Full Critical care medicine review 1000 questions and answers 1st edition abraham sonny & edward a
Questions and Answers 1st Edition
Abraham Sonny & Edward A Bittner & Ryan J. Horvath & Sheri Berg.
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Neurocritical Care Board Review Questions and Answers 1st Edition Asma Zakaria Md
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Preface
This book was conceived as a result of feedback from our critical care fellows on the absence of a comprehensive question and answer book to learn from, during fellowship training. Subsequently, we compiled this book, over a span of one year, to bridge this gap in educational resource.
Our goal was to create a resource equipped to help all trainees in critical care, irrespective of their primary discipline. The content of this book was developed from keywords in critical care published by various boards, specifically American board of Anesthesiology, Internal Medicine, Neurology, and Surgery. The chapters were contributed by critical care fellows and junior faculty from various reputed institutions across the United States, working in conjunction with senior authors who are recognized experts in their discipline.
This book covers all topics pertinent to the practice of critical care in a question and answer format, divided into twelve section and 123 chapters. A large majority of the questions are clinically oriented with case scenarios, making it pertinent to your clinical practice. After each question, the readers are directed toward relevant references and resources, for additional reading on a certain topic. Furthermore, this book also provides a “grab bag” chapter which contains a random collection of questions from various common topics in critical care.
We hope this book can improve your knowledge in critical care medicine especially during fellowship training and also serve as reference guide in future.
FellowPhysician, Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
Avneep Aggarwal MD
Staff physician, Anesthesiology Institute, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
Abdulaziz S. Almehlisi MBBS
Assistant Professor, Department of Emergency Medicine, King Saud University, Riyadh, Saudi Arabia
Reem Almuqati MD
Critical care fellow, Department of Anesthesiology, Cleveland clinic foundation, Cleveland, Ohio
John Andre MD
Chief of Skills and Simulation, Department of General Surgery, Loyola University Medical Center, Maywood, Illinois
Daniel Austin MD
Resident, Department of Anesthesia & Perioperative Care, University of California, San Francisco, California
Ji Sun Christina Baek MD
Department of Anesthesiology, University of California,San Diego, California
Theresa Barnes MD, MPH
Associate Professor, Department of Anesthesiology, Emory University, Atlanta, Georgia
Sean M. Baskin DO, MA
Resident, Department of Anesthesiology and Perioperative Medicine, Penn
State Milton S. Hershey Medical Center, Hershey, Pennsylvania
DaMarcus Baymon MD
Resident, Department of Emergency Medicine, Massachusetts General Hospital - Harvard, Boston, Massachusetts
Lisa M. Bebell MD
Instructor, Harvard Medical School, Assistant in Medicine, Massachusetts General Hospital, Infectious Diseases Unit, Boston, Massachusetts
William J. Benedetto MD
Assistant Professor, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Sheri M. Berg MD
Instructor in Anesthesia, Medical Director, Post Anesthesia Care Units, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Lorenzo Berra MD
Reginald Jenney Associate Professor of Anaesthesia, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
Leah N. Bess MD
Resident, Department of Anesthesiology and Perioperative Medicine, Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
Annie van Beuningen MD
Fellowin Cardiovascular Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
Somnath Bose MD
Instructor of Anesthesiology, Harvard Medical School, Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Jason K. Bowman MD
Chief Resident, Departments of Emergency Medicine, Massachusetts General Hospital, Brigham and Women’s Hospital, Boston, Massachusetts
Joanna Brenneman MD
Staff Anesthesiology & Critical Care Medicine, Cleveland Clinic Akron General, Akron, Ohio
Edward A. Bittner MD, PhD, MS.Ed, FCCM
Associate Professor, Program Director, Critical Care Anesthesiology
Fellowship, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Erika Lore Brinson MD
Assistant Clinical Professor of Anesthesia, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
Lundy Campbell MD
