headache

· Timing
 Stress: Migraine and tension headaches

 Specific Triggers (e.g. Chocolate): Migraine

 Specific Time Every Day: Cluster headache

 Worse in the Morning: Brain tumour

· Exacerbating
 Bright Lights and Loud Noises: Migraine, subarachnoid

haemorrhage and CNS inflammation

 Lying Down: Brain tumour and IIH

· Severity: Though each type of headache can be severe in its

own right, the headaches that are typically associated with being
very severe are cluster headaches, migraines, subarachnoid
haemorrhage and venous sinus thrombosis.

Read through the classical presentations table in the following sec-

tion to develop an understanding of how the main differentials are
classically present.

Classical Presentations
Differential Classical Presentation
Acute onset unilateral throbbing headache
associated with photophobia and phonophobia.
Migraine Patients may feel nauseous, and some may
experience an aura before the onset of the
headache.
 Headache 7

Relatively mild bitemporal headache with a

Tension band-like distribution across the forehead. May
Headache be associated with stress, poor sleep or ill
health.
Medication Recurrent headaches in patients who frequently
Overuse use painkillers (e.g. paracetamol).
Gradual onset headache associated with coryzal
symptoms. Patients may complain of the pain
Sinusitis
worsening when leaning forward and when
tapping their forehead.
Extradural: Head injury with initial loss of
consciousness followed by a lucid interval and,
later, a rapid deterioration in consciousness.
Subdural: May or may not have a clear history
of preceding head injury. Gradually worsening
Intracranial confusion, headache and drowsiness. More
Bleed
common in the elderly.
Subarachnoid: Sudden onset worst headache
ever (maximum intensity within seconds), often
occipital and associated with nausea, vomiting,
photophobia and neck stiffness.
Generally unwell with a fever, generalised
headache, photophobia and neck stiffness.
CNS
Some patients may have a rash. Patients with
Inflammation
encephalitis may develop seizures and reduced
consciousness.
Persistent headaches that are worse when lying
Brain
down and in the mornings. May be associated
Tumour
with nausea and vomiting.
Unilateral headache associated with temporal
Giant Cell artery tenderness, scalp tenderness and jaw
Arteritis claudication. Visual impairment is a serious sign
suggestive of retinal artery involvement.
Venous Acute onset severe headache that does not
Sinus respond well to analgesia. May be associated
Thrombosis with lateralising neurology and seizures.
8  Clinical Reasoning for Medical Students: Bridge the Gap

Intense unilateral headache that occurs at

Cluster roughly the same time every day and may occur
Headache for weeks or months. Often associated with
lacrimation.
Idiopathic
Persistent generalised headache that is worse
Intracranial
when lying down. Associated with obesity.
Hypertension

Red Flags

Though headaches are common, it is vital that you screen appro-

priately for dangerous causes of a headache as they could be cata-
strophic if missed.
 Headache 9

Patients who are unwell with a fever secondary to a simple viral

infection often complain of a headache, however, it is important
to screen for a constellation of symptoms that are classically
­associated with meningitis and encephalitis: neck stiffness and
photophobia. Risk factors for venous thromboembolism (e.g.
pregnancy) should raise suspicion of a venous sinus thrombosis.
GCA usually presents in older patients and may be associated with
jaw claudication, scalp tenderness and, most worryingly, visual
changes. Several causes of a headache can be extremely severe
and debilitating but subarachnoid haemorrhages are associated
with causing a sudden onset worst headache ever (thunderclap)
that reaches maximal intensity within seconds of onset.
Brain tumours tend to present insidiously with persistent
headaches that usually fail to respond to simple analgesia. Other
important features include the headaches being worse in the
morning, progressive worsening over several weeks or months
and, in particular, the presence of focal neurology. It should
also be considered as a differential in anyone under the age of
10 years or over the age of 50 years presenting for the first time
with a headache.

Assessment

Observations
In most cases, the observations of a patient presenting with a head-
ache will be normal. Patients with intracranial infections may have
a fever and other features of systemic upset (e.g. tachycardia and
hypotension). If patients present acutely with an intracranial bleed,
10  Clinical Reasoning for Medical Students: Bridge the Gap

it is important to monitor for Cushing’s reflex (hypertension and

bradycardia) which is a feature of raised intracranial pressure that
requires urgent neurosurgical attention.

Examination
Patients with space-occupying lesions, such as brain tumours
and intracranial bleeds, can develop focal neurological features
(e.g. lateralising weakness and visual field defects). Similarly,
venous sinus thromboses can cause cranial nerve defects.
Patients with GCA classically have a tender temporal artery with
an impalpable pulse and may demonstrate scalp tenderness. In
severe cases of meningococcal septicaemia, patients may develop
a non-blanching rash secondary to coagulopathy and damage to
blood vessels.

Migraine

Definition
Migraines are a very common cause of headache, and they are
thought to arise due to issues with blood vessel dilation within
the brain. They tend to recur and may have specific triggers
(e.g. chocolate, stress and lack of sleep). Some patients may
 Headache 11

experience abnormal sensory phenomena immediately before a

migraine (e.g. zig-zag patterns in their field of vision); this is
referred to as an aura.

Investigations
Migraines are primarily a clinical diagnosis and do not usually
require further investigation. A headache diary may be recom-
mended to help identify potential triggers.

Management
The acute management of a migraine involves managing the pain
as best as possible. If taken early, triptans (e.g. sumatriptan) can
help terminate the migraine. It can be administered orally, intrana-
sally or subcutaneously. Once a migraine is established, the
analgesic options that are generally recommended are Aspirin
­
900 mg, Paracetamol 1000 mg or Ibuprofen 400 mg. Sometimes,
migraines are associated with nausea, and this can be managed
with antiemetics (e.g. prochlorperazine).
Patients who experience frequent migraines may be started on
topiramate, amitriptyline or propranolol which can reduce the
frequency of migraine attacks. Patients should also be advised to
attempt to identify and avoid any triggers.
12  Clinical Reasoning for Medical Students: Bridge the Gap

Bridge Box

Differentials for headache.

 Chapter 2

Confusion

Confusion is a relatively common presentation among elderly

patients presenting to A&E and primary care services. A thorough
clinical assessment as well as a collateral history are necessary to
determine the underlying cause.

13
14  Clinical Reasoning for Medical Students: Bridge the Gap
 Confusion 15

Patient Background
The patient’s age is of particular importance
in patients presenting with confusion as
the differentials vary considerably between
older and younger patients. Older patients
generally have lower ­physiological and cog-
nitive reserves and so are more susceptible
to becoming confused as a result of rela-
tively minor insults (e.g. urinary tract infec-
tions). Younger patients are more likely to
abuse illicit drugs and present for the first
time with psychotic disorders.
In older patients who have a background of cognitive impair-
ment (e.g. dementia), a detailed collateral history should be taken
to identify their baseline cognitive and functional state, thereby
enabling you to determine whether the patient is off their baseline.
The patient’s social setting and baseline mobility should also
be noted as they provide an idea of the degree of their frailty
and the risk of them having potentially sustained an unwitnessed
head injury (e.g. an elderly patient with Parkinson’s disease who
16  Clinical Reasoning for Medical Students: Bridge the Gap

mobilises with a Zimmer frame and lives alone is at high risk of

having an unwitnessed fall).
In the social history, a background of alcohol excess means
that the patient is at risk of developing Wernicke’s encephalopa-
thy and subdural haemorrhages (because of cerebral atrophy
and the risk of falling while intoxicated). A history of illicit drug use
could alert you to the possibility of intoxication being the cause of
the confusion.

Differential Diagnosis

As discussed above, though there is a degree of overlap, the

age of the patient can immediately help narrow the differential
diagnosis.
The most common cause of acute confusion in older patients is
delirium, which is defined as an acute confusional state caused by
an underlying physical health problem (e.g. infection). Elderly
patients with a chronic history of cognitive decline may be develop-
ing dementia — the patterns of decline can be useful in helping
delineate the different types (e.g. stepwise in vascular dementia vs
gradual in Alzheimer’s disease). Intracranial bleeds (in particular,
subdural haemorrhages) should always be considered in elderly
patients presenting with confusion where there is no other obvious
cause of the confusion or where there has been a history of recent
head injury.
In younger patients, acute confusion is rare and very concern-
ing as it may be the presenting symptom of serious intracranial
 Confusion 17

pathology. In any first presentation, it is important to ask probing

questions about recreational drug use as intoxication can mani-
fest with confusion and some drugs can precipitate psychotic
episodes. CNS inflammation (i.e. encephalitis) is an important
cause that must be treated empirically as it can progress rapidly
and lead to other troublesome complications, such as seizures and
reduced GCS. In patients with a subacute history of confusion or
personality changes, brain tumours should be considered as a
possible cause. In all patients, metabolic disturbances such as
hypoglycaemia, hyponatraemia and hypercalcaemia can cause
confusion.
Clinicians should do their best to resist developing tunnel vision
when focusing on any one differential as they can exist in tandem.
For example, a patient can have a background of a psychotic dis-
order but also present intoxicated and having sustained a head
injury.
Read through the classical presentations table in the following
section to develop an understanding of how the main differentials
are classically present.

