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 21 st Edition

^
HARRISON'S
P R

INTERNAL
I N C I P L E S O F

MEDICINE
LOSCALZO
FAUCI
KASPER
HAUSER
LONGO
VOLUME 1
JAMESON
Harrison's Principles of Internal
Medicine, Twenty-First Edition (Vol1 &
Vol2)
1. Cover
2. Nav
3. Cover
4. Title Page
5. Copyright Page
6. Contents
7. Contributors
8. Preface
9. Harrison’s Related Resources
10. PART 1 The Profession of Medicine
1. 1 The Practice of Medicine
2. 2 Promoting Good Health
3. 3 Vaccine Opposition and Hesitancy
4. 4 Decision-Making in Clinical Medicine
5. 5 Precision Medicine and Clinical Care
6. 6 Screening and Prevention of Disease
7. 7 Global Diversity of Health System Financing and Delivery
8. 8 The Safety and Quality of Health Care
9. 9 Diagnosis: Reducing Errors and Improving Quality
10. 10 Racial and Ethnic Disparities in Health Care
11. 11 Ethical Issues in Clinical Medicine
12. 12 Palliative and End-of-Life Care
11. PART 2 Cardinal Manifestations and Presentation of Diseases
1. SECTION 1 Pain
1. 13 Pain: Pathophysiology and Management
2. 14 Chest Discomfort
3. 15 Abdominal Pain
4. 16 Headache
5. 17 Back and Neck Pain
2. SECTION 2 Alterations in Body Temperature
 1. 18 Fever
2. 19 Fever and Rash
3. 20 Fever of Unknown Origin
3. SECTION 3 Nervous System Dysfunction
1. 21 Syncope
2. 22 Dizziness and Vertigo
3. 23 Fatigue
4. 24 Neurologic Causes of Weakness and Paralysis
5. 25 Numbness, Tingling, and Sensory Loss
6. 26 Gait Disorders, Imbalance, and Falls
7. 27 Confusion and Delirium
8. 28 Coma
9. 29 Dementia
10. 30 Aphasia, Memory Loss, and Other Cognitive
Disorders
11. 31 Sleep Disorders
4. SECTION 4 Disorders of Eyes, Ears, Nose, and Throat
1. 32 Disorders of the Eye
2. 33 Disorders of Smell and Taste
3. 34 Disorders of Hearing
4. 35 Upper Respiratory Symptoms, Including Earache,
Sinus Symptoms, and Sore Throat
5. 36 Oral Manifestations of Disease
5. SECTION 5 Alterations in Circulatory and Respiratory
Functions
1. 37 Dyspnea
2. 38 Cough
3. 39 Hemoptysis
4. 40 Hypoxia and Cyanosis
5. 41 Edema
6. 42 Approach to the Patient with a Heart Murmur
7. 43 Palpitations
6. SECTION 6 Alterations in Gastrointestinal Function
1. 44 Dysphagia
2. 45 Nausea, Vomiting, and Indigestion
3. 46 Diarrhea and Constipation
4. 47 Unintentional Weight Loss
 5. 48 Gastrointestinal Bleeding
6. 49 Jaundice
7. 50 Abdominal Swelling and Ascites
7. SECTION 7 Alterations in Renal and Urinary Tract Function
1. 51 Interstitial Cystitis/Bladder Pain Syndrome
2. 52 Azotemia and Urinary Abnormalities
3. 53 Fluid and Electrolyte Disturbances
4. 54 Hypercalcemia and Hypocalcemia
5. 55 Acidosis and Alkalosis
8. SECTION 8 Alterations in the Skin
1. 56 Approach to the Patient with a Skin Disorder
2. 57 Eczema, Psoriasis, Cutaneous Infections, Acne,
and Other Common Skin Disorders
3. 58 Skin Manifestations of Internal Disease
4. 59 Immunologically Mediated Skin Diseases
5. 60 Cutaneous Drug Reactions
6. 61 Photosensitivity and Other Reactions to Sunlight
9. SECTION 9 Hematologic Alterations
1. 62 Interpreting Peripheral Blood Smears
2. 63 Anemia and Polycythemia
3. 64 Disorders of Granulocytes and Monocytes
4. 65 Bleeding and Thrombosis
5. 66 Enlargement of Lymph Nodes and Spleen
12. PART 3 Pharmacology
1. 67 Principles of Clinical Pharmacology
2. 68 Pharmacogenomics
13. PART 4 Oncology and Hematology
1. SECTION 1 Neoplastic Disorders
1. 69 Approach to the Patient with Cancer
2. 70 Prevention and Early Detection of Cancer
3. 71 Cancer Genetics
4. 72 Cancer Cell Biology
5. 73 Principles of Cancer Treatment
6. 74 Infections in Patients with Cancer
7. 75 Oncologic Emergencies
8. 76 Cancer of the Skin
9. 77 Head and Neck Cancer
 10. 78 Neoplasms of the Lung
11. 79 Breast Cancer
12. 80 Upper Gastrointestinal Tract Cancers
13. 81 Lower Gastrointestinal Cancers
14. 82 Tumors of the Liver and Biliary Tree
15. 83 Pancreatic Cancer
16. 84 Gastrointestinal Neuroendocrine Tumors
17. 85 Renal Cell Carcinoma
18. 86 Cancer of the Bladder and Urinary Tract
19. 87 Benign and Malignant Diseases of the Prostate
20. 88 Testicular Cancer
21. 89 Gynecologic Malignancies
22. 90 Primary and Metastatic Tumors of the Nervous
System
23. 91 Soft Tissue and Bone Sarcomas and Bone
Metastases
24. 92 Carcinoma of Unknown Primary
25. 93 Paraneoplastic Syndromes:
Endocrinologic/Hematologic
26. 94 Paraneoplastic Neurologic Syndromes and
Autoimmune Encephalitis
27. 95 Cancer Survivorship and the Long-Term Impact of
Cancer and Its Treatment
2. SECTION 2 Hematopoietic Disorders
1. 96 Hematopoietic Stem Cells
2. 97 Iron Deficiency and Other Hypoproliferative
Anemias
3. 98 Disorders of Hemoglobin
4. 99 Megaloblastic Anemias
5. 100 Hemolytic Anemias
6. 101 Anemia Due to Acute Blood Loss
7. 102 Bone Marrow Failure Syndromes Including
Aplastic Anemia and Myelodysplasia
8. 103 Polycythemia Vera and Other Myeloproliferative
Neoplasms
9. 104 Acute Myeloid Leukemia
10. 105 Chronic Myeloid Leukemia
 11. 106 Acute Lymphoid Leukemia
12. 107 Chronic Lymphocytic Leukemia
13. 108 Non-Hodgkin’s Lymphoma
14. 109 Hodgkin’s Lymphoma
15. 110 Less Common Lymphoid and Myeloid
Malignancies
16. 111 Plasma Cell Disorders
17. 112 Amyloidosis
18. 113 Transfusion Therapy and Biology
19. 114 Hematopoietic Cell Transplantation
3. SECTION 3 Disorders of Hemostasis
1. 115 Disorders of Platelets and Vessel Wall
2. 116 Coagulation Disorders
3. 117 Arterial and Venous Thrombosis
4. 118 Antiplatelet, Anticoagulant, and Fibrinolytic Drugs
14. PART 5 Infectious Diseases
1. SECTION 1 Basic Considerations in Infectious Diseases
1. 119 Approach to the Patient with an Infectious Disease
2. 120 Molecular Mechanisms of Microbial Pathogenesis
3. 121 Microbial Genomics and Infectious Disease
4. 122 Approach to the Acutely Ill Infected Febrile Patient
5. 123 Immunization Principles and Vaccine Use
6. 124 Health Recommendations for International Travel
7. 125 Climate Change and Infectious Disease
2. SECTION 2 Clinical Syndromes: Community-Acquired
Infections
1. 126 Pneumonia
2. 127 Lung Abscess
3. 128 Infective Endocarditis
4. 129 Infections of the Skin, Muscles, and Soft Tissues
5. 130 Infectious Arthritis
6. 131 Osteomyelitis
7. 132 Intraabdominal Infections and Abscesses
8. 133 Acute Infectious Diarrheal Diseases and Bacterial
Food Poisoning
9. 134 Clostridioides difficile Infection, Including