Professor, Department of Anesthesiology, Chief, Division of Cardiothoracic Anesthesiology, University of California, San Francisco, California
Marvin G. Chang MD
Faculty, Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
Anoop Chhina MD
Anesthesiologist and Intensivist, Department of Anesthesiology, Henry Ford Hospital, Detroit, Michigan
Christine Choi MD
Assistant Professor, Department of Anesthesiology, University of California, San Diego, San Diego, California
Margaret R. Connolly MD
Resident, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
Jennifer Cottral MD
Clinical Fellowin Anaesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Phat Tan Dang MD
Anesthesiology Critical Care Fellow, Department of Anesthesiology, University of California, San Diego, La Jolla, California
Christopher Dinh MD
Critical Care Fellow, Department of Anesthesiology, University of California, San Diego, San Diego, California
David M. Dudzinski MD, JD
Director, Cardiac Intensive Care Unit, Massachusetts General Hospital, Assistant Professor, Harvard Medical School, Boston, Massachusetts
Brett Elo DO
Department of Anesthesia and Critical Care, Cleveland Clinic, Cleveland, Ohio
Faith Natalie Factora MD
Medical Director, Surgical Intensive Care Unit, Cleveland Clinic, Cleveland, Ohio
Peter Fagenholz MD
Assistant Professor of Surgery, Harvard Medical School, Attending Surgeon, Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
Hassan Farhan MD
Anesthesia Resident, Department of Anesthesia, Critical Care and Pain medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Raffaele Di Fenza MD
Resident, School of Anesthesia, Critical Care and Pain Medicine, University of Milan-Bicocca, Milan, Italy
Rachel C. Frank MD
Cardiovascular Medicine Fellow, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
Kevin E. Galicia MD, MA
Resident, Department of General Surgery, Loyola University Medical Center, Maywood, Illinois
Mariya Geube MD, FASE
Assistant Professor, Cleveland Clinic Lerner College of Medicine, Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio
Jeffrey Gotts MD, PhD
Assistant Professor, Department of Medicine, University of California San Francisco, San Francisco, California
Ngoc-Tram Ha MD
Pulmonary and Critical Care Fellow, Department of Pulmonary and Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania
Dusan Hanidziar MD, PhD
Instructor in Anesthesia, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Charles Corey Hardin MD, PhD
Assistant Professor of Medicine, Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Massachusetts
Qasim AlHassan MBBS
Anesthesiology Critical Care Fellow, Department of Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio
Kathryn A. Hibbert MD
Instructor in Medicine, Director, Medical ICU, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Kristen Holler DO
Anesthesiology Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
Ryan J. Horvath MD, PhD
Instructor in Anesthesia, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Steven Hur MD
Fellow, Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, California
John O. Hwabejire MD, MPH
Clinical Fellowin Trauma, Acute Care Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Saef Izzy MD
Neurocritical Care faculty, Divisions of Stroke, Cerebrovascular, and
Critical Care Neurology, Assistant Professor in Neurology, Department of Neurology, Brigham and Women’s hospital, Harvard Medical School, Boston, Massachusetts
Emergency Medicine Resident, Harvard Affiliated Emergency Medicine
Residency, Brigham and Women’s/Massachusetts General Hospital, Boston, Massachusetts
Paul S. Jansson MD, MS
Critical Care Medicine Fellow, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
Teny M. John MD
Assistant Professor, Department of Infectious Disease, Infection Control & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
Sonia John MD
Critical Care Fellow, Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts
Sneha Kannan MD
Resident, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
Kunal Karamchandani MD, FCCP
Associate Professor, Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey,
Pennsylvania
Riaz M. Karukappadath MD
Assistant Professor, Department of Anesthesiology and Critical Care, University of Alabama at Birmingham, Birmingham, Alabama
Sandeep Khanna MD
Assistant Professor, Cleveland Clinic Lerner College of Medicine, Staff, Department of General Anesthesiology, Department of Outcomes Research, Cleveland Clinic Foundation, Ohio
Mina Khorashadi MD
Department of Anesthesia and Perioperative Care, University of California
San Francisco, San Francisco, California