Classical Presentations
Differential Classical Presentation
Characterised by abnormal thought patterns
and delusions (false, fixed beliefs that are held
Psychosis despite the presence of conflicting evidence).
May be associated with visual or auditory
hallucinations.
Persistent headaches that are worse when lying
Brain
down or in the mornings. May be associated
Tumour
with nausea and vomiting.
Generally unwell with a fever, generalised
headache, photophobia and neck stiffness.
Encephalitis
Some patients may have a rash. Patients may
develop seizures and reduced GCS.
18  Clinical Reasoning for Medical Students: Bridge the Gap

Acute deterioration in cognitive function. Can be

described as hypoactive (associated with
Delirium reduced engagement with others) or hyperac-
tive (associated with more noticeable symp-
toms, such as agitation and aggression).
Alzheimer’s Disease: Gradual deterioration in
short-term memory and cognitive function.
Vascular Dementia: Stepwise decline in
­cognitive function.
Dementia with Lewy Bodies: Progressive
deterioration in cognitive function associated
Dementia
with hallucinations and Parkinsonian symptoms.
Frontotemporal Dementia: Characterised by
impairments in executive function (e.g. sexually
inappropriate, offensive and aggressive behav-
iour). Often occurs at a younger age compared
to other forms of dementia.
Extradural: Head injury with initial loss of
consciousness followed by a lucid interval and
then a later, rapid deterioration in
consciousness.
Subdural: May or may not have a clear history
Intracranial of preceding head injury. Gradually worsening
Bleed confusion, headache and drowsiness. More
common in the elderly.
Subarachnoid: Sudden onset worst headache
ever (maximum intensity within seconds), often
occipital and associated with nausea, vomiting,
photophobia and neck stiffness.
Depends on the underlying pathology. Patients
Metabolic with diabetes who take hypoglycaemic drugs
Disturbances (e.g. insulin) may develop drowsiness, sweating
and anxiety.
 Confusion 19

Red Flags

Several manifestations such as altered GCS, seizures, focal neu-

rology and loss of consciousness can arise due to different
underlying diagnoses. Altered GCS and seizures are of particular
concern as patients may lose the ability to maintain their airway
and require additional support (e.g., intensive care unit (ICU)).
Features of sepsis (e.g. fever) in young people with confusion are
highly suggestive of intracranial infection. In older patients, it is
more likely that the source of sepsis is chest or urinary and that the
confusion is due to delirium. A recent history of head injury should
be explored further to determine the temporal relationship between
the head injury and the onset of confusion.

Assessment

Observations
As mentioned earlier, a fever may be suggestive of intracranial
infection in younger patients presenting with confusion, whereas it
is more likely to be due to an infection elsewhere driving delirium in
20  Clinical Reasoning for Medical Students: Bridge the Gap

older patients. In cases of intracranial bleeds, an increase in intrac-

ranial pressure can manifest with Cushing’s triad (hypertension,
bradycardia and irregular breathing). This is a deeply concerning
feature that requires urgent cross-sectional brain imaging and dis-
cussion with the neurosurgical team.

Examination
A neurological examination is a vital part of the assessment of a
patient with confusion. Lateralising neurology (e.g. unequal
pupils) is highly suggestive of an intracranial abnormality such as a
bleed. Features of meningeal irritation may also be identifiable
upon examination (e.g. Brudzinski and Kernig’s signs). In younger
patients, features of drug toxidromes may also be noted (e.g. rest-
lessness and agitation in patients who have taken MDMA).

Encephalitis

Definition
Encephalitis is inflammation of the brain resulting in manifestations
of brain dysfunction (e.g. confusion, seizures and drowsiness).
It is most commonly caused by a viral infection (usually Herpes
Simplex Virus) but can also be autoimmune.
 Confusion 21

Investigations
At the bedside, non-invasive assessments of consciousness (using
the Glasgow Coma Scale) and mental state (using the mini-­
mental state examination) should be considered. This requires
close monitoring.
In patients with evidence of sepsis, a venous blood gas is an
appropriate initial investigation to perform as it allows rapid meas-
urement of pH and serum lactate concentration, which is used to
determine the severity of sepsis. Similarly, a full blood count and
CRP may demonstrate raised inflammatory markers in keeping
with an infectious cause. Blood cultures should also be taken,
ideally before commencing antimicrobial treatments.
A CT head scan is often normal in the early stages of encepha-
litis but, in some cases, may reveal low density within the temporal
lobe. If the CT scan is inconclusive, an MRI head may be
requested. A lumbar puncture is essential as the diagnosis can
be confirmed based on the pattern noted on cerebrospinal fluid
(CSF) analysis. It can also help identify the causative organism
(e.g. HSV PCR). An electro­encephalogram (EEG) may be per-
formed to demonstrate sei­zure activity.

Management
Infection is the most common cause of encephalitis. It is usually
caused by Herpes Simplex Virus, so patients should be promptly
commenced on treatment with IV Aciclovir. Bacteria such as
Streptococcus pneumoniae, Neisseria meningitidis and Listeria
monocytogenes can cause serious intracranial infections so
empirical antibiotics (usually ceftriaxone with or without amoxicil-
lin) are often started to cover bacterial infections. The results of
blood cultures and CSF analysis can help guide antimicrobial
treatment.
Autoimmune encephalitis is a much rarer yet very important
diagnosis that can be successfully treated using approaches
that aim to reduce the levels of the causative autoantibodies.
This includes steroids, IVIG, plasmapheresis and immuno­
modulating drugs.
22  Clinical Reasoning for Medical Students: Bridge the Gap

Seizures are a concerning manifestation of encephalitis that

can put the patient at risk of injury and airway compromise
so symptomatic treatment with anticonvulsants should be
considered in patients with encephalitis who are experiencing
­
seizures.

Bridge Box

Intracranial causes of confusion.

 Chapter 3

Collapse

A collapse can be a dramatic and concerning presentation in the

emergency department. A detailed history that explores the events
immediately before, during and after the collapse is vital in identify-
ing the underlying cause.

23
24  Clinical Reasoning for Medical Students: Bridge the Gap
 Collapse 25

Patient Background
Several different organs and organ sys-
tems can be responsible for a patient
collapsing (e.g. cardiac, neurological and
metabolic). Patients with a background of
cardiovascular disease or those with
multiple cardiac risk factors are at
greater risk of developing cardiogenic
syncope (e.g. arrhythmia and valvular
disease). It is also important to enquire
about whether the patient has diabetes
26  Clinical Reasoning for Medical Students: Bridge the Gap

mellitus and how it is treated. Those who take hypoglycaemic

agents (e.g. insulin and sulfonylureas) are at risk of developing
hypoglycaemia which can lead to collapse. The drug history should
also be screened for drugs that have an antihypertensive effect
(e.g. calcium channel blockers, beta-blockers and diuretics). These
can impair the body’s ability to maintain its blood pressure when
standing from a seated position (orthostatic hypotension).

Differential Diagnosis

The causes of collapse can be categorised based on the system

affected.

Cardiogenic
This relates to the various ways in which impaired heart function
can lead to a reduction in cardiac output and, hence, perfusion
of the brain. Abnormalities in the rhythm, outflow obstruction (e.g.
aortic stenosis and hypertrophic obstructive cardiomyopathy
(HOCM)) and acute ischaemic events can all lead to a decline in
cardiac output resulting in collapse.

Neurological
Seizures are defined as excessive and abnormal brain activity that
can first present with an episode of collapse. If presenting for the
first time with a seizure, it is important to consider possible precipi-
tants (e.g. tumour, intracranial bleed and intracranial infection).
 Collapse 27

Metabolic
Patients with a background of diabetes mellitus which is treated
with hypoglycaemic agents (e.g. insulin and sulfonylureas) are at
risk of developing hypoglycaemia which can lead to collapse.
Patients with liver failure are another subgroup who are at risk of
developing hypoglycaemia due to depleted hepatic glycogen
stores. Intoxication with drugs and alcohol is a very common
cause of collapse in patients brought in by ambulance to A&E.
Read through the classical presentations table in the following
section to develop an understanding of how the main differentials
are classically present.

Classical Presentations
Differential Classical Presentation
Patients may describe feeling palpitations
before collapsing for a short period of time
Arrhythmia with rapid, full recovery afterwards. Sometimes
associated with chest discomfort and, at other
times, there may be no warning at all.
Classically presents with central crushing
chest pain that radiates to the jaw. Associated
Acute
with sweating, anxiety and nausea. Patients
Coronary
may describe a prior history of experiencing
Syndrome
chest pain on exertion that is relieved by rest
(stable angina).
Sudden onset loss of consciousness that
occurs without warning. Patients may mention
Outflow previously experiencing chest pain on exertion
Obstruction and shortness of breath. Aortic stenosis is more
common in older patients, whereas HOCM
typically is present in active, young patients.
Dizziness and/or collapse that occurs when
Orthostatic standing up from a sitting or lying position.
Hypotension More common in elderly patients who are on
medications that affect their blood pressure.
28  Clinical Reasoning for Medical Students: Bridge the Gap

Patients may experience a sensory aura

before collapsing. May be associated with
stiffness and shaking of the limbs, tongue
Seizures
biting and urinary incontinence. Patients will
often be drowsy or confused for hours after
the episodes (postictal phase).
Characterised by drowsiness, sweating and
anxiety though some patients may lack
Hypoglycaemia hypoglycaemia awareness. There may be a
precipitant, such as inappropriate insulin use
or nausea and vomiting.
Depends largely on the drug that is con-
Intoxication sumed. May be associated with nausea and
vomiting.
Very common cause of collapse. Patients will
describe feeling dizzy and lightheaded before
Vasovagal
collapsing for a matter of seconds with rapid
Syncope
recovery. May be precipitated by heat or
strong emotions (e.g. fear).