Pseudomembranous Colitis
 10. 135 Urinary Tract Infections, Pyelonephritis, and
Prostatitis
11. 136 Sexually Transmitted Infections: Overview and
Clinical Approach
12. 137 Encephalitis
13. 138 Acute Meningitis
14. 139 Chronic and Recurrent Meningitis
15. 140 Brain Abscess and Empyema
16. 141 Infectious Complications of Bites
3. SECTION 3 Clinical Syndromes: Health Care–Associated
Infections
1. 142 Infections Acquired in Health Care Facilities
2. 143 Infections in Transplant Recipients
4. SECTION 4 Therapy for Bacterial Diseases
1. 144 Treatment and Prophylaxis of Bacterial Infections
2. 145 Bacterial Resistance to Antimicrobial Agents
5. SECTION 5 Diseases Caused by Gram-Positive Bacteria
1. 146 Pneumococcal Infections
2. 147 Staphylococcal Infections
3. 148 Streptococcal Infections
4. 149 Enterococcal Infections
5. 150 Diphtheria and Other Corynebacterial Infections
6. 151 Listeria monocytogenes Infections
7. 152 Tetanus
8. 153 Botulism
9. 154 Gas Gangrene and Other Clostridial Infections
6. SECTION 6 Diseases Caused by Gram-Negative Bacteria
1. 155 Meningococcal Infections
2. 156 Gonococcal Infections
3. 157 Haemophilus and Moraxella Infections
4. 158 Infections Due to the HACEK Group and
Miscellaneous Gram-Negative Bacteria
5. 159 Legionella Infections
6. 160 Pertussis and Other Bordetella Infections
7. 161 Diseases Caused by Gram-Negative Enteric Bacilli
8. 162 Acinetobacter Infections
9. 163 Helicobacter pylori Infections
 10. 164 Infections Due to Pseudomonas, Burkholderia, and
Stenotrophomonas Species
11. 165 Salmonellosis
12. 166 Shigellosis
13. 167 Infections Due to Campylobacter and Related
Organisms
14. 168 Cholera and Other Vibrioses
15. 169 Brucellosis
16. 170 Tularemia
17. 171 Plague and Other Yersinia Infections
18. 172 Bartonella Infections, Including Cat-Scratch
Disease
19. 173 Donovanosis
7. SECTION 7 Miscellaneous Bacterial Infections
1. 174 Nocardiosis
2. 175 Actinomycosis
3. 176 Whipple’s Disease
4. 177 Infections Due to Mixed Anaerobic Organisms
8. SECTION 8 Mycobacterial Diseases
1. 178 Tuberculosis
2. 179 Leprosy
3. 180 Nontuberculous Mycobacterial Infections
4. 181 Antimycobacterial Agents
9. SECTION 9 Spirochetal Diseases
1. 182 Syphilis
2. 183 Endemic Treponematoses
3. 184 Leptospirosis
4. 185 Relapsing Fever and Borrelia miyamotoi Disease
5. 186 Lyme Borreliosis
10. SECTION 10 Diseases Caused by Rickettsiae,
Mycoplasmas, and Chlamydiae
1. 187 Rickettsial Diseases
2. 188 Infections Due to Mycoplasmas
3. 189 Chlamydial Infections
11. SECTION 11 Viral Diseases: General Considerations
1. 190 Principles of Medical Virology
 2. 191 Antiviral Chemotherapy, Excluding Antiretroviral
Drugs
12. SECTION 12 Infections Due to DNA Viruses
1. 192 Herpes Simplex Virus Infections
2. 193 Varicella-Zoster Virus Infections
3. 194 Epstein-Barr Virus Infections, Including Infectious
Mononucleosis
4. 195 Cytomegalovirus and Human Herpesvirus Types 6,
7, and 8
5. 196 Molluscum Contagiosum, Monkeypox, and Other
Poxvirus Infections
6. 197 Parvovirus Infections
7. 198 Human Papillomavirus Infections
13. SECTION 13 Infections Due to DNA and RNA Respiratory
Viruses
1. 199 Common Viral Respiratory Infections, Including
COVID-19
2. 200 Influenza
14. SECTION 14 Infections Due to Human Immunodeficiency
Virus and Other Human Retroviruses
1. 201 The Human Retroviruses
2. 202 Human Immunodeficiency Virus Disease: AIDS
and Related Disorders
15. SECTION 15 Infections Due to RNA Viruses
1. 203 Viral Gastroenteritis
2. 204 Enterovirus, Parechovirus, and Reovirus Infections
3. 205 Measles (Rubeola)
4. 206 Rubella (German Measles)
5. 207 Mumps
6. 208 Rabies and Other Rhabdovirus Infections
7. 209 Arthropod-Borne and Rodent-Borne Virus
Infections
8. 210 Ebolavirus and Marburgvirus Infections
16. SECTION 16 Fungal Infections
1. 211 Pathogenesis, Diagnosis, and Treatment of Fungal
Infections
2. 212 Histoplasmosis
 3. 213 Coccidioidomycosis
4. 214 Blastomycosis
5. 215 Cryptococcosis
6. 216 Candidiasis
7. 217 Aspergillosis
8. 218 Mucormycosis
9. 219 Less Common Systemic Mycoses and Superficial
Mycoses
10. 220 Pneumocystis Infections
17. SECTION 17 Protozoal and Helminthic Infections: General
Considerations
1. 221 Introduction to Parasitic Infections
2. 222 Agents Used to Treat Parasitic Infections
18. SECTION 18 Protozoal Infections
1. 223 Amebiasis and Infection with Free-Living Amebae
2. 224 Malaria
3. 225 Babesiosis
4. 226 Leishmaniasis
5. 227 Chagas Disease and African Trypanosomiasis
6. 228 Toxoplasma Infections
7. 229 Protozoal Intestinal Infections and Trichomoniasis
19. SECTION 19 Helminthic Infections
1. 230 Introduction to Helminthic Infections
2. 231 Trichinellosis and Other Tissue Nematode
Infections
3. 232 Intestinal Nematode Infections
4. 233 Filarial and Related Infections
5. 234 Schistosomiasis and Other Trematode Infections
6. 235 Cestode Infections
15. PART 6 Disorders of the Cardiovascular System
1. SECTION 1 Introduction to Cardiovascular Disorders
1. 236 Approach to the Patient with Possible
Cardiovascular Disease
2. 237 Basic Biology of the Cardiovascular System
3. 238 Epidemiology of Cardiovascular Disease
2. SECTION 2 Diagnosis of Cardiovascular Disorders
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 1. 239 Physical Examination of the Cardiovascular
System
2. 240 Electrocardiography
3. 241 Noninvasive Cardiac Imaging: Echocardiography,
Nuclear Cardiology, and Magnetic
Resonance/Computed Tomography Imaging
4. 242 Diagnostic Cardiac Catheterization and Coronary
Angiography
3. SECTION 3 Disorders of Rhythm
1. 243 Principles of Clinical Cardiac Electrophysiology
2. 244 The Bradyarrhythmias: Disorders of the Sinoatrial
Node
3. 245 The Bradyarrhythmias: Disorders of the
Atrioventricular Node
4. 246 Approach to Supraventricular Tachyarrhythmias
5. 247 Physiologic and Nonphysiologic Sinus Tachycardia
6. 248 Focal Atrial Tachycardia
7. 249 Paroxysmal Supraventricular Tachycardias
8. 250 Common Atrial Flutter and Macroreentrant and
Multifocal Atrial Tachycardias
9. 251 Atrial Fibrillation
10. 252 Approach to Ventricular Arrhythmias
11. 253 Premature Ventricular Contractions, Nonsustained
Ventricular Tachycardia, and Accelerated
Idioventricular Rhythm
12. 254 Sustained Ventricular Tachycardia
13. 255 Polymorphic Ventricular Tachycardia and
Ventricular Fibrillation