Thomas J. Krall MD
Assistant Professor, Department of Anesthesia and Perioperative Care, University of California - San Francisco, San Francisco, California
Assistant Professor, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Yvonne Lai MD
Clinical Instructor, Associate Residency Program Director, Department of Anesthesia, Critical Care, and Pain, Management Massachusetts General Hospital, Boston, Massachusetts
Jarone Lee MD, MPH, FCCM
Associate Professor, Harvard Medical School, Boston, Massachusetts
Nathan M. Lee MD
Assistant Professor, Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Illinois
Brian P. Lemkuil MD
Associate Professor, Department of Anesthesiology, University of California,
San Diego, California
David P. Lerner MD
Assistant Professor, Department of Neurology, Lahey Hospital and Medical Center, Burlington, Massachusetts
Casey McBride Luckhurst MD
Surgical Critical Care Fellow, Massachusetts General Hospital, Boston, Massachusetts
Jason H. Maley MD
Fellow, Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
Critical Care Anesthesia Fellow, Anesthesia Institute, Cleveland Clinic Foundation, Cleveland, Ohio
Lydia R. Maurer MD
General Surgery Resident, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
Zeb McMillan MD
Associate Professor, Department of Anesthesiology, Division of Critical Care, University of California San Diego, San Diego, California
Jenna McNeill MD
Pulmonary and Critical Care Fellow, Department of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Massachusetts
April E. Mendoza MD, MPH
Instructor, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
Nino Mihatov MD
Fellowin Cardiovascular Medicine, Chief Medical Resident, Massachusetts
General Hospital, Boston, Massachusetts
Yuk Ming Liu MD, MPH
Assistant Professor, Department of Surgery, Loyola University Medical Center, Maywood, Illinois
Anushirvan Minokadeh MD
Professor, Department of Anesthesiology, UC San Diego Health, San Diego, California
Ilan Mizrahi MD
Instructor of Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Christoph G. S. Nabzdyk MD, MEd
Cardiothoracic and Critical Care Anesthesia Fellow, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Revati Nafday MD
Adult Cardiothoracic Anesthesiology Fellow, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
Alexander Nagrebetsky MD, MSc
Assistant Professor, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Alan S. Nova DO
Neurocritical Care Fellow, Department of Neurosciences, University of California San Diego, La Jolla, California
Nandini C. Palaniappa MD
Assistant Professor, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
Riccardo Pinciroli MD
Assistant Professor of Anesthesia, University of Milan-Bicocca, School of Medicine and Surgery, Anesthesiologist and Intensivist, Department of
Anesthesia and Critical Care, Niguarda Hospital, Milan, Italy
Alexandra Plichta MD
Critical Care Fellow, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Kenneth Potter MD
Assistant Professor, Department of Anesthesiology, Virginia Commonwealth University Health System, Richmond, Virginia
Irfan Qureshi MD, MS
Clinical instructor Trauma Surgery, Department of Surgery, Colorado Plains Medical Center, Morgan, Colorado
Jeremy T. Rainey DO
Fellow, Center for Critical Care Medicine Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
Phillip Ramirez MD
Anesthesia Institute, Cleveland Clinic Foundation, Cleveland, Ohio
Kimberly S. Robbins MD
Associate Clinical Professor, Department of Anesthesiology and Critical Care, UC San Diego Medical Center, La Jolla, California
Martin G. Rosenthal MD
Instructor in Surgery, Department of Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
Galen Royce-Nagel MD
Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Ofer Sadan MD, PhD
Department of Neurology and Neurosugery, Division of Neurocritical Care, Emory University Hospital, Atlanta, Georgia
Debdoot Saha MD
Fellow, Critical Care Medicine, Geisinger Medical Center, Danville, Pennsylvania
Ulrich Schmidt MD, PhD, MBA
Vice Chair Critical Care Medicine, Clinical Professor of Anesthesiology, University of California San Diego, San Diego, California
Milad Sharifpour MD, MS
Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Emory University Hospital, Atlanta, Georgia
Archit Sharma MD, MBA
Fellowship Director, Critical Care Fellowship, Department of Anesthesiology, University of Iowa Carver College of Medicine, Iowa City, Iowa
Hasan Khalid Siddiqi MD
Fellow, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
Wendy Smith MD