Red Flags
 Collapse 29

Of the various potential causes of syncope, neurological and car-

diac causes are particularly concerning as the issue could recur
resulting in further injury or death.

Cardiac Outflow Obstruction

HOCM and aortic stenosis are two potential causes of cardiac out-
flow obstruction that can be fatal. Both conditions can lead to myo-
cardial ischaemia, heart failure and complete outflow obstruction
resulting in cardiac arrest.
The presence of an outflow tract obstruction can impair the
heart’s ability to increase output to match demand during periods
of increased activity (e.g. exercise). Therefore, collapse during
exercise can be a manifestation of both HOCM and aortic steno-
sis. These patients may also comment that they sometimes experi-
ence chest pain when they exert themselves.

Neurogenic
A collateral history from a bystander can be useful to assess for
features suggestive of a neurogenic cause of collapse. These
include limb jerking, tongue biting, urinary incontinence and
postictal confusion. If patients have an unwitnessed seizure, they
may present in the postictal phase, and it may be difficult to estab-
lish a clear history.

Head Injury
Enquiring or assessing a patient for a potential head injury is
essential as it could be the cause or consequence of collapse.
A head injury followed by a lucid interval or acute cognitive decline
prior to collapse may be suggestive of an intracranial bleed
(extradural or subdural). On the other hand, a collapse caused by
cardiogenic or neurogenic causes can lead to a head injury, so it is
important to consider cross-sectional brain imaging for patients
with collapse.
30  Clinical Reasoning for Medical Students: Bridge the Gap

Before, During and After

A useful structure to follow when taking a history from a patient

presenting with collapse is to ask what happened before, during
and after the episode.

Before
Patients with cardiogenic syncope due to outflow tract obstruction
or arrhythmia often have no warning at all before losing conscious-
ness. In some cases, however, they may experience some preced-
ing chest pain or palpitations.
Patients with neurogenic syncope due to seizures may mention
that they felt some form of aura. This could take the form of per-
ceptual changes (e.g. visual, olfactory and sensory) that arise
before the collapse. It is key that patients are asked specifically
about recent head injury as the collapse may be a manifestation
of a traumatic intracranial bleed.
The activities of the patient at the time of the collapse should
also be established. A sudden change from a seated or lying to a
standing position can be suggestive of orthostatic hypotension.
Patients who have been standing for a prolonged period or exposed
to frightening stimuli may develop vasovagal syncope.

During
This part of the history may need to be established by taking a col-
lateral history from a witness.
The duration of time that the patient was unconscious can
indicate the likely system affected. Generally, cardiogenic syncope
 Collapse 31

is short-lived and lasts a matter of seconds, whereas seizures can

last longer. Patients and those giving a collateral history should
also be asked about limb jerking, tongue biting and urinary
incontinence — these features would be in keeping with a seizure.
Assessing for potential head injury at the time of the collapse is
also essential as the patient may require cross-sectional brain
imaging to rule out an intracranial bleed.

After
Patients with cardiogenic syncope usually recover fully within
seconds. They may feel dazed and startled by the collapse, how-
ever, they will likely be coherent and be able to make sense of what
has just happened to them. Patients who have had a seizure, on
the other hand, are often drowsy and confused for several hours
after the collapse.

Assessment

Observations
The heart rate may indicate whether the patient has an arrhythmia
that precipitated their fall. This could both be tachyarrhythmias (e.g.
atrial fibrillation) or bradyarrhythmias (e.g. complete heart block).
Furthermore, the blood pressure can reveal evidence of valvular
abnormalities (e.g. narrow pulse pressure in aortic stenosis).
Lying–standing blood pressure should also be measured to
check for orthostatic hypotension.
32  Clinical Reasoning for Medical Students: Bridge the Gap

Examination
A cardiovascular and neurological assessment should be carried
out to check for the likely cause of collapse as well as performing
an external assessment to check for injuries that may have been
sustained from the collapse.

· Cardiovascular: The rate, rhythm and character of the pulse

can alert you to the possibility of an underlying arrhythmia.
Murmurs upon auscultation (in particular, an ejection systolic
murmur at the left sternal edge suggestive of aortic stenosis) will
provide some evidence of underlying valvular abnormalities that
may have caused an outflow obstruction. In HOCM and aortic
stenosis with left ventricular hypertrophy, a heave may be
palpable.
· Neurological: The presence of focal neurology (e.g. lateralis-
ing weakness and cranial nerve palsies) may be suggestive of a
stroke or an intracranial bleed. The consciousness should also
be assessed as it could be suggestive of a patient being in the
postictal phase or of metabolic or intracranial pathology.
· External Assessment: A collapse can cause serious damage,
especially in frail older patients. It is, therefore, important to per-
form a thorough assessment to check for other injuries that
may have been sustained when they fell, such as fractures and
lacerations.

Aortic Stenosis
 Collapse 33

Definition
Aortic stenosis refers to narrowing of the aortic valve that can result
in a cardiac outflow obstruction. Its clinical manifestations include
chest pain (due to impaired coronary blood flow and the increased
demand of a hypertrophic left heart), shortness of breath (due to
left heart failure leading to pulmonary oedema) and syncope (due
to a brief reduction in cardiac output due to the obstruction).

Investigations
At the bedside, an ECG can demonstrate arrhythmias and show
evidence of left ventricular hypertrophy (increased R wave ampli-
tude in left-sided leads and increased S wave depth in right-sided
leads). A BNP can provide evidence of heart failure and a troponin
will demonstrate evidence of myocardial ischaemia, both of which
could result from aortic stenosis. Ultimately, an echocardiogram is
required to visualise the valvular abnormality and determine its
severity.

Management
If asymptomatic or mild, conservative measures may be taken,
such as monitoring the condition and optimising relevant comor-
bidities. If severe or symptomatic (as it would be in a patient that
has collapsed), the patient may be considered for valve replace-
ment which can either be achieved using an open approach or
transcatheter aortic valve implantation (TAVI).
34  Clinical Reasoning for Medical Students: Bridge the Gap

Bridge Box

Cardiogenic causes of collapse.

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 Oliver Rane was in his bedchamber; a front apartment facing the
road. It will be as well to give a word of description to this first floor,
for it may prove needed as the tale goes on. It consisted of a large
landing-place, its boards white and bare, with a spacious window
looking to the side of the other house, as the dining-room beneath it
did. Wide, low and curtainless was this window; giving, in
conjunction with the bare floors and walls, a staring appearance to
the place. Mrs. Cumberland's opposite landing (could you have seen
it) presented a very different aspect, with its rich carpet, its statues,
vases, bookcases, and its pretty window-drapery. Dr. Rane could not
afford luxuries yet; or, indeed, superfluous furniture of any sort. The
stairs led almost close to this window, so that in coming down from
any of the bedrooms, or the upper floor, you had to face it.

To get into Dr. Rane's chamber--the best in the house--an ante-

room had to be passed through, and its door was opposite the large
window. Two chambers opened from the back of the landing: they
faced the back lane that ran along beyond the garden wall. Above, in
the roof, were two other rooms, both three-cornered. Phillis, the old
serving-woman, slept on that floor in one of them, Dr. Rane on this:
the house had no other inmates.

The ante-room had no furniture: unless some curious-looking

articles lying on the floor could be called so. They seemed to consist
chiefly of glass: jars covered in dust, a cylindrical glass-pump, and
other things belonging to chemistry, of which science the doctor was
fond. Certainly the architect had not made the most of this floor, or
he would never have given so much space to the landing. But if this
ante-room was not furnished, Dr. Rane's chamber was; and well
furnished too. The walls were white and gold, the dressing-table and
glass stood before the window and opposite the door. On the left
was the fireplace; the handsome white Arabian bedstead was picked
out with gold, and its hangings of green damask, matched the
window drapery and the soft colours of the carpet.
 Seated at the round table in the middle of the room, his hand
raised to support his head, was Dr. Rane. He had only just come in,
and it was now one o'clock--his usual dinner hour. It was that same
morning mentioned in the last chapter, when he had quitted Mrs.
Gass's house with that dangerous piece of paper weighing upon his
pocket and his heart. He had been detained out. As he was entering
the house of the sick man, Ketler, whom he had proceeded at once
to see, a bustle in the street, and much wild running of women,
warned him that something must have happened. Two men had
fallen into the river at the back of the North Works; and excited
people were shouting that they were drowned. Not quite: as Dr.
Rane saw when he reached the spot: not beyond hope of
restoration. Patiently the doctor persevered in his endeavours. He
brought life into them at length; and stayed afterwards caring for
them. After that, he had Ketler and other patients to see, and it was
nearly one when he bent his steps towards home. In the morning he
had said to himself that he would call at the Hall on his return; but
he passed its gates; perhaps because it was his dinner hour, for one
o'clock was striking.