14. 256 Electrical Storm and Incessant Ventricular
Tachycardia
4. SECTION 4 Disorders of the Heart, Muscles, Valves, and
Pericardium
1. 257 Heart Failure: Pathophysiology and Diagnosis
2. 258 Heart Failure: Management
3. 259 Cardiomyopathy and Myocarditis
4. 260 Cardiac Transplantation and Prolonged Assisted
Circulation
 5. 261 Aortic Stenosis
6. 262 Aortic Regurgitation
7. 263 Mitral Stenosis
8. 264 Mitral Regurgitation
9. 265 Mitral Valve Prolapse
10. 266 Tricuspid Valve Disease
11. 267 Pulmonic Valve Disease
12. 268 Multiple and Mixed Valvular Heart Disease
13. 269 Congenital Heart Disease in the Adult
14. 270 Pericardial Disease
15. 271 Atrial Myxoma and Other Cardiac Tumors
16. 272 Cardiac Trauma
5. SECTION 5 Coronary and Peripheral Vascular Disease
1. 273 Ischemic Heart Disease
2. 274 Non-ST-Segment Elevation Acute Coronary
Syndrome (Non-ST-Segment Elevation Myocardial
Infarction and Unstable Angina)
3. 275 ST-Segment Elevation Myocardial Infarction
4. 276 Percutaneous Coronary Interventions and Other
Interventional Procedures
5. 277 Hypertension
6. 278 Renovascular Disease
7. 279 Deep-Venous Thrombosis and Pulmonary
Thromboembolism
8. 280 Diseases of the Aorta
9. 281 Arterial Diseases of the Extremities
10. 282 Chronic Venous Disease and Lymphedema
11. 283 Pulmonary Hypertension
16. PART 7 Disorders of the Respiratory System
1. SECTION 1 Diagnosis of Respiratory Disorders
1. 284 Approach to the Patient with Disease of the
Respiratory System
2. 285 Disturbances of Respiratory Function
3. 286 Diagnostic Procedures in Respiratory Disease
2. SECTION 2 Diseases of the Respiratory System
1. 287 Asthma
 2. 288 Hypersensitivity Pneumonitis and Pulmonary
Infiltrates with Eosinophilia
3. 289 Occupational and Environmental Lung Disease
4. 290 Bronchiectasis
5. 291 Cystic Fibrosis
6. 292 Chronic Obstructive Pulmonary Disease
7. 293 Interstitial Lung Disease
8. 294 Disorders of the Pleura
9. 295 Disorders of the Mediastinum
10. 296 Disorders of Ventilation
11. 297 Sleep Apnea
12. 298 Lung Transplantation
13. 299 Interventional Pulmonary Medicine
17. PART 8 Critical Care Medicine
1. SECTION 1 Respiratory Critical Care
1. 300 Approach to the Patient with Critical Illness
2. 301 Acute Respiratory Distress Syndrome
3. 302 Mechanical Ventilatory Support
2. SECTION 2 Shock and Cardiac Arrest
1. 303 Approach to the Patient with Shock
2. 304 Sepsis and Septic Shock
3. 305 Cardiogenic Shock and Pulmonary Edema
4. 306 Cardiovascular Collapse, Cardiac Arrest, and
Sudden Cardiac Death
3. SECTION 3 Neurologic Critical Care
1. 307 Nervous System Disorders in Critical Care
18. Part 9 Disorders of the Kidney and Urinary Tract
1. 308 Approach to the Patient with Renal Disease or Urinary
Tract Disease
2. 309 Cell Biology and Physiology of the Kidney
3. 310 Acute Kidney Injury
4. 311 Chronic Kidney Disease
5. 312 Dialysis in the Treatment of Kidney Failure
6. 313 Transplantation in the Treatment of Renal Failure
7. 314 Glomerular Diseases
8. 315 Polycystic Kidney Disease and Other Inherited
Disorders of Tubule Growth and Development
 9. 316 Tubulointerstitial Diseases of the Kidney
10. 317 Vascular Injury to the Kidney
11. 318 Nephrolithiasis
12. 319 Urinary Tract Obstruction
13. 320 Interventional Nephrology
19. PART 10 Disorders of the Gastrointestinal System
1. SECTION 1 Disorders of the Alimentary Tract
1. 321 Approach to the Patient with Gastrointestinal
Disease
2. 322 Gastrointestinal Endoscopy
3. 323 Diseases of the Esophagus
4. 324 Peptic Ulcer Disease and Related Disorders
5. 325 Disorders of Absorption
6. 326 Inflammatory Bowel Disease
7. 327 Irritable Bowel Syndrome
8. 328 Diverticular Disease and Common Anorectal
Disorders
9. 329 Mesenteric Vascular Insufficiency
10. 330 Acute Intestinal Obstruction
11. 331 Acute Appendicitis and Peritonitis
2. SECTION 2 Nutrition
1. 332 Nutrient Requirements and Dietary Assessment
2. 333 Vitamin and Trace Mineral Deficiency and Excess
3. 334 Malnutrition and Nutritional Assessment
4. 335 Enteral and Parenteral Nutrition
3. SECTION 3 Liver and Biliary Tract Disease
1. 336 Approach to the Patient with Liver Disease
2. 337 Evaluation of Liver Function
3. 338 The Hyperbilirubinemias
4. 339 Acute Viral Hepatitis
5. 340 Toxic and Drug-Induced Hepatitis
6. 341 Chronic Hepatitis
7. 342 Alcohol-Associated Liver Disease
8. 343 Nonalcoholic Fatty Liver Diseases and
Nonalcoholic Steatohepatitis
9. 344 Cirrhosis and Its Complications
10. 345 Liver Transplantation
 11. 346 Diseases of the Gallbladder and Bile Ducts
4. SECTION 4 Disorders of the Pancreas
1. 347 Approach to the Patient with Pancreatic Disease
2. 348 Acute and Chronic Pancreatitis
20. PART 11 Immune-Mediated, Inflammatory, and Rheumatologic
Disorders
1. SECTION 1 The Immune System in Health and Disease
1. 349 Introduction to the Immune System
2. 350 Mechanisms of Regulation and Dysregulation of
the Immune System
3. 351 Primary Immune Deficiency Diseases
2. SECTION 2 Disorders of Immune-Mediated Injury
1. 352 Urticaria, Angioedema, and Allergic Rhinitis
2. 353 Anaphylaxis
3. 354 Mastocytosis
4. 355 Autoimmunity and Autoimmune Diseases
5. 356 Systemic Lupus Erythematosus
6. 357 Antiphospholipid Syndrome
7. 358 Rheumatoid Arthritis
8. 359 Acute Rheumatic Fever
9. 360 Systemic Sclerosis (Scleroderma) and Related
Disorders
10. 361 Sjögren’s Syndrome
11. 362 Spondyloarthritis
12. 363 The Vasculitis Syndromes
13. 364 Behçet Syndrome
14. 365 Inflammatory Myopathies
15. 366 Relapsing Polychondritis
16. 367 Sarcoidosis
17. 368 IgG4-Related Disease
18. 369 Familial Mediterranean Fever and Other
Hereditary Autoinflammatory Diseases
3. SECTION 3 Disorders of the Joints and Adjacent Tissues
1. 370 Approach to Articular and Musculoskeletal
Disorders
2. 371 Osteoarthritis
3. 372 Gout and Other Crystal-Associated Arthropathies
 4. 373 Fibromyalgia
5. 374 Arthritis Associated with Systemic Disease, and
Other Arthritides
6. 375 Periarticular Disorders of the Extremities
21. PART 12 Endocrinology and Metabolism
1. SECTION 1 Endocrinology
1. 376 Approach to the Patient with Endocrine Disorders
2. 377 Mechanisms of Hormone Action
3. 378 Physiology of Anterior Pituitary Hormones
4. 379 Hypopituitarism
5. 380 Pituitary Tumor Syndromes
6. 381 Disorders of the Neurohypophysis
7. 382 Thyroid Gland Physiology and Testing
8. 383 Hypothyroidism