Assistant Clinical Professor, Department of Anesthesia & Perioperative Care, University of California at San Francisco, San Francisco, California
Abraham Sonny MD, FASE
Assistant Professor, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Jamie Sparling MD
Associate in Anesthesia, Department of Anesthesia, Critical Care and Pain Medicine, Boston, Massachusetts
Roshni Sreedharan MD
Program Director, Anesthesiology Critical Care Medicine Fellowship, Assistant Professor of Anesthesiology, CCLCM, Faculty, Center for Excellence in Healthcare Communication, Department of General Anesthesiology, Anesthesiology Institute/Center for Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio, Chair, In-training section of the SCCM
Rachel Steinhorn MD
Resident physician, Massachusetts General Hospital, Boston, Massachusetts
Alex T. Suginaka DO
Fellowin Critical Care Medicine, Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, Iowa
Jaya Prakash Sugunaraj MD
Assistant Professor, Department of Pulmonary & Critical Care, Geisinger, Danville, Pennsylvania
Kristina Sullivan MD
Professor, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
Madiha Syed MD
Clinical Assistant Professor, Anesthesiology Institute and Center for Critical Care, Cleveland Clinic Foundation, Cleveland, Ohio
Maryam Bita Tabrizi MD, FACS
Clinical Instructor Harvard University, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
Kevin C. Thornton MD
Clinical Professor, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
Minh Hai Tran MBBS
Assistant Clinical Professor, Department of Anesthesiology, University of California San Diego, San Diego, California
William J. Trudo MD
Resident Physician, Department of Anesthesiology, Emory School of Medicine, Atlanta, Georgia
Aaron C. Tyagi MD
Emergency Medicine Critical Care Fellow, Department of Anesthesia, University of Iowa Hospitals and Clinics
Bharathram Vasudevan MBBS, MD
Critical care fellow, Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
Anand Venkatraman MD
Resident, Department of Neurology, Massachussets General Hospital/Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
Brett J. Wakefield MD
Critical Care Medicine Fellow, Department of Anesthesiology, Washington University - Barnes Jewish Hospital, St Louis, Missouri
Anureet K. Walia MD
Clinical Assistant Professor, Department of Anesthesiology, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa city, Iowa
Daniel P. Walsh MD
Instructor in Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Sarah Welch PharmD, BCCCP
Surgical Intensive Care Pharmacy Specialist, Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
Jeanine P. Wiener-Kronish MD
Henry Isaiah Dorr Professor of Research and Teaching in Anaesthetics and Anaesthesia, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Anesthetist-in-Chief, Massachusetts General Hospital, Boston, Massachusetts
Dario Winterton MD
School of Anesthesia Critical Care and Pain Medicine, University of MilanBicocca, Milano, Italy
Amanda S. Xi MD, MSE
Anesthesia Critical Care Fellow, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Howard Zee MD
Resident, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Table of Contents
I. Neurologic Disorders
1.Brain Death and Degenerative Diseases
David P. Lerner, Anand Venkatraman, and Saef Izzy
2.Cerebrovascular Diseases
David P. Lerner and Saef Izzy
3.Seizure Disorder
David P. Lerner, Anand Venkatraman, and Saef Izzy
4.Neuromuscular Disorders
David P. Lerner and Saef Izzy
5.Increased Intracranial Pressure
David P. Lerner and Saef Izzy
6.Neurotrauma
David P. Lerner, Anand Venkatraman, and Saef Izzy
7.Spinal Cord Injury
Leah N. Bess and Kunal Karamchandani
8.Encephalopathy and Delirium
Alexander Nagrebetsky and Jeanine P. Wiener-Kronish
9.Clinical Syndromes
Archit Sharma and AlexT Suginaka
10.Inflammatory and Demyelinating
Minh Hai Tran, Brian P. Lemkuil, and Ulrich Schmidt
11.Neuro Oncology
Milad Sharifpour and Ofer Sadan
12.Analgesia, Sedation and Neuromuscular Blockade
Daniel P. Walsh and Somnath Bose
13.Neuro Monitoring and Diagnostic Modalities
David P. Lerner, Noor Abdalla, and Saef Izzy
14.Management Strategies
Ofer Sadan and Milad Sharifpour
II. Cardiovascular Disorders
15.Acute Coronary Syndrome
Nino Mihatovand David M. Dudzinski
16.Arrhythmias and Pacemaker
Christoph G. S. Nabzdyk and Yvonne Lai
17.Heart Failure
Christoph G. S. Nabzdyk and Yvonne Lai
18.Vascular Disorders
Kristen Holler and Mariya Geube
19.Valvular Heart Disease
Brett J. Wakefield and Mariya Geube
20.Pericardial Diseases
Hasan Khalid Siddiqi and David M. Dudzinski
21.Myocardial Disease
Rachel C. Frank and David M. Dudzinski