Hanging up his hat in the small hall, leaving his cane in the
corner--a pretty trifle with a gold stag for its handle--he was making
straight for the stairs, when the servant, Phillis, came out of the
kitchen. A little woman of some five-and-fifty years, with high
shoulders, and her head carried forward. Her chin and nose were
sharp now, but the once good-looking face was meek and mild, the
sweet dark eyes were subdued, and the hair, peeping from beneath
the close white cap, was grey. She wore a dark cotton gown and
check apron. A tidy-looking, respectable woman, in spite of her
unfashionable appearance.

"Is that you, sir? Them folks have been over from the brick-kilns,
saying the woman's not so well to-day, if you'd please to go to her."

Dr. Rane nodded. He went on up the stairs and into his own room,
the door of which he locked. Why? Phillis was not in the habit of
intruding upon him, and there was no one else in the house. The
first thing he did was to take the paper received from Mrs. Gass out
of his pocketbook, and read it attentively twice over. Then he struck
a match, set fire to it, and watched it consume away in the empty
grate. A dangerous memento, whosesoever hand had penned it; and
the physician did well, in the interests of humanity, to put it out of
sight for ever. The task over, he leaned against the window-frame,
and lapsed into thought. He was dwelling upon the death at Dallory
Hall, and what it might bring forth.

Hepburn, the undertaker, was right. There was to be no inquest.

So much Dr. Rane had learned from Richard North: who had
hastened to the works on hearing of the accident to his men. The
two Whitborough doctors had given the certificate of death:
apoplexy, to which there had been a previous tendency, though
immediately brought on by excitement: and nothing more was
required by law. From a word spoken by Richard, Dr. Rane gathered
that it was madam who had set her veto against an inquest. And
quite right too; there was no necessity whatever for one, had been
the comment made by Oliver Rane to Richard. But now--now when
he was alone with himself and the naked truth: when there was no
man at hand whose opinion it might be well to humour or deceive:
no eye upon him save God's, he could not help acknowledging that
had he been Mr. North, had it been his son who was thus cut off
from life, he should have caused an inquest to be held. Ay, ten
inquests, an' the law would have allowed them; if by that means he
might have traced the letter home to its writer.

Quitting the window, he sat down at the table and bent his
forehead upon his hand. Never in his whole life had anything so
affected him as this death: and it was perhaps natural that he should
set himself to see whether, or not, any sort of excuse might be
found for the anonymous writer.

He began by putting himself in idea in the writer's place, and

argued the point for him: for and against. Chiefly for; it was on that
side his bias leaned. It is very easy, as the world knows, to find a
plea for those in whom we are interested or on whom misfortune
falls; it is so natural to indulge for their sakes in a little sophistry.
Such sophistry came now to the help of the physician.

"What need had Edmund North to fly into a furious passion?" ran
the self-argument. "Only a madman might have been expected to do
so. There was nothing in the letter that need have excited him,
absolutely nothing. It was probably written with a very harmless
intention; certainly the writer never could have dreamt that it might
have the effect of destroying a life."

Destroying a man's life! A flush passed into Oliver Rane's face at

the thought, dyeing neck and brow. And, with it, recurred the words
of Hepburn--that the writer was a murderer and might come to be
tried for it. A murderer! There is no other self-reproach under
heaven that can bring home so much anguish to the conscience.
But--could a man be justly called a murderer if he had never had
thought or intention of doing anything of the kind?

"Halt here," said Dr. Rane, suddenly speaking aloud, as if he were

a special pleader arguing in a law court. "Can a man be called a
murderer who has never had the smallest intention of murdering--
who would have flown in horror from the bare idea? Let us suppose
it was--Mrs. North--who wrote the letter? Alexander suspects her, at
any rate. Put it that she had some motive for writing it. It might
have been a good motive--that of stopping Edward North in his
downward career, as the letter intimated--and she fancied this might
be best accomplished by letting his father hear of what he, in
conjunction with Alexander, was doing. According to Alexander, she
does not interfere openly between the young men and their father;
it isn't her policy to do so: and she may have considered that the
means she took were legitimate under the circumstances. Well,
could she for a moment imagine that any terrible consequences
would ensue? A rating from Mr. North to his son, and the matter
would be over. Just so: she was innocent of any other thought. Then
how could she be thought guilty?"

Dr. Rane paused. A book lay on the table: he turned its leaves
backwards and forwards in abstraction, his mind revolving the
subject. Presently he resumed.

"Or--take Alexander's view of the letter--that it was written to

damage him with Mr. North and the neighbourhood generally.
Madam--say again--had conceived a dislike to Alexander, wished him
dismissed from the house, but had no plea for doing it, and so took
that means of accomplishing her end. Could she suspect that the
result would be fatal to Edmund North? Would she not have shrunk
with abhorrence from writing the letter, had she foreseen it?
Certainly. Then, under these circumstances, how can a man--I mean
a woman--be responsible, legally or morally, for the death? It would
be utterly unjust to charge her with it. Edmund North is alone to
blame. Clearly so. The case is little better than one of unintentional
suicide."

Having arrived at this view of the subject--so comforting for the

unknown writer--Dr. Rane rose briskly, and began to wash his hands
and brush his hair. He took a note-case from his pocket, in which he
was in the habit of entering his daily engagements, to see at what
hour he could most conveniently visit the brick-fields, in compliance
with the message received. The sick woman was in no danger, as he
knew, and he might choose his own time. In passing through the
ante-room--a room, by the way, generally distinguished as the Drab
Room, from the unusual colour of the hideous walls--he took up one
of the glass jars, requiring it for some purpose downstairs. And then
he noticed something that displeased him.

"Phillis!" he called, going out to the landing: "Phillis!" And the

woman, a very active little body, came running up.

"You have been sweeping the Drab Room?"

 "It was so dirty, sir."

"Now look here," he cried, angrily. "If you sweep out a room
again, when I tell you it is not to be swept, I'll keep every place in
the house locked up. Some of the glass here is valuable, and I won't
run the risk of having it broken with your brooms and brushes."

Down went Phillis, taking the reproof in silence. As Dr. Rane

crossed the landing to follow her, his eyes fell on his mother's house
through the large window. The window opposite was being cleaned
by one of the servants: at the window of the dining-room
underneath, his mother was sitting. It reminded Dr. Rane that he
had not been in to see her for nearly two days; not since Edmund
North----

Suddenly a sense of the delusive nature of the sophistry he had

been indulging, flashed into his brain, and the truth shone out
distinct and bare. Edmund North was dead; had been killed by the
anonymous letter. But for that fatal letter he had been alive and well
now. A sickening sensation, as of some great oppression, came over
Oliver Rane, and his nerveless fingers dropped the jar.

Out ran Phillis, lifting her hands at the crash of glittering particles
lying in the passage. "He has broken one himself now," thought she,
referring to the recent reproof.

"Sweep the pieces carefully into a dust-pan, and throw them

away," said her master as he passed on. "The jar slipped out of my
fingers."

Phillis stared a minute, exhausting her surprise, and then turned

away for the dust-pan. The doctor went on to the front-door, instead
of into the dining-room, as Phillis expected.

"Sir," she called out, hastening after him, "your dinner's waiting.
Will you not take it now?"
 But Dr. Rane passed on as though he had not heard her, and shut
the door loudly.

He turned into his mother's house. Not by the open window; not
by stepping over the slight fence; but he knocked at the front-door,
and was admitted as an ordinary visitor. Whether it was from having
lived apart for so many years of their lives, or that a certain
cordiality was wanting in the disposition of each, certain it was that
Dr. Rane and his mother observed more ceremony with each other
than usually obtains between mother and son.

Mrs. Cumberland sat at the open dining-room window just as he

had seen her from his staircase landing; a newspaper lay behind her
on a small table, as if just put down. Ellen Adair, as might be heard,
was at the piano in the drawing-room, playing, perhaps from
unconscious association, and low and softly as it was her delight to
play, the "Dead March in Saul." The dirge grated on the ears of Dr.
Rane.

"What a melancholy performance!" he involuntarily exclaimed; and

Mrs. Cumberland looked up, there was so much irritation in his tone.

He shook hands with his mother, but did not kiss her, which he
was not accustomed to do, and stood back against the broad
window, his face turned to it.

"You are a stranger, Oliver," she said. "What has kept you away?"

"I have been busy. To-day especially. They had an accident at the
works--two men were nearly drowned--and I have been with them
all the morning."

"I heard of it. Jelly brought me in the news; she seems to hear
everything. How fortunate that you were at hand!"

He proceeded, rather volubly for him, to give particulars of the

accident and of the process he adopted to recover the men. Mrs.
Cumberland looked and listened with silent, warm affection; but that
she was a particularly undemonstrative woman, she would have
betrayed it in her manner. In her eyes, there was not so fine and
handsome and estimable a man in all Dallory as this her only son.

"Oliver, what a dreadful thing this is about Edmund North! I have

not seen you since. Why did you not come in and tell me the same
night?"