9. 384 Hyperthyroidism and Other Causes of
Thyrotoxicosis
10. 385 Thyroid Nodular Disease and Thyroid Cancer
11. 386 Disorders of the Adrenal Cortex
12. 387 Pheochromocytoma
13. 388 Multiple Endocrine Neoplasia Syndromes
14. 389 Autoimmune Polyendocrine Syndromes
2. SECTION 2 Sex- and Gender-Based Medicine
1. 390 Sex Development
2. 391 Disorders of the Testes and Male Reproductive
System
3. 392 Disorders of the Female Reproductive System
4. 393 Menstrual Disorders and Pelvic Pain
5. 394 Hirsutism
6. 395 Menopause and Postmenopausal Hormone
Therapy
7. 396 Infertility and Contraception
8. 397 Sexual Dysfunction
9. 398 Women’s Health
10. 399 Men’s Health
11. 400 Lesbian, Gay, Bisexual, and Transgender (LGBT)
Health
 3. SECTION 3 Obesity, Diabetes Mellitus, and Metabolic
Syndrome
1. 401 Pathobiology of Obesity
2. 402 Evaluation and Management of Obesity
3. 403 Diabetes Mellitus: Diagnosis, Classification, and
Pathophysiology
4. 404 Diabetes Mellitus: Management and Therapies
5. 405 Diabetes Mellitus: Complications
6. 406 Hypoglycemia
7. 407 Disorders of Lipoprotein Metabolism
8. 408 The Metabolic Syndrome
4. SECTION 4 Disorders of Bone and Mineral Metabolism
1. 409 Bone and Mineral Metabolism in Health and
Disease
2. 410 Disorders of the Parathyroid Gland and Calcium
Homeostasis
3. 411 Osteoporosis
4. 412 Paget’s Disease and Other Dysplasias of Bone
5. SECTION 5 Disorders of Intermediary Metabolism
1. 413 Heritable Disorders of Connective Tissue
2. 414 Hemochromatosis
3. 415 Wilson’s Disease
4. 416 The Porphyrias
5. 417 Disorders of Purine and Pyrimidine Metabolism
6. 418 Lysosomal Storage Diseases
7. 419 Glycogen Storage Diseases and Other Inherited
Disorders of Carbohydrate Metabolism
8. 420 Inherited Disorders of Amino Acid Metabolism in
Adults
9. 421 Inherited Defects of Membrane Transport
22. PART 13 Neurologic Disorders
1. SECTION 1 Diagnosis of Neurologic Disorders
1. 422 Approach to the Patient with Neurologic Disease
2. 423 Neuroimaging in Neurologic Disorders
3. 424 Pathobiology of Neurologic Diseases
2. SECTION 2 Diseases of the Central Nervous System
1. 425 Seizures and Epilepsy
 2. 426 Introduction to Cerebrovascular Diseases
3. 427 Ischemic Stroke
4. 428 Intracranial Hemorrhage
5. 429 Subarachnoid Hemorrhage
6. 430 Migraine and Other Primary Headache Disorders
7. 431 Alzheimer’s Disease
8. 432 Frontotemporal Dementia
9. 433 Vascular Dementia
10. 434 Dementia with Lewy Bodies
11. 435 Parkinson’s Disease
12. 436 Tremor, Chorea, and Other Movement Disorders
13. 437 Amyotrophic Lateral Sclerosis and Other Motor
Neuron Diseases
14. 438 Prion Diseases
15. 439 Ataxic Disorders
16. 440 Disorders of the Autonomic Nervous System
17. 441 Trigeminal Neuralgia, Bell’s Palsy, and Other
Cranial Nerve Disorders
18. 442 Diseases of the Spinal Cord
19. 443 Concussion and Other Traumatic Brain Injuries
20. 444 Multiple Sclerosis
21. 445 Neuromyelitis Optica
3. SECTION 3 Nerve and Muscle Disorders
1. 446 Peripheral Neuropathy
2. 447 Guillain-Barré Syndrome and Other Immune-
Mediated Neuropathies
3. 448 Myasthenia Gravis and Other Diseases of the
Neuromuscular Junction
4. 449 Muscular Dystrophies and Other Muscle Diseases
4. SECTION 4 Myalgic Encephalomyelitis/Chronic Fatigue
Syndrome
1. 450 Myalgic Encephalomyelitis/Chronic Fatigue
Syndrome
5. SECTION 5 Psychiatric and Addiction Disorders
1. 451 Biology of Psychiatric Disorders
2. 452 Psychiatric Disorders
3. 453 Alcohol and Alcohol Use Disorders
 4.454 Nicotine Addiction
5.455 Marijuana and Marijuana Use Disorders
6.456 Opioid-Related Disorders
7.457 Cocaine, Other Psychostimulants, and
Hallucinogens
23. PART 14 Poisoning, Drug Overdose, and Envenomation
1. 458 Heavy Metal Poisoning
2. 459 Poisoning and Drug Overdose
3. 460 Disorders Caused by Venomous Snakebites and
Marine Animal Exposures
4. 461 Ectoparasite Infestations and Arthropod Injuries
24. PART 15 Disorders Associated with Environmental Exposures
1. 462 Altitude Illness
2. 463 Hyperbaric and Diving Medicine
3. 464 Hypothermia and Peripheral Cold Injuries
4. 465 Heat-Related Illnesses
25. PART 16 Genes, the Environment, and Disease
1. 466 Principles of Human Genetics
2. 467 The Practice of Genetics in Clinical Medicine
3. 468 Mitochondrial DNA and Heritable Traits and Diseases
4. 469 Telomere Disease
5. 470 Gene- and Cell-Based Therapy in Clinical Medicine
6. 471 The Human Microbiome
26. PART 17 Global Medicine
1. 472 Global Issues in Medicine
2. 473 Emerging and Reemerging Infectious Diseases
3. 474 Primary Care and Global Health
4. 475 Health Effects of Climate Change
27. PART 18 Aging
1. 476 Biology of Aging
2. 477 Caring for the Geriatric Patient
28. PART 19 Consultative Medicine
1. 478 Approach to Medical Consultation
2. 479 Medical Disorders During Pregnancy
3. 480 Medical Evaluation of the Surgical Patient
29. PART 20 Frontiers
1. 481 Behavioral Economics and Health
 2. 482 Complementary and Integrative Therapies and
Practices
3. 483 The Role of Epigenetics in Disease and Treatment
4. 484 Applications of Stem Cell Biology in Clinical Medicine
5. 485 The Role of Circadian Biology in Health and Disease
6. 486 Network Medicine: Systems Biology in Health and
Disease
7. 487 Emerging Neurotherapeutic Technologies
8. 488 Machine Learning and Augmented Intelligence in
Clinical Medicine
9. 489 Metabolomics
10. 490 Circulating Nucleic Acids as Liquid Biopsies and
Noninvasive Disease Biomarkers
11. 491 Protein Folding Disorders
12. 492 Novel Approaches to Diseases of Unknown Etiology
30. Index
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 "The other day he was dining off a suet-pudding: he ate it with
salt," interrupted Fullarton's eager voice.
"How fond he must be of salt!" exclaimed Savage. And the boys
laughed.
"He's working at some translation like old Blazes—sits up at night
to do it," resumed Powell. "He told Loftus minor it was for a
bookseller, who was to give him thirty pounds for it. He'd not work in
that way if he didn't need money awfully."
"But where does his money go? His salary—what does he do with
it?" wondered the boys.
"He must have private expenses," said Trace.
"What expenses?"
This was a question. They had once had an usher who indulged
himself in horse exercise; they had had another who gave forty-five
pounds for a violin, and half ruined himself buying new music. Mr.