22.Congenital Heart Disease in Adults
Archit Sharma and Aaron C. Tyagi
23.Shock States
Jason H. Maley and Kathryn A. Hibbert
24.Mechanical Circulatory Support and the Transplanted Heart
Raffaele Di Fenza, Riccardo Pinciroli, and Lorenzo Berra
35.Airway Diseases
Jenna McNeill and Charles Corey Hardin
36.Diseases of the Chest Wall
Charles Corey Hardin and Jenna McNeill
37.Thromboembolic Disease and Hemoptysis
Maram Marouki, Joanna Brenneman, and Roshni Sreedharan
38.Pleural Disorders
Galen Royce-Nagel
39.Sleep Apnea
Dario Winterton, Riccardo Pinciroli, and Lorenzo Berra
40.Pulmonary Infections
Jason H. Maley and Kathryn A. Hibbert
41.Neoplasm
Jenna McNeill and Charles Corey Hardin
42.Lung Transplantation, Complications, and VV ECMO
Archit Sharma and Bharathram Vasudevan
43.Respiratory Diagnostic Modalities and Monitoring
Phat Tan Dang, Christopher Dinh, Abdulaziz S. Almehlisi, and Ulrich
Schmidt
IV. Renal, Electrolyte and Acid Base Disorders
44.Acute Renal Failure
Qasim AlHassan, Madiha Syed, and Roshni Sreedharan
45.Oliguria and Polyuria
Abdulaziz S. Almehlisi, Phat Tan Dang, Ji Sun Christina Baek, Anushirvan
Minokadeh, Alan S. Nova, Zeb McMillan, Kimberly S. Robbins, and Ulrich
Schmidt
46.Renal Replacement Therapy
Riaz M. Karukappadath, Faith Natalie Factora, and Roshni Sreedharan
47.Drug Dosing in Renal Failure
Abdulaziz S. Almehlisi, Phat Tan Dang, Ji Sun Christina Baek, and Ulrich
Schmidt
48.Renal Transplantation
Hassan Farhan
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CHAPTER XVI
The departing Guests
THE Sergeant unloosed the landlord’s coat and ordered one of his men to procure water and dash it in his face. But Gamaliel had gone too far to be brought round easily, and the time spent in restoring him to his senses was the King’s deliverance.
Presently the landlord opened his eyes and looked about him. The reaction brought with it a full measure of consciousness, and with it a command of his faculties. He could think; and, now it was too late, the power of speech was again vouchsafed to him.
“The King went out at that door!” he cried. “The King is escaped! That was the King you conducted to the door.”
“What do you mean?” demanded the astonished Sergeant. “Speak, clown and fool that you are! I tell you the King is upstairs.”
The landlord had now the power to unbosom his soul; and there was such a singular fervour of conviction in his words, that the soldier, vividly impressed by them, and bewildered by them too, made all haste up the stairs to Captain Culpeper, who, as he supposed, was still attending on the King.
The thoroughly alarmed and uneasy Sergeant came to him at the side of the bed, and recited the landlord’s story.
“What is this you say, Sergeant Williams?” said the Captain.
His heart sank with an overmastering foreboding that the landlord had spoken the truth. He had not known the King when he entered the chamber, never having set eyes upon his Majesty before; and none of his men knew him either—they had only hearsay to guide them. Could it be that he was the victim of a trick. He turned furiously upon the man in the bed and the woman beside him.
“My God!” he said, “you have duped me; you have deceived me. The King’s servitor was the King. You have been playing a part.”
The man and the woman looked at him defiantly Every instant they could maintain their rôles was of the utmost advantage to the fugitive; and in any case their own lives were forfeit.
“What do you mean?” said young Lord Farnham, striving to enact the comedy to the bitter end.
“We have been tricked!” cried the Captain.
The truth had burst upon Captain Culpeper with stunning force. He saw it all. He became as one beside himself. He stamped, he raved, he swore. They had allowed the prize actually to slip away when their hands were upon it.
The King must be pursued. They must pursue him hot-foot. Up hill and down dale, over the rocks, into the very jaws of the sea they must hunt the royal fugitive. He had but ten minutes start of them, and he was on foot.
No, he was not on foot. It seemed that he had taken a horse from the stable and had ridden away Those who saw him do so believed that he had the Captain’s permission, as he was said to be on some errand of his Majesty lying upstairs.
The Captain gnashed his teeth. He drove his men out of the room before him like a flock of sheep. There was not a precious instant to lose. They must get to horse. Dark as it was, they must scour every yard of the surrounding country. There never was such a noise and a rattle as, with that, these soldiers fled down the stairs and forth of the kitchen door.