He turned his eyes on her for a moment in surprise, and paused.

"I am not in the habit of coming in to tell you when called out to
patients, mother. How was I to know you wished it?"

"Nonsense, Oliver! This is not an ordinary thing: the Norths were

something to me once. I have had Edmund on my knee when he
was a baby; and I should have liked you to pay me the attention of
bringing in the news. It appears to be altogether a more romantic
event than one meets with every day, and such things, you know,
are of interest to lonely women."

Dr. Rane made no rejoinder, possibly not having sufficient excuse

for his carelessness. He stood looking dreamily from a corner of the
window. Phillis, as might be seen from there, was carrying away the
fowl prepared for his dinner, and a tureen of sauce. Mrs. Cumberland
probably thought he was watching with critical curiosity the
movements of his handmaid. She resumed:

"They say, Oliver, there has been no hope of him from the first."

"There was very little. Of course, as it turns out, there could have
been none."

"And who wrote the letter? With what motive was it written?"
proceeded Mrs. Cumberland, her grey face bent slightly forward, as
she waited for an answer.
 "It is of no use to ask me, mother. Some people hold one opinion,
some another; mine would go for little."

"They are beginning now to think that it was not written at all to
injure Edmund, but Mr. Alexander."

"Who told you that?" he asked, a sharper accent discernible in his

tone.

"Captain Bohun. He came in this morning to tell me of the death.

Considering that I have no claim upon him, that a year ago I had
never spoken to him, I must say that Arthur Bohun is very kind and
attentive to me. He is one in a thousand."

Perhaps the temptation to say, "It's not for your sake he is so

attentive," momentarily assailed Oliver Rane. But he was good-
natured in the main, and he knew when to be silent, and when to
speak: no man better. Besides, it was no business of his.

"I entertain a different opinion," he observed, referring to the

point in discussion. "Of course it is all guess work as to the writer's
motive: there can be no profit in discussing it, mother: and I must
be going, for my dinner's waiting. Thank you for sending me the
chicken."

"A moment yet, Oliver," she interposed, as he was moving away.

"Have you heard that Alexander is going to leave?"

"Yes: he was talking to me about it this morning."

If ever a glow of light had been seen lately on Mrs. Cumberland's

marble face, it was seen then. The tightly-drawn features had lost
their grey tinge.

"Oliver, I could go down on my knees and thank Heaven for it. You
don't know how grieved I have felt all through these past two years,
to see you put into the shade by that man, and to know that it was I
who had brought you here! It will be all right now. New houses are
to be built, they say, at the other end of the Ham, and the practice
will be worth a great deal. I shall sleep well to-night."

He smiled as he shook hands with her; partly in affection, partly at

her unusual vehemence. In passing the drawing-room, Ellen Adair
happened to be coming out of it, but he went on. She supposed he
had not observed her, and spoke.

"Ah! how do you do, Miss Adair?" he said, turning back, and
offering his hand. "Forgive my haste; I am busy to-day."

And before she had time to make any reply, he was gone; leaving
an impression on her mind, she could not well have told why or
wherefore, that he was ill at ease; that he had hastened away, not
from pressure of work, but because he did not care to talk to her.

If that feeling was possessing Dr. Rane, and had reference to the
world in general, and not to the young lady in particular, it might not
have been agreeable to him to encounter an acquaintance as he
turned out of his mother's house. Mr. Alexander was swiftly passing
on his way towards home from the lower part of the Ham, and
stopped.

"I wish I had never said a syllable about going away until I was
off," cried he in his off-hand manner--a pleasanter and more sociable
manner than Dr. Rane's. "The news has been noised abroad, and the
whole place is upon me; asking this, that, and the other. One man
comes and wants to know if I'll sell my furniture; another thinks he'd
like the house as it stands. My patients are up in arms;--say I'm
doing it to kill them. I shall have some of them in a fever before the
day's over."

"Perhaps you won't go, after all," observed Dr. Rane.

"Not go! How can I help going? I'm elected to the post. Why, it's
what I've been looking out for ever so long--almost ever since I
came here. No, no, Rane: a short time, and Dallory Ham will have
seen the last of me."

He hastened across the road to his house, like a man who has the
world's work on his busy shoulders. Dr. Rane's thoughts, as he
glanced after him, reverted to the mental argument he had held in
his chamber, and he unconsciously resumed it, putting himself in the
place of the unknown, unhappy writer, as before.

"It's almost keener than the death itself--if the motive was to
injure Alexander in his profession, or drive him from the place--to
know that he, or she--Mrs. North--might have spared her pains!
Heavens! what remorse it must be!--to commit a crime, and then
find there was no necessity for doing it!"

Dr. Rane passed his white handkerchief over his brow--the day
was very warm--and turned into his house. Phillis once more placed
the dinner on the table, and he sat down to it.

But not a mouthful could he swallow; his throat felt like so much
dried-chip, and the food would not go down. Phillis, who was coming
in for something or other, saw him leave his plate and rise from
table.

"Is the fowl not tender, sir?"

"Tender?" he responded, as though the sense of the question had

not reached him, and paused. "Oh, it's tender enough: but I must go
off to a patient. Get your own dinner, Phillis."

"Surely you'll come back to yours, sir?"

"I've had as much as I want. Take the things away."

"I wonder what's come to him?" mused the woman as his quick
steps receded from the house, and she was left with the rejected
dishes. A consciousness came dimly penetrating to her hazy brain
that there was some change upon him. What it was, or where it lay,
she did not define. It was unusual for his strong firm fingers to drop
a glass; it was still more unusual for him to explain cause and effect.
"The jar slipped from my fingers." "I've had as much as I want. I
must go off to a patient." It was quite out of the order of routine for
Dr. Rane to be explanatory to his servant on any subject whatever:
and perhaps it was his having been so in these two instances that
impressed Phillis.

"How quick he must have eaten his dinner!"

Phillis nearly dropped the dish. The words were spoken close
behind her, and she had believed herself alone in the house.
Turning, she saw Jelly, standing half in, half out of the window.

"Well, I'm sure!" cried Phillis, in wrath. "You needn't come startling
a body in that way, Mrs. Jelly. How did you know but the doctor
might be at table?"

"I've just seen him go down the lane," returned Jelly, who had
plenty of time for gossiping with her neighbours, and had come
strolling over the fence now with no other object. "Has he had his
dinner? It's but the other minute he was in at our house."

"He has had as much as he means to have," answered Phillis, her

anger evaporating, for she liked a gossip also. "I'm sure it's not
worth the trouble of serving meals, if they are to be left in this
fashion. It was the same thing at breakfast."

Jelly recollected the scene at breakfast; the startled pallor on Dr.

Rane's face, when told that Edmund North was dead: she supposed
that had spoiled his appetite. Her inquisitive eyes turned
unceremoniously to the fowl, and she saw that the merest slice off
the wing was alone eaten.

"Perhaps he is not well to-day," said Jelly.

 "I don't know about his being well; he's odder than I ever saw
him," answered Phillis. "I shouldn't wonder but he has had his
stomach turned over them two half-drowned men."

She carried the dinner-things across to the kitchen. Jelly, who

assisted at the ceremony, as far as watching and talking went, was
standing in the passage, when her quick eyes caught sight of two
small pieces of glass. She stooped to pick them up.

"Look, Phillis! You have been breaking something. It's

uncommonly careless to leave the bits about."

"Is it!" retorted Phillis. "Your eyes are in everything. I thought I

took 'em all up," she added, looking on the ground.

"What did you break?"

"Nothing. It was the doctor. He dropped one of them dusty glass

jars down the stairs. It did give me a start. You should have heard
the smash."

"What made him drop it?" asked Jelly.

"Goodness knows," returned the older woman. "He's not a bit like
himself to-day; it's just as if something had come to him."

She began her dinner as she spoke, standing, her usual mode of
taking it. Jelly, following her free-and-easy habits, stood against the
door-post, apparently interested in the progress of the meal. They
presented a contrast, these two women, the one a thin, upright
giantess, the other a dwarf stooping forward. Jelly, a lady's-maid,
held herself of course altogether above Phillis, an ignorant (as Jelly
would have described her) servant-of-all-work, though
condescending to drop in for the sake of gossip.

"Did you happen to hear how the doctor found Ketler?"

 "As if I should be likely to hear!" was Phillis's retort. "He'd not tell
me, and I couldn't ask. My master's not one you can put questions
to, Jelly."

A silence ensued. The gossip apparently flagged to-day. Phillis had

it chiefly to herself, for Jelly vouchsafed only a brief remark now and
again. She was engaged in the mental process of wondering what
had come to Dr. Rane.

CHAPTER V.

RETROSPECT

There must be a little retrospect to make things intelligible to the

reader; and it may as well be given at once.