Henry did neither.
"Perhaps he has got a wife and family," hazarded Brown major,
impulsively.
The notion of Mr. Henry's having a wife and family was so rich,
that the boys laughed till their sides ached. Which rather offended
Brown major.
"I'm sure I've heard those foreign French fellows often marry at
twenty-one; Germans too," quoth he. "You needn't grin. When a
man's got a wife and family, he has to keep 'em. His money must go
somewhere. Dick Loftus saw some new boots come home for him
the other day, and he couldn't pay for them. What are you staring
at, Trace?"
Trace was not staring at Brown major or any one else in particular.
The mention of the boots called up a train of ideas that half startled
him. This incident of the boots had occurred on the very evening of
the loss; the following day (when they were in the midst of
searching for the pencil) Mr. Henry had gone by train into London
after morning school, and was not back until three o'clock. Soon
after he returned, Trace, by the merest accident, saw him take out
his purse, and there were several sovereigns in it. The thing, to
Trace's mind, seemed to be getting unpleasantly clear. But he said
nothing.
"What are you all doing here?" exclaimed Gall, coming up at this
juncture. "Holding a council?"
They told him in an undertone: that the German master had been
pacing about before the study-window the night the pencil must
have been lost out of the room; and they spoke of his hard work, his
want of money, of all the rest they had been saying and hinting at.
Gall stopped the grave hint in its bud. The suspicion was perfectly
absurd as regarded Mr. Henry; most unjustifiable, he assured them;
and they had better get rid of it at once.
It was rather a damper, and in the check to their spirits, they
began to disperse. Gall had a great deal of good plain common
sense; and his opinion was always listened to. Trace rose from the
projecting base of a pillar on which he had been seated, knees to
nose, put his arm within Gall's and drew him away.
He told him everything; adding this fact of seeing the money in
Mr. Henry's purse, which he had not disclosed to the rest. Gall would
not be convinced. It might look a little suspicious, he acknowledged,
but he felt sure Mr. Henry was not one to do such a thing: he'd not
dare to do it. Besides, think of his high character, as given to the
Head Master from the university of Heidelberg.
Trace maintained his own opinion. He thought there were ways
and means of getting those high characters furnished, when people
had a need for them; he said he had mistrusted the man from the
first moment he saw him. "Look at his peaching about the smoking!
Look at the mean way he lives, the food he eats!" continued Trace,
impressively. "He must have private expenses of some sort; or else
what makes him so poor?"
"He may have left debts behind him in Germany," suggested Gall,
after a pause of reflection.
 "And most likely has," was the scornful rejoinder. "But he'd not
make his dinner off potatoes and work himself into a skeleton, to
pay back debts in Germany. Rubbish, Gall!"
"Look here, Trace. I know nothing of Mr. Henry's private affairs;
they may be bad or good for aught I can tell; but if I were you, I'd
get rid of that suspicion as to the pencil-case. Rely upon it,"
concluded Gall, emphatically, "it won't hold water. Put it away from
you."
Good advice, no doubt; and Trace, cautions always, intended to
take it. It happened, however, that same afternoon, that the Head
Master sent him to his study for a book. Trace opened the door
quickly, and there saw Miss Brabazon, on her hands and knees,
searching round the edge of the carpet. She sprang to her feet with
a scared look.
"A pencil-case will roll into all sorts of odd places," she observed,
as if in apology. "I cannot understand the loss; it is troubling me
more than I can express."
"It must have been lost through the window, Miss Brabazon," said
Trace. "That is, some one must have got in that way."
"Yes; unless it rolled down and is hiding itself," she answered, her
eyes glancing restlessly into every corner. "I think I shall have the
carpet taken up to-morrow. It will be a great trouble, with all this
fixed furniture."
"I don't think you need have it done," observed Trace, who was
standing with his back to her before the large bookcase. "I fancy it
went out through the window."
"You have some suspicion, Trace!" she quickly exclaimed. "What is
it?"
"If I have, Miss Brabazon, it is one that I cannot mention. It may
be a wrong suspicion, you see; perhaps it is."
"Trace," she said, laying her hand upon his arm, and her voice,
her eyes were full of strange earnestness, "you must tell it me. Tell
me in confidence; I have a suspicion too; perhaps we may keep the
secret together. I would give the pencil and its value twice over to
find it behind the carpet, in some crack or crevice of the wainscoting
—and I know it is not there."
She spoke with some passion. The words, the manner altogether,
disarmed Trace of his caution; and he breathed his doubts into her
ear. They were received with intense surprise.
"Mr. Henry! that kind, gentlemanly German master! Why, Trace,
you must be dreaming."
Trace thought himself an idiot. "To tell you the truth, Miss
Brabazon, I fancied you were suspecting him yourself, though I don't
know why I took up the notion," he resumed, in his mortification.
"But for that, I should not have mentioned it. I won't eat my words,
though, as I have spoken; I do believe him to be guilty."
"I cannot think it; he seems as honest as the day. Just go over
your grounds of suspicion again, Trace. I was too much surprised to
listen properly."
Trace did so; the huge book he had come for standing upright in
his arm, supported by his shoulder. He mentioned everything; from
Lamb having seen Mr. Henry before the study that night, down to
the empty purse filled suddenly with gold.
Did you ever happen to witness a knot of boys favoured personally
with an unexpected explosion of gunpowder on the fifth of
November? I'm sure they did not leap apart in a more startled
manner than did Trace and Miss Brabazon now, at the entrance of
Mr. Henry. He had come to see after Trace and the book; the Head
Master thought Trace must be unable to find it. Away went Trace.
Miss Brabazon stooped to put down the corner of the hearthrug,
saying something rather confusedly about searching for the pencil,
now that it was known to have been lost in that room.
It happened that Mr. Henry, an outdoor master, had not heard that
that fact was established. Miss Brabazon told him of it.
"Some one must have got in through the unfastened window, and
taken it," she continued, looking at him. "It is very curious.
Strangers are never there: the grounds are private."
 "Got in through the window," he repeated, as a recollection
flashed across his mind. "Why, I saw a man on the gravel-path;
there," pointing to the one on which the window opened, "that same
night. He was looking for the entrance to the college, and I directed
him round to the front."
"How came you to see him?" she returned, speaking rather
sharply.
"I had been hard at work at my translation, the one I told the
doctor of, and strolled across for a breath of fresh air. This man was
coming down the path, must have just passed the window, and I
asked him what he wanted. He replied that he had a letter for Dr.
Brabazon."
"Why did you not speak of this before, Mr. Henry?"
"I never thought to connect it with the loss. It was believed that
the pencil was lost from the hall. The man did not seem in the least
confused or hurried. I should fancy his business was quite
legitimate, Miss Brabazon; merely the delivery of the letter. I saw
one in his hand."
She went at once to question the servants, debating in her mind
whether this was fact, or an invention of the German master's to
throw suspicion from himself. Not any tidings could she get of a
letter having been brought by hand that night. Dean was positive
that no such letter had been delivered: One came the previous
night, he said, for Mr. Baker and he took it to him. Miss Brabazon
went back to the study, and asked Mr. Henry, waiting there by her
desire, whether he had not made a mistake in the night.
"None whatever," was his reply. "I had received a letter from
Heidelberg that day, enclosing an order for a little money due to me,
and when I met this man I was considering how I could shape my
duties on the following one, so as to have time to go to London and
get it cashed."
"And did you go?"
"Yes, as soon as morning school was over. I told the doctor what
my errand was. When I left, they were searching the hall for the
pencil."
This, if true, disposed of one part of Mr. Trace's suspicions. Miss
Brabazon thought how candid and upright he looked as he stood
there talking to her. "Should you know the man again, Mr. Henry?"
she suddenly asked.
"I might know his voice: I did not see much of his face. A
youngish man; thirty, or rather more. I thought he walked a little
lame."
Miss Brabazon lifted her head with more quickness than the
information seemed to warrant. "Lame! Lame?"
"It struck me so."
She said no more. She sat looking out straight before her with a
sort of bewildered stare. Mr. Henry left her to return to the hall; but
she sat on, staring still and seeing nothing.
 CHAPTER IX.
Christmas Day.
Some weeks elapsed. Things had blown over, and the Christmas
holidays were coming on. Wonders and calamities; and, in some
degree, suspicions; yield to the soothing hand of time. Talbot's
accident was almost forgotten; the lost pencil (never found) was not
thought of so much as it had been, and the gossip respecting it had
ceased.
The bitterness had not lessened against George Paradyne. Gall
could not fathom its source. There was no cause for it, as far as he
knew, except that the boy had been placed at once at the first desk,
and had entered his name for the Orville prize; both of which facts
were highly presumptuous in a new scholar, and an outsider. It was
also known that he was in the habit of flying to Mrs. Butter's house
for help in his studies: the boys supposed that the German (as they
derisively called Mr. Henry) was paid for giving it: and many an ill-
natured sneer was levelled at them both.
"Are you going to coach Paradyne through the holidays?" asked
Trace of Mr. Henry, condescending to address him for once in a way:
and be it remarked that when Trace so far unbended, he did not
forget his usual civility. But Mr. Henry always detected the inward
feeling.
"Trace," he said, every tone betraying earnest kindness, "you
spend the holidays at Sir Simon's, therefore I shall be within reach.
Come to me, and let me read with you: I know you are anxious to
get the Orville. Come every day; I will do my very best to push you
on."
"You are a finished scholar?" observed Trace, cynically.
 "As finished as any master in the college. When a young man
knows (as I did) that he has nothing else to trust to, he is wise to
make use of his opportunities. I believe also that I have a peculiar
aptitude for teaching. Come and try me."
"What would be your terms?"
"Nothing. I would do it for"—he laughed as he spoke—"love. Oh,
Trace, I wish you would let me help you! I wish I could get you to
believe that it would be one pleasure in my lonely life."
"What a hypocrite!" thought Trace: "I wonder what he's saying it
for? Thank you," he rejoined aloud, with distant coldness; "I shall
not require your assistance." And so the offer terminated; and Trace,
speaking of it to Loftus, said it was like the fellow's impudence to
make it.
One thing had been particularly noticeable throughout the term—
that the young German usher seemed to have a facility for healing
breaches. In ill-feelings, in quarrellings, in fightings, so sure was he
to step in, and not only stop the angry tongues, but soothe their
owners down to calmness. Rage, in his hands, became peace;
mountains of evil melted down to molehills; fierce recrimination gave
place to hand-shaking. He did all so quietly, so pleasantly, so
patiently! and, but for the under-current of feeling against him that
was being always secretly fanned, he would have been an immense
favourite. Putting aside the untoward events at its commencement,
the term had been one of the most satisfactory on record.
Loftus and his brother, Trace, James Talbot, and Irby were
spending the holidays at Pond Place. Sir Simon Orville generally had
two of the boys, besides his nephews. They had wanted Irby and
Leek this time; but Sir Simon chose to invite Talbot, and gave them
their choice of the other two. And it happened that Sir Simon, the
day after their arrival, overheard Trace and Loftus talking of sundry
matters, and became cognisant of the offer made to Trace by Mr.
Henry.
"And you didn't accept it, Raymond?" he asked, plunging suddenly
upon the two in his flowery dressing-gown. "If I were going in for
the Orville competition, I shouldn't have sneezed at it. This comes of
your pride: you won't study with Paradyne."
"No, it does not, uncle," replied Trace; "though I should object to
study with Paradyne. It comes of my dislike to Mr. Henry."
"What is there to dislike in Mr. Henry?"
Trace hesitated, making no direct reply. Bertie Loftus moved away.
Sir Simon pressed his question.
Wisely or unwisely, Trace, in his ill-nature, forgot his ordinary
caution, his long-continued silence, and disclosed the suspicions
attaching to Mr. Henry in regard to the lost pencil. It was so
delightful a temptation to speak against him! Loftus came back
during the recital, and curled his lip in silent condemnation of Trace.
"Look here," said Sir Simon, wrathfully, "I'd rather suspect one of
you."
Loftus went away again without making any answer. Trace smiled
very grandly compassionate.
"You were always suspicious, Trace," continued Sir Simon; "it's in
your nature to be so, as it was in your poor mother's. He's a kindly,
honest gentleman, so far as I've seen of him. Steal a pencil, indeed!
Who rose the report? You?"
"There has not been any report," said Trace, with composure.
"Lamb saw him before the study window that night, and we
wondered whether he had come in and taken it. The doubt was
hushed up, and has died away."
"Not hushed up as far as you go, it seems. Raymond, I'd——"
Talbot and Dick Loftus came running in, and Sir Simon changed
the private bearings of the subject, for the more open one of
Raymond's pride, as he called it, in not accepting Mr. Henry's offer.
"Giving him two hours a day in the holidays!" exclaimed Talbot. "I
wish it had been made to me!"
"You do!" cried Sir Simon. "I suppose you hope to get the prize
yourself?"
 "I shall try my best for it, sir," said the boy, laughing. "Seventy
pounds a year for three years! It would take me to Oxford; and
there's no other chance of my getting there."
Holidays for everybody but poor Mr. Henry! He was slaving on. He
took George Paradyne for two hours a day; he took another boy, one
of the outsiders, who was poor, friendless, and very backward;
receiving nothing for either; he gave Miss Rose Brabazon her daily
lessons, French one day, German the next, alternately; he went to
Mrs. Gall's, to drill three of her little boys, not out at school yet, in
Latin and Greek; and he worked hard at his translation, which
translation was a very difficult one to get on quickly with,
necessitating continual references to abstruse works; for Mr. Henry
discovered numerous errors in the original, and desired, in his
conscientiousness, to set them right in the English version.
He was at home one morning, a few days after the holidays
began, buried in his translation books, marking the faults in Miss
Rose Brabazon's last French dictation—and he believed nobody else
could have made so many—when Sir Simon Orville walked in. The
sweet, kind, patient expression in Mr. Henry's face had always struck
him: very patient and wearied did it look to-day. It was Christmas
Eve.
"Hard at work? But this is holiday time, Mr. Henry."
Mr. Henry smiled and brightened up. "Some of us don't get the
chance of any holiday, Sir Simon," he cheerfully said, as if it were a
good joke.
"Bad, that! All work and no play, you know but I'd better not
enlarge on that axiom," broke off Sir Simon, "since my errand here is
to give you more work. Of the boys whose names are down for the
Orville, one comes to you daily, I hear."
"Yes; Paradyne," replied Mr. Henry, feeling rather sensitive at
mentioning the name which must be so unwelcome to the brother of
the late Mrs. Trace.
"Ay, Paradyne. You made an offer to my nephew, Raymond Trace,
to take him also for the holidays, I hear. And he declined."
 "I should have been so glad to be of service to him!" returned Mr.
Henry, his eyes lighting with the earnestness of the wish.
"The prejudiced young jackass!" explosively cried Sir Simon. "Well,
the loss is his. But now, I want you to make the same offer to
another, one who won't refuse it; and that's Talbot—Lord
Shrewsbury, as they call him. He's staying with me—you know it,
perhaps—and he can come to you daily. The boy has only his
education to look to in life; he does not possess a golden horde laid
up in lavender to make ducks and drakes of when he comes of age,
as some of the rascals do; and through those other two bright
nephews of mine his studies were stopped for some four or five
weeks. Will you take him?"
"Yes, and gladly, Sir Simon. He—perhaps"—Mr. Henry paused and
hesitated—"will have no objection to study with young Paradyne?"
"He'd better not let me hear of it, if he has," retorted Sir Simon.
"Why should he? Paradyne and his people have not hurt him. No,
no; Talbot's another sort of fellow to that. And now, what shall we
say about terms? Don't be afraid of laying it on, Mr. Henry; it's my
treat."