Mr. North, now of Dallory Sail, had got on entirely by his own
industry. Of obscure, though in a certain way respectable,
parentage, he had been placed as apprentice to a firm in
Whitborough. It was a firm in extensive work, not confining itself to
one branch. They took contracts for public buildings, small and
large: did mechanical engineering; had planned one of the early
railways. John North--plain Jack North he was known as, then--
remained with the firm when he was out of his time, and got on in
it. Steady and plodding, he rose from one step to another; and at
length, in conjunction with one who had been in the same firm, he
set up for himself. This other was Thomas Gass. Gass had not risen
from the ranks as North had: his connections were good, and he had
received a superior education; but his friends were poor. North and
Gass, as the new firm called itself, began business near to Dallory;
quietly at first--as all people, who really expect to get on, generally
do begin. They rose rapidly. The narrow premises expanded; the
small contracts grew into large ones. People said luck was with
them--and in truth it seemed so. The Dallory works became noted in
the county, employing quite a colony of people: the masters were
respected and sought after. Both lived at Whitborough; Mr. North
with his wife and family; Mr. Gass a bachelor.

Thomas Gass had one brother; a clergyman. Their only sister,

Fanny, a very pretty girl, had her home with him in his rectory, but
she came often to Whitborough on a visit to Thomas. Suddenly it
was announced to the world that she had become engaged to marry
a Captain Rane, entirely against the wish of her two brothers. She
was under twenty. Captain Rane, a poor naval man on half-pay, was
almost old enough to be her grandfather. Their objection lay not so
much in this, as in himself. For some reason or other, neither of
them liked him. The Reverend William Gass forbid his sister to think
of him; Mr. Thomas Gass, a fiery man, swore he would never
afterwards look upon her as a sister, if she persisted in thus throwing
herself away.

Miss Gass did persist. She possessed the obstinate spirit of her
brother Thomas, though without his fire. She chose to take her own
way, and married Captain Rane. They sailed at once for Madras;
Captain Rane having obtained some post there, connected with the
Government ships.

Whether Miss Gass repented her marriage, her brothers had no

means of learning: for she, retaining her anger, never wrote to them
during her husband's lifetime. It was a very short one. Barely a
twelvemonth had elapsed after the knot was tied, when there came
a pitiful letter from her. Captain Rane had died, just as her little son
Oliver (named after a friend, she said) was born. Thomas Gass, to
whom the letter had been specially written, gathered that she was
left badly off; though she did not absolutely say so. He went into
one of his angry moods, and tossed the epistle across the desk to
his partner. "You must do something for her, Gass," said John North
when he had read it. "I never will," hotly affirmed Mr. Gass. "Fanny
knows what I promised if she married Rane--that I would never help
her during my lifetime or after it. She knows another thing--that I
am not one to go from my word. William may help her if he likes; he
has not much to give away, but he can have her home to live with
him." "Help the child, then," suggested Mr. North, knowing further
remonstrance to be useless. "No," returned obstinate Thomas Gass;
"I'll stick to the spirit of my promise as well as the letter." And Mr.
North bent his head again--he was going over some estimates--
feeling that the affair was none of his. "I don't mind putting the boy
in the tontine, North," presently spoke the junior partner. "The
tontine!" echoed John North in surprise, "what tontine?" "What
tontine?" returned the hard man--though in truth he was not hard in
general, "why, the one that you and others are getting up; the one
you have just put your baby, Bessy, into; I know of no other
tontine." "But that will not benefit the boy," urged Mr. North:
"certainly not now; and the chances are ten to one against its ever
benefiting him in the future." "Never mind; I'll put him into it," said
Mr. Gass, whose obstinacy always came out well under opposition.
"You want a tenth child to close the list, and I'll put him into it." So
into the tontine Oliver Rane, unconscious infant, was put.

But Mrs. Rane did not further trouble either of her brothers; or, as
things turned out, require assistance from them. She remained in
India; and after a year married a Government chaplain there, the
Reverend George Cumberland, who possessed some private
property. Little, if any, communication took place afterwards
between her and her brothers; she cherished resentment for old
grievances, and would not write to them. And so the sister and the
brothers seemed to fade away from each other from henceforth. We
all know how relatives, parted by time and distance, become
estranged, disappearing almost from memory.
 Whilst the firm, North and Gass, was rising higher and higher in
wealth and importance, the wife of its senior partner died. She left
three children, Edmund, Richard, and Bessy. Subsequently, during a
visit to London, chance drew Mr. North into a meeting with a
handsome young woman, the widow of Major Bohun. She had not
long returned from India, where she had buried her husband. A
designing, attractive syren, who began forthwith to exercise her
dangerous fascinations on plain, unsuspicious Mr. North. She had
only a poor pittance; what money there was belonged to her only
child, Arthur; a little lad: sent out of sight already to a preparatory
school. Report had magnified Mr. North's wealth into something
fabulous; and Mrs. Bohun did not cease her scheming until she had
caught him in her toils and he had made her Mrs. North.

Men do things sometimes in a hurry, only to repent of them at

leisure. That Mr. North had been in a hurry in this case was
indisputable--it was just as though Mrs. Bohun had thrown a spell
over him; whether he repented when he woke up and found himself
with a wife, a stepmother for his children at home, was not so
certain. He was a sufficiently wise man in those days to conceal
what he did not want known.

Whom he had married, beyond the fact that she was the widow of
Major Bohun, he did not know from Adam. For all she disclosed
about her own family, in regard to whom she maintained an absolute
reticence, she might have dropped from the moon, or "growed" like
Topsy; but, from the airs and graces she assumed, Mr. North might
have concluded they were dukes and duchesses at least. Her late
husband's family were irreproachable, both in character and position.
The head of it was Sir Nash Bohun, representative of an ancient
baronetcy, and elder brother of the late major. Before the wedding
tour was over, poor Mr. North found that his wife was a cold,
imperious, extravagant woman, not to be questioned by any means
if she so chose. When her fascinations were in full play (while she
was only Mrs. Bohun) Mr. North had been ready to think her an
angel. Where had all the amiability flown to? People do change after
marriage somehow. At least, there have been instances known of it.

A little circumstance occurred one day that--to put it mildly--had

surprised Mr. North. He had been given to understand by his wife
that Major Bohun died suddenly of sunstroke; she had certainly told
him so. In talking at a dinner-party at Sir Nash Bohun's with some
gentlemen not long from India, he and Mr. North being side by side
at the table after the ladies had retired, the subject of sunstrokes
came up. "My wife's former husband, Major Bohun, died of one,"
innocently observed Mr. North. "Died of what?" cried the other,
putting down his claret-glass, which he was conveying to his mouth.
"Of sunstroke," repeated Mr. North. "Bohun did not die of
sunstroke," came the impulsive answer; "who told you he died of
that?" "She did--my wife," was Mr. North's answer. "Oh!" said his
friend; and took up his claret again. "Why, what did he die of, if it
was not sunstroke?" asked Mr. North, with curiosity. "Well,--I--I don't
know; I'd rather say no more about it," was the conclusive reply: "of
course Mrs. North must know better than I." And nothing more
would he say on the subject.

They were staying at this time at Sir Nash Bohun's. In passing

through London after the Continental wedding trip on their way to
Whitborough, Sir Nash had invited them to make his house their
resting-place. Not until the day following his conversation at the
dinner-table had Mr. North an opportunity of questioning his wife;
but, that some false representation, intentionally or otherwise, had
been made to him on the subject of her late husband's death, he felt
certain. They were alone in her dressing-room. Mrs. North, who had
a great deal of beautiful black hair, was standing before the glass,
doing something to a portion of it, when her husband suddenly
accosted her. He called her by her Christian name in those first
married days. It was a very fine one.

"Amanda, you told me, I think, that Major Bohun died of

sunstroke."
 "Well?" she returned carelessly, occupied with her hair.

"But he did not die of sunstroke. He died of--of something else."

Mr. North had watched women's faces turn to pallor, but never in
his whole life had he seen so livid a look of terror as now overspread
his wife's. Her hair dropped from her nerveless hands.

"Why, what is the matter?" he exclaimed.

She murmured something about a spasm of the heart, to which

she was subject: an excuse, as he saw. Another moment, and she
had recovered her composure, and was busy with her hair again.

"You were asking me something, were you not, Mr. North?"

"About Major Bohun: what was it he died of---if it was not

sunstroke?"

"But it was of sunstroke," she said, in a sharp, ringing accent, that

would have required only a little more to be a scream. "What else
should he die of suddenly in India's burning climate? He went out in
the blazing midday sun, and was brought home dead!"

And nothing more, then or afterwards, did Mr. North learn. Her
manner rendered it impossible to press the subject. He might have
applied to Sir Nash for information, but an instinct prevented his
doing so. After all, it did not matter to him what Major Bohun had
died of, Mr. North said to himself and determined to forget the
incident. But that some mystery must have attended Major Bohun's
death, some painful circumstances which could blanch his wife's face
with sickly terror, remained on Mr. North's mind as a fact not to be
disputed.

Mrs. North effected changes. Almost the very day she was taken
home to Whitborough, she let it be known that she should rule with
an imperious will. Her husband became a very reed in her hands;
yielding passively to her sway, as if all the spirit he had ever owned
had gone out of him. Mrs. North professed to hate the very name of
trade; that any one with whom she was so nearly connected should
be in business, brought her a sense of degradation and a great deal
of talk about it. The quiet, modest, comfortable home at
Whitborough was at once given up for the more pretentious Manor
Hall at Dallory Ham, which happened to be in the market. And they
set up there in a style that might have more properly belonged to
the lord-lieutenant of the county. Perhaps it was her assumption of
grandeur indoors and out, combined with the imperious manner, the
like of which had never before been seen in the simple
neighbourhood, that caused people to call her "Madam." Or, it might
have been to distinguish her from the first Mrs. North.