"I could not charge," said Mr. Henry, interrupting the cheering
laugh. "Excuse me, Sir Simon; but I am not helping the boys for
money. It would scarcely be an honourable thing. I am well paid by
Dr. Brabazon; and any little assistance I can give them out of school
is only their due."
"But you are not paid to teach them Latin and Greek and
mathematics. You have the right to make the most of your holidays."
"I scarcely see that I have, so far as the college pupils are
concerned. Let Talbot come to me at once, Sir Simon; but please say
no more about payment. Robbing me of my time? No, indeed, not of
a minute, if he comes with Paradyne: their studies are the same. As
to any little trouble of my own, I would not think of accepting money
for that. I am too glad to give it."
Sir Simon nodded approvingly; he liked the generosity of the
feeling, and shook Mr. Henry's hand heartily as he went out.
 "The cocked-up young Pharisee!" he soliloquized, apostrophizing
the unconscious Trace, and dashing an enormous gig umbrella, that
he had brought as a walking-stick, into the ground. "If ever there
was an honest, honourable, good spirit, it's his I have just left. Mr.
Trace and his uncharitable suspicions will get taken down some day,
as sure as he is living."
Turning into the college, he went straight on to the sitting-room,
where Miss Brabazon was, to all appearance, alone. Rose was
behind the curtain at the far end of the room, ostensibly learning her
German, for Mr. Henry would be due in ten minutes; really buried in
a charming fairy-tale book, lent to her by Jessie Gall. And her sister
had forgotten she was there.
"What is it that these rascally boys have picked up against that
poor young German master?" began Sir Simon, in his impulsive
fashion. "Do you know, Miss Emma?"
Emma Brabazon laid down the pretty baskets of flowers she was
arranging for the evening; for her married brothers and sisters and
their children were coming that day on their usual Christmas
sojourn. But she did not answer.
"Trace has been talking to me about the lost pencil," resumed Sir
Simon. "But surely it is a slander to suspect him of having taken it.
Miss Emma, I'd lay my life he is as honest as I am; and he's a vast
deal more of a gentleman."
"It was very foolish of Trace to speak of it," she said. "Pray forget
it, Sir Simon. The thing has dropped."
"But did you suspect him? You must forgive me, my dear, for
asking you these questions; I intended to ask Dr. Brabazon, not you,
but I find he is out."
"And I am very glad he is, Sir Simon, for I have never told papa.
There were circumstances that seemed to throw a suspicion on Mr.
Henry at the time, but they were so doubtful that it was best not to
speak of them; and I desired Trace—who was the one to bring them
under my notice—to let them die away."
 "Oh, Trace brought them to you, did he? But how do you mean
they were doubtful?"
"In so far as that Mr. Henry, if applied to, might have been able to
explain them all away. It would have been very cruel to bring
accusation against any one on grounds so slight."
"Just so. Well, my dear lady, I'd stake Pond Place against Mr.
Raymond Trace's prejudices, that the young man is as upright as he
is—perhaps more so. We poor sinners shan't be able to stand in
Master Trace's presence with our hats on soon; he must be going on
for heaven head-foremost, he must, with all this self-righteousness."
Emma Brabazon laughed, and followed Sir Simon out, talking.
Upon which Miss Rose emerged from her hiding-place to escape, her
German book in her hand, and the fairy tale stuffed up her frock.
"What did they mean?" debated the young lady, who had but
imperfectly understood. "If I could find out, I'd tell him. He is always
kind to me with my German, though I am so tiresome. I hate that
Trace: he never gives me anything; and he stole one of my letters
out of Dick's drawer the other day, and made game of it."
People called Sir Simon Orville an odd man. Mr. Raymond Trace in
particular could not understand him; there were moments when that
young gentleman deemed his respected uncle fit only for a lunatic
asylum. He had surely thought him so this morning, had he been
behind him. For Sir Simon, quitting Dr. Brabazon's, went on direct to
Mrs. Paradyne's. It was not the first visit he had paid her in her
present residence. Deprecating, as he did, the past frauds and
crimes of which her husband was guilty, he yet in his benevolent
heart thought the poor widow as much deserving of commiseration
as were his own relatives; and he chose to show her that he thought
it. His errand was to invite her and George to dinner on the next day,
Christmas; that day of peace and goodwill to men. Mrs. Paradyne at
first declined; but Sir Simon was so heartily pressing, there was no
withstanding it, and she at length yielded. He went home, chuckling
at the surprise it would be to his nephews, for they knew nothing of
it, and he did not intend to tell them.
 A surprise it proved. They went for a very long walk after morning
service on the following day, and had not been home many minutes
when the guests arrived. Trace stared with all his eyes: he thought
he must be dreaming. Was that Mrs. Paradyne, coming into the
room on the arm of Sir Simon, or were his eyes deceiving him? He
might be wrong: he had not seen her indoors for many years. She
wore a handsome silk gown, and a cap of real lace; rather reserved
and discontented in her manner, but essentially a lady. George
followed her in, and there could be doubt no longer. George was
free, merry, open, cordial, as it was in George Paradyne's nature to
be, and he went up to Trace with his hand outstretched, wishing him
heartily a merry Christmas. Trace turned salmon-coloured: he would
not see the hand; did not respond to it. Bertie Loftus, as if to cover
the marked rudeness, put his hand cordially into George Paradyne's;
and Trace would have annihilated Bertie, could looks have done it.
"Is he mad?" groaned Trace in a side-whisper, alluding to his
uncle.
Bertie laughed. "Let us drop old grievances for once, Ray. It's
Christmas Day."
"If my mother—who died here—could but rise from her grave and
see this!" retorted Trace. He went and stood at the window, looking
out, his bosom beating with its wrongs.
Dick leaped three feet into the air when he came in and saw the
guests. The more the merrier, was Dick's creed. It was that of Talbot
and Irby. And now that they met George Paradyne on equal
grounds, away from the prejudices of the school, they all saw how
much there was to admire and like in him—Trace excepted. Had
George Paradyne suddenly cast his shell as a chrysalis does, and
appeared before them an angel, Trace, in his condemning prejudice,
would have turned his back upon him. It crossed Trace's mind to
refuse to sit down to table. But he feared Sir Simon: it would not do
to offend him.
It was at the dessert, when the banquet was nearing its close and
Mrs. Paradyne had drawn on her gloves, that Sir Simon told Talbot
he was to go and read daily with Paradyne at Mr. Henry's. Mr.
Henry's kind offer, he called it; and he spoke a few emphatic words
of praise of the hardworking usher. Apparently the theme was not
palatable to Mrs. Paradyne. She folded her gloved hands one over
the other, said a word or two in slighting disparagement of Mr.
Henry, and then resolutely closed her lips. Evidently she had not yet
forgiven the mistake which had brought them to Orville. George, as
if reading her thoughts and struck with their injustice, glanced
reproachfully at her as he turned to Sir Simon.
"Mr. Henry is very kind to me," said the boy: "he is kind to us all.
Nobody knows how good he is. He must be very lonely to-day. He
was to have dined with us."
Sir Simon gave a start. "I wish I had asked him here! The
thoughtless savage I was! No more right feeling about me than if I'd
never heard of Christmas. I might as well have been born a Red
Indian."
Mr. Henry was at home, eating his dinner alone. Not potatoes or
suet-pudding to-day: he had learned to keep Christmas in Germany,
and was lavish in its honour. As George—a great deal too open-
speaking to please his mother—said, he had been invited to Mrs.
Paradyne's, but when she arranged to go to Sir Simon's she sent an
apology to Mr. Henry. Mrs. Butter cooked him a fowl and made him a
jam-pudding. He went to church in the morning and stayed for the
after-service. As he sat over the fire after dinner, in the twilight of
the evening, he could not help feeling as if he were alone in the
world—that there was nobody to care for him. At the best, his life, in
its social aspect, was not a very happy one. He had a great deal of
care always upon him, and he saw no chance of its ever being
removed; but he was learning to live for a better world than this.
Miss Rose Brabazon had let her tongue run riot the previous day,
telling him something confidentially—he could not make out what.
Rose's own ideas were obscure upon the point, therefore it was too
much to expect they would be clear to him. The young lady thought
that "Trace and Emma and 'some of them' feared he might have
been capable of taking papa's diamond pencil-case, just as much as
the real thief who came in at the glass doors and stole it." It had
startled Mr. Henry beyond measure; startled him, and thrown him
into a mass of perplexity. The impression conveyed to him was, not
that he was suspected of taking the pencil, but, that he might be
capable of taking one. What reason could they have for believing
him capable of such a thing?
Later in the evening he strolled out in the cold starlight air. He felt
so very lonely, so isolated from all the world, that only to look at the
gay windows of other people was company. Every house, poor and
rich, seemed to be holding its Christmas party. Quite a flood of light
streamed from Mr. Gall's—from Dr. Brabazon's; all but himself were
keeping Christmas. There was neither envy nor rebellion in his heart.
His only thought was, "If they knew I was here alone, they would
invite me in." He pictured the inside gladness, and rejoiced in it as
though it were his own. "Peace on earth, and goodwill to men!" he
murmured gratefully over and over again.
The muslin curtains were before the dining-room windows at Dr.
Brabazon's, but not the shutters. It was a large party—all the
children and grandchildren. A smile crossed Mr. Henry's lips as he
thought of Miss Rose in her element. Save the admiration of the
college boys, there was nothing that young damsel liked so much as
company. Mr. Henry halted and looked across the lawn, and by so
doing apparently disturbed another watcher. A man turned round
from the window, against which he had been crouched, and came
away.
"What do you want there?" exclaimed Mr. Henry, going forward to
confront him.
"Nothing to-night," was the ready answer; "I'll come another
time."
All in a moment, Mr. Henry recognized the voice; recognized the
low-crowned hat, and the slightly lame step. He placed himself in
the intruder's way.
"I saw you here once before, at the back of the house then: you
were looking for the entrance, you said, to deliver a letter. Did you—
did you enter the house that night and take anything?"
"No; you did."
The cool and positive assertion nearly took away Mr. Henry's
presence of mind. He had spoken upon impulse. He was quite
uncertain what he ought to do in the emergency, whether anything
or not. Meanwhile the stranger was walking quietly away, and Mr.
Henry did nothing.
The following day he met Miss Brabazon with some of her
relatives and a whole troop of children. She was a little behind the
rest, hastening to catch them up.
"Will you allow me to speak to you for one moment, Miss
Brabazon?"
"Well," she answered, rather impatiently, as if it were a trouble to
remain. It cannot be denied that she had at times treated him with
scant courtesy since the suspicion of him instilled into her mind by
Trace.
He told her what he had seen; that he recognised the voice to be
the same; recognised the man and his lameness. Miss Brabazon's
face grew white.
"He was looking in at us, you say?"
"Undoubtedly."
"Are you coming, Emma? What are you about?" called out the
party in front, who had turned and halted. "John will miss the train."
"Mr. Henry, oblige me in one thing," she hurriedly said; "don't
speak of this. I may trust you?"
"Indeed you may," he answered. "You may doubt me, Miss
Brabazon; you have perhaps only too good cause to doubt me; but
you may at least rely upon me in this."
Emma Brabazon ran on, the curious words ringing their echo on
her ears.
 CHAPTER X.
A Man in a Blaze.
The winter holidays soon passed, and the boys came back to
college again. "No pistols this time, I hope, Mr. Loftus," was the
Head Master's greeting to that gentleman, and it called a mortified
expression into the handsome face. Loftus's whiskers were growing,
and he had taken to wear a ring in private. Trace smiled pityingly;
Dick made fun of both appendages; but their owner knew not which
of the two to admire most.
The routine of school set in, and the boys were busy; some few
studying hard, chiefly those who were to go up for the Oxford
examination in June; others going in for idleness, mischief, and
sport; playing football, snow-balling, making presents and writing
love-letters to Miss Rose. All the candidates for the Orville prize were
going up for the Oxford examination; it was essential they should
pass that, or else withdraw from the competition for the Orville.
But none, whether boys or masters, worked on so patiently and
persistently as Mr. Henry, for none had so much to do. His private
assistance to Talbot terminated with the holidays; but not so that to
George Paradyne. Trace was outrageously angry at the latter fact,
and spoke his mind: as Paradyne was going in for the Orville prize, it
was disgraceful to give him an advantage that the others did not
get. Trace's opinion carried the school with it: Paradyne was
shunned worse than before, and resentment prevailed against the
German master.
"You have only to come to me," Mr. Henry reiterated to them; "I
can read with a dozen of you just as well as I can with one. I have
no wish surreptitiously to get Paradyne on; I would a great deal
rather that you should all keep together, and enjoy the same
advantages, one as the other; but if you will not come to me, and he
does, the blame rests with you."
"Such a thing as coaching a fellow for the Orville prize was never
heard of before, you know," retorted Brown major.
"I am not coaching him for the Orville prize. I am not coaching
him at all, for the matter of that. He reads the classics with me, and
I explain away his difficulties in mathematics. It is preparatory to the
Oxford examination, not the Orville."
"The one implies the other," said the angry boys. And they
spurned the assistance for themselves; which, metaphorically
speaking, was like cutting off their noses to spite their faces. Talbot
would have liked to continue, but could not fly in the teeth of
popular prejudice.
"Perhaps I'd better give it up," said George Paradyne one day,
throwing himself back in his chair at Mr. Henry's.
"Give what up?"
"Everything. What with the life at college and the life at home, I'm
ready to—to—pitch the whole overboard," concluded Mr. George,
having hesitated for an expression sufficiently strong to denote his
feelings.
"You have only to bear up bravely against the one; you'll live it
down in time——"
"Rather a prolonged time, it seems," put in George, who was quite
unlike his own light-hearted self to-day.
"And for the other," continued Mr. Henry, ignoring the interruption,
"you should bear it cheerfully, for you know it is born of love for
you."
"Ah, but you can't imagine what it is," said the boy, leaning
forward, his wide-open bright grey eyes full of eagerness. "It has
been worse since we dined at Sir Simon's; that called up to mamma
all the old forfeited prosperity. The grumbling never ceases; the
lamentation's dreadful. We can't make ourselves rich, if we are not
rich, so where's the use of groaning over it? It drives me wild."
 "Hush, George."
"But I can't hush. Mamma is so ungrateful. There's poor Mary
slaving in that school, never coming up for the holidays; and here's
——"
"George, I'll not hear this. Your mother's trials are very great."
"There's an awful bother about the Christmas bills," went on
George, paying slight attention to the reproof. "I wish you'd come
down and talk with her."
"I! My talking might do more harm than good."
"You might try to smooth things a little—get her to look at
troubles in a different light. Won't you? I can tell you it is miserable
for me."
"Well, I'll see. Go on with your Greek now."
Mr. Henry, ever ready to do good where it was to be done—to
throw oil on troubled waters—went down that evening to Mrs.
Paradyne's. His interference was not received graciously. Mrs.
Paradyne invited him to an opposite chair, and talked at him from
the sofa.
"I should like to know what business it is of Mr. Henry's," she
exclaimed, her cold resentful manner in full play. And of course he
could not reply that it was any business of his; but he spoke of the
trouble it was causing that fine boy, George; he spoke a little of the
sad past, he spoke cheerily of a future that should be brighter. Mrs.
Paradyne was often in a grumbling mood, but never in a worse than
that evening.
"I can't pay the Christmas bills. The money prepared for them I
have had to encroach upon for other things. A new silk gown I was
obliged to have; I can't go like an alms-woman. Never before did I
have Christmas bills; I paid as I went on; but the cost of things in
this place is frightful. I did not want money embarrassment added to
my other troubles. It is all through our having come up here."
Mr. Henry winced at the last reproach, too evidently directed to
him. "I did it for the best," he gently said. "I was anxious that
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