In proportion as Mrs. North made herself hated and feared by her

husband, his children, and the household, so did she become
popular with society. It sometimes happens that the more
fascination a woman displays to the world, the more unbearable is
she in her own house. It was the case here. Madam put on all her
attractions when out-of-doors; she visited and dressed and dined;
and gave fêtes again at Dallory Hall utterly regardless of expense.
Little wonder that she swayed the neighbourhood.

Not the immediate neighbourhood. With the exception of the

Dallory family (and they did not live there always), there was not a
single person she would have visited. A few gentle-people resided at
Dallory Ham; Mrs. North did not condescend to know any of them.
People living at a greater distance she made friends with, but not
those around her; and with as many of the county families as would
make friends with her. The pleasantest times were those when she
would betake herself off on long visits, to London or elsewhere: they
grew to be looked forward to.

But the most decided raid made by Mrs. North was on her
husband's business connections. Had Thomas Gass been a chimney-
sweeper, she could not have treated him with more intense
contempt. Thomas Gass had his share of sense, and pitied his
partner far more than he would have done had that gentleman gone
in for hanging instead of second marriage. Mr. Gass was a very
wealthy man now; and had built himself a handsome and
comfortable residence in Dallory.

But, as the years went on, he was doomed to furnish food himself
to all the gossips within miles. Dallory rose from its couch one fine
morning, to hear that Thomas Gass, the confirmed old bachelor, had
married his housekeeper. Not one of your "lady-housekeepers," but a
useful, good, hard-working damsel, who had passed the first bloom
of youth, and had not much beauty to recommend her. It was a nine
days' wonder. Of course, however much the neighbours might solace
their feelings by ridiculing him and abusing her, they could not undo
the marriage. All that remained to them was, to make the best of it;
and by degrees they wisely did so. The new Mrs. Gass glided easily
into her honours. She made an excellent wife to her ailing husband--
for Thomas Gass's health had begun to fail before his marriage--she
put on no airs of being superior to what she was; she turned out to
be a thoroughly capable woman of business, giving much judicious
advice to those about her: she was very good to the sick and
suffering, caring for the poor, ready to give a helping hand wherever
and whenever it might be needed. In spite of her fine dresses, which
sat ludicrously upon her, and of her manner of talking, which she did
not attempt to improve; above all, in spite of their own prejudices,
Dallory grew to like and respect Mrs. Gass, and its small gentle-
people admitted her to their houses on an equality.

And so time and years went on, Mr. North withdrawing himself
more and more from personal attendance on the business, which
seemed to have grown utterly distasteful to him. His sons had
become young men. Edmund was a civil engineer: by profession at
least, not much by practice. Never in strong health, given to
expensive and idle habits, Edmund North was generally either in
trouble abroad, or leading a lazy life at home, his time being much
divided between going into needless passions and writing poetry.
Richard was at the works, the mainspring of the business. Mr. Gass
had become a confirmed invalid, and could not personally attend to
it; Mr. North did not do so. There was only Richard--Dick, as they all
called him; but he was a host in himself. Of far higher powers than
Mr. North had ever possessed, cultivated in mind, he was a thorough
man of business, and at the same time a finished gentleman.
Energetic, persevering, firm in controlling, yet courteous and
considerate to the very lowest, Richard North was loved and
respected. He walked through life doing his duty by his fellow-men:
striving to do it to God. He had been tried at home in many ways
since his father's second marriage, and borne all with patient
endurance: how much he was tried out of home, he alone knew.

For a long time past there had been trouble in the firm, ill-feeling
between the two old partners; chiefly because Mr. North put no limit
to the sums he drew out for his private account. Poor Mr. North at
length confessed that he could not help it: the money was wanted
by his wife: though how on earth she contrived to get rid of so
much, even with all her extravagance, he could not conceive. Mr.
Gass insisted on a separation: John North must withdraw from the
firm; Richard might take his place. Poor Mr. North yielded meekly.
"Don't let it get abroad," he only stipulated, speaking as if he were
half heartbroken, which was nothing new; "I should not like the
world to know that I was superseded." They respected his wishes,
and the change was made privately: very few being aware that the
senior partnership in the firm had passed into the hands of a young
man. Thenceforth Mr. North ceased to have any control in the
business; in fact, to have any actual connection with it. Dallory
suspected it not: Mrs. North had not the faintest idea of it. Richard
North signed the cheques as he had done before, "North and Gass:"
and perhaps the bank at Whitborough alone knew that he signed
them now as principal.

Richard was the scape-goat now. Mr. North's need of money, or

rather his wife's, did not cease: the sum arranged to be paid to him
as a retiring pension--a very liberal sum, and Mr. Gass grumbled at
it--seemed to be as nothing; it melted in madam's hands like so
much water. Richard was constantly appealed to by his father; and
responded generously, though it crippled him.

The next change came in the shape of Mr. Gass's death. The bulk
of his property was left to his wife; a small portion, comparatively
speaking, to charities and servants; two thousand pounds to Richard
North. He also bequeathed to his wife his interest in the business,
which by the terms of the deed of partnership he had power to do.
So that his share of the capital was not drawn out, and the firm
remained, actually as well as virtually, North and Gass. People
generally supposed that the "North" was Mr. North; and madam
went into a world of indignation at her husband's name being placed
in conjunction with "that woman's." In the years gone by, Mr. North
had had a nice time of it, finding it a difficult matter to steer his
course between his partner and madam, and give offence to neither.
Madam had never condescended to notice Thomas Gass's wife in the
least degree: she took to abusing her now, asking her husband how
he could suffer himself to be associated with her. Mr. North, when
goaded almost beyond endurance, had hard work to keep his tongue
from retorting that it was not himself that was associated with her,
but Richard.

Mrs. Gass showed her good sense in regard to the partnership, as

she did in most things. She declined to interfere actively in the
business. Richard North went to her house two or three times a-
week to keep her cognizant of what was going on; he consulted her
opinion on great matters, just as he had consulted her husband's.
She knew she could trust to him. Ever and anon she would volunteer
some advice to himself personally: and it was invariably good advice.
It could not be concealed from her that large sums (exclusively
Richard's) were ever finding their way to the Hall, and for this she
took him to task. "Stop it, Mr. Richard," she said--always as
respectful to him as she had been in her housekeeping days: "Stop
it, sir. Their wants are like a cullender, the more water you pour into
it the more you may. It's doing them no good. An end must come to
it some time, or you'll be in the workhouse. The longer it goes on,
the more difficult it will be to put an end to, and the harder it will be
for them." But Richard, sorely tried between prudence and filial duty,
could not bring himself to stop it so easily; and the thing went on.

We must now go back to Mrs. Cumberland. It was somewhat

singular that, the very week Thomas Gass died, she should make her
unexpected appearance at Dallory. But so it was. Again a widow, she
had come home to settle near her brother Thomas. She arrived just
in time to see him put into his coffin. The other brother, William, had
been dead for years. Mrs. Gass, who knew all about the
estrangement, received her with marked kindness, and heartily
offered her a home for the future.

Yet that was declined. Mrs. Cumberland preferred to have a home

of her own, possessing ample means to establish one in a moderate
way. She gave a sketch of her past life to Mrs. Gass. After her
marriage with the Reverend George Cumberland, they had remained
for some time at his chaplaincy in the Madras presidency; but his
health began to fail, and he exchanged to Australia. Subsequently to
that, years later, he obtained a duty in Madeira. Upon his death,
which occurred recently, she came to England. Her only son, Oliver
Rane, had been sent home at the age of seven, and was placed with
a tutor in London. When the time came for him to choose a
profession he decided on the medical, and qualified himself for it,
studying in London, Paris, and Vienna. He passed all the
examinations with great credit, including that of the College of
Physicians. He next paid a visit to Madeira, remaining three months
with his mother and stepfather, and then came home and
established himself in London, with money furnished by his mother.
But practice does not always come quickly to young beginners, and
Oliver Rane found his means lessening. He had a horror of debt, and
wisely decided to keep out of it: taking a situation as assistant, and
giving up the expensive house he had entered on. This had just
been effected when Mrs. Cumberland returned. For the present she
let her son remain as he was: Oliver had all a young man's pride and
ambition, and she thought the discipline might do him good.

Mrs. Cumberland took on lease one of the two handsome gothic

villas on the Ham, and established herself in it; with Jelly for a
waiting-maid, and two other servants. This necessitated spending
the whole of her income, which was a very fair one. A portion of it
would die with her, the rest was willed to her son Oliver.

In the old days when she was Fanny Gass, and Mr. North, plain
John North--Jack with his friends--they were intimate as elder
brother and young sister. If Mrs. Cumberland expected this
agreeable state of affairs to be resumed, she was destined to find
herself mistaken. Madam set her scornful face utterly against Mrs.
Cumberland: just as she had against others. It did not matter. Mrs.
Cumberland simply pitied the underbred woman: her health was
very delicate, and she did not intend to visit any one. The gentle-
people of the neighbourhood called upon her; she returned the call,
and there the acquaintance ended. When invitations first came in,
she wrote a refusal, explaining clearly and courteously why she was
obliged to do so--that her health did not allow her to visit. If she and
Mr. North met each other, as by chance happened, they would linger
in conversation, and be happy in the reminiscences of past days.

Mrs. Cumberland had thus lived on in retirement for some time,

when the medical man who had the practice of Dallory Ham, and
some of that of Dallory, died suddenly. She saw what an excellent
opportunity it would be for her son to establish himself, if he would
but take up general practice, and she sent a summons for him.
When Oliver arrived in answer to it, he entered into the prospect
warmly; left his mother to make arrangements, and returned to
London, to superintend his removal. Mrs. Cumberland went to Mr.
North, and obtained his promise to do what he could to further
Oliver's interests. It was equivalent to an assurance of success--for
Dallory Hall swayed its neighbours--and Mrs. Cumberland did not
hesitate to secure the gothic villa adjoining her own, which
happened to be vacant, believing that the future practice would
justify it. In a week's time Oliver Rane came down and took
possession.

But fate was against him. Dr. Rane said treachery. A young fellow
whom he knew in London had told a medical friend--a Mr.
Alexander--of this excellent practice that had fallen in at Dallory, and
that Rane was hoping to secure it for himself. What was Dr. Rane's
mortification when, upon arriving at the week's end at Dallory Ham
to take possession, he found another there before him. Mr.
Alexander had arrived the previous day, was already established in
an opposite house, and had called on every one. Dr. Rane went over
and reproached him with treachery--they had not previously been
personally acquainted. Mr. Alexander received the charge with
surprise; he declared that the field was as open to him as to Dr.
Rane--that if he had not thought so, nothing would have induced
him to enter it. He spoke his true sentiments, for he was a
straightforward man. An agent in Whitborough had also written up
to tell him of this opening; he came to look at it, and decided to try
it. The right to monopolize it, was no more Dr. Rane's, he urged,
than it was his. Dr. Rane took a different view, and said so: but
contention would not help the matter now, and he could only yield
to circumstances. So each held to his right in apparent amicability,
and Dallory had two doctors instead of one; secret rivals from
henceforth.

Not for a moment did Oliver Rane think Mr. Alexander could long
hold out against him, as he had secured, through his mother, the
favour of Dallory Hall. Alas, a very short time showed him that this
was a mistake; Dallory Hall turned round upon him, and was doing
what it could to forward his rival. Mrs. Cumberland went to Mr.
North, seeking an explanation. He could only avow the truth--his
wife, who was both master and mistress, had set her face against
Oliver, and was recommending Alexander. "John, you promised me,"
urged Mrs. Cumberland, "I know I did, and I'd keep to it if I could,"
was Mr. North's mournful answer; "but no one can hold out against
her." "Why should she have taken this dislike to Oliver?" rejoined
Mrs. Cumberland. "Heaven knows; a caprice, I suppose. She sets
herself against people without reason: she has never taken to either
Richard or Bessy; and only a little to Edmund. If I can do anything
for Oliver under the rose, I'll do it. I have every desire to help him,
Fanny, in remembrance of our friendship of the old days."

Mrs. Cumberland carried home news of her non-success to Oliver.

As to madam, she simply ignored him, bestowing her patronage
upon his rival. How bitterly the slight touched his heart, none but
himself could tell. Mrs. Cumberland resented it; but ah, not as he
did. A sense of wrong was ever weighing upon his spirit, and he
thought Fate was against him. One puzzle remained on his mind
unsolved--what he could have done to offend Mrs. North.

Mr. Alexander obtained a fair practice: Dr. Rane barely sufficient to

keep himself. His wants and those of the old servant Phillis were few.
Perhaps the entire fault did not lie with madam. Alexander had a
more open manner and address than Dr. Rane, and they go a long
way with people; he was also an older man, and a married man, and
was supposed to have had more experience. A sense of injury
rankled ever in Oliver Rane's heart; of injury inflicted by Alexander.
Meanwhile he became engaged to Bessy Rane. During an absence
from home of madam's, the doctor grew intimate at the Hall, and an
attachment sprang up between him and Bessy. When madam
returned, his visits had to cease, but he saw Bessy at Mrs. Gass's
and elsewhere.

I think that is all the retrospect that need be gone into. It brings
us down to the present time, the period of the anonymous letter and
Edmund North's death. Exactly two years ago this same month, May,
the rival doctors had appeared in Dallory Ham; and now one of them
was about to leave it.

One incident must be told, bearing on something that has been

related, and then the chapter shall close.
 The summer of the past year had been a very hot one. A
labouring man, working on Mr. North's grounds, suddenly fell; and
died on the spot. Mr. Alexander, summoned hastily, thought it must
have been sunstroke. "That is what my father died of," remarked
Captain Bohun, who stood with the rest. Mr. North turned to him:
"Do you say your father died of sunstroke, Arthur?" "Yes, sir, that is
what he died of. Did you not know it?" was the ready reply. "You are
sure of that?" continued Mr. North. "Quite sure, sir," repeated Arthur,
turning his dreamy blue eyes full upon his stepfather, in all their
proud truthfulness.

Mr. North knew that he spoke in the sincerity of belief. Arthur

Bohun possessed in an eminent degree the pride of his father's race.
That innate, self-conscious sense of superiority that is a sort of
safeguard to those who possess it: the noblesse oblige feeling that
keeps them from wrong-doing. It is true, Arthur Bohun held an
exalted view of his birth and family: in so far as that his pride in it
equalled that of any man living or dead. He was truthful, generous,
honourable; the very opposite in all respects to his mother. Her pride
was an assumed pride; a despicable, false, contemptible pride,
offensive to those with whom she came into contact. Arthur's was
one that you admired in spite of yourself. Of a tarnish to his honour,
he could almost have died; to bring disgrace on his own name or on
his family, would have caused him to bury his head for ever.
Sensitively regardful of other people's feelings, courteous in manner
to all, he yet unmistakably held his own in the world. His father had
been just the same; and in his day was called "Proud Bohun."

To have asserted that Major Bohun died of sunstroke, had any

doubt of the fact lain on his mind, would have been simply
impossible to Arthur Bohun. Therefore, Mr. North saw that, whatever
the mystery might be, regarding the real cause of Major Bohun's
death, Arthur was not cognizant of it.
 CHAPTER VI.

WATCHING THE FUNERAL

In Mrs. Gass's comfortable dining-room, securely ensconced

behind the closed blinds, drawn to-day, sat that lady and a visitor. It
was the day of the funeral of Edmund North; and Mrs. Gass had put
on mourning out of respect to the family: a black silk gown and
white net cap. It need not be said that the change improved her
appearance greatly: she looked, as she herself would have phrased
it, genteel to-day. This was her favourite sitting-room; she rarely
used any other: for one thing it gave her the opportunity of seeing
the movements of her neighbours. The drawing-room faced the
garden at the back: a large and beautiful apartment, opening to the
smooth green lawn.

The visitor was Mrs. Cumberland. For once in her life Mrs.
Cumberland emerged from her shell of indifference and
condescended to show a little of the curiosity of ordinary people.
She had come to Mrs. Gass's to see the funeral pass: and that lady
made much of her, for their meetings were rare. Mrs. Cumberland
was also in black silk: but she rarely wore anything else. The two
women sat together, talking in subdued voices of bygone times: not
that they had known each other then; but each had interest in the
past. Mrs. Gass was full of respect, never presuming on her
elevation; though they were sisters-in-law, she did not forget that
she had once been only a servant in Mrs. Cumberland's family. They
had little in common, though, and the topics of conversation
exhausted themselves. Mrs. Cumberland was of a silent nature, not
at all given to gossip in general. She began to think the waiting long.
For the convenience of two mourners, who were coming from a
distance, the funeral had been put off until four o'clock.

"Holidays don't improve the working class--unless they've the

sense to use 'em as they ought," observed Mrs. Gass. "Just look at
them three, ma'am. They've been at the tap--and more shame to
'em! They'd better let Mr. Richard catch his eye upon 'em. Putting
themselves into that state, when he is following his brother to the
grave."

She alluded to some men belonging to the Dallory Works, closed

to-day. They had taken more than was becoming, and were lounging
against the opposite shutters, quarrelling together. Mrs. Gass could
bear it no longer; in defiance of appearances she drew up the blind
and dashed open the window.

"Are you three men not ashamed of yourselves? I thought it was

you, Dawson! When there's any ill-doing going on, you're safe to be
in it. As to you, Thomas, you'll not like to show your face tomorrow.
Don't come to me again, Smith, to beg grace for you of Mr. Richard
North."

The men slunk away and disappeared down an entry. Mrs. Gass,
in one sense of the word, was their mistress; at any rate, their
master's partner. She closed the window and drew down the blind.

"Are the men paid for to-day, or do they lose it?" asked Mrs.
Cumberland.

"They're paid, ma'am, of course. It would be very unjust to dock

them when the holiday's none of their making. Neither Mr. Richard
nor me would like to be unjust."

"And he--Richard--seems to act entirely for his father."

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