“To horse, to horse; the King is escaped!” was the cry that rang out to the rocks by the side of the sea. Horses stamped under the signboard of the “Sea Rover”; boots, spurs, and stirrups struck one against the other; bridles shook; hoarse commands were given; the cavalcade moved fiercely and swiftly away.
Now that the crisis was past, the landlord was sufficiently master of himself to watch them go from his door. After this fiasco it was highly
necessary, he argued, that he should do all he could to win their favour and their confidence. Captain Culpeper, despite the rage and excitement under which he was labouring, called out as he sprang to the saddle:
“Landlord, I charge you to detain the man and the woman upstairs against my return, on the peril of your life. I hold you already responsible for the King’s escape. Do you watch over these two persons, therefore, yet more jealously. I cannot spare any of my men to look after them, but you have your son and that strapping servantgirl. We will fetch them as soon as maybe, and lodge them in greater security.”
While the last of these words were being uttered, Captain Culpeper and his troops were riding away. Stunned by their import, the landlord went within and closed the door. It was as though he had heard the sentence of his own death, for he knew it was wholly out of his power to detain the man and the woman upstairs should Diggory Fargus only prove true to his appointment. The sailor had promised to come, in the company of three of his friends, at half-past nine, to bear away the lady and her stricken husband.
If they came, what an irony it was to suppose that he, his son Joseph, and Cicely, the serving-maid, could possibly prevail against the redoubtable mariner and three of his pirates or his smugglers!
As a preliminary measure, the landlord locked the door Not only did he lock it, but he bolted it at the top and at the bottom, and ran the chain across. Then he looked at the clock. Ten minutes to ten. Diggory Fargus had promised to come at half-past nine. Probably he had purposely held off when he saw that the soldiers were at the inn. He even might have had so tender a regard for his own skin as to go back again. God grant that that were so! He even might not have meant to come at all. The landlord prayed with all his soul that Diggory Fargus and his men might not appear. The loss of the King was effaced for the time being from his mind by this new matter
The security of his own person was involved in it, and the immunity of that sacred thing was of even greater moment to Gamaliel than the loss of a King’s ransom. All his life he had had a holy dread of
violence. God in heaven be merciful to him a sinner, and keep away that ruthless sailor!
The landlord looked at the clock again. Five minutes to ten. Diggory Fargus was already twenty-five minutes behind his time. But there was hardly any comfort in the thought. Hours must elapse ere Captain Culpeper could come to his aid, unless by a miracle the King were retaken immediately. A little bitterly the landlord reflected that miracles did not happen to him. Was not his life stern, terrible, inexorable matter of fact? At least, it seemed so then.
The landlord fell once again to his principal occupation of that tragic day. He began to hobble up and down the kitchen, with ever and anon an anxious eye for the clock.
There might be hours of this form of torture. If there were, Gamaliel felt that surely he must go out of his mind. It was a suspense to which there would be no end. There was no limit to the hour at which Captain Culpeper might return to claim the two persons left in his custody. It might be an hour, or it might be twelve; it might be a day, a week, or a month. But be that as it may, his instructions were perfectly clear. He must detain those two guilty persons at his inn, by force, if necessary, or he would forfeit his life.
The first stroke of ten had barely struck, when the landlord caught a sound that froze the blood in his veins. The noise of persons on foot coming down the bridle-path rose above the distant roar of the sea. He heard rough voices. The kitchen door was tried; a lusty smack was delivered upon it.
“Open the door, mate!” cried the great voice of Diggory Fargus.
The landlord did not stir. He leant against the wall for support; he had not the strength of a mouse.
“Open the door, mate, d’ye hear me?” demanded Diggory Fargus.
A terrific blow shook the lusty oak. Still the landlord leant sickly against the wall.
The lady appeared at the head of the stairs, cloaked, masked, and gloved for a journey. Hearing that her deliverers were at hand, she
ran down the stairs, and, not heeding the helpless landlord, thrust back the bolts, the chain, and the lock of the kitchen door.
The mariner and three companions as rude and ill-favoured as himself stepped out of the night.
“We’re behind our time, ma’am,” said Diggory Fargus; “but, d’ye see, at half-past nine we had to tack and go about, for the place was full of soldiers. We supposed they had come to take ye, but we thought it our dooty to return and satisfy ourselves.”
“God requite you, sailor,” said the woman, fervently. “My husband is still upstairs. But let us make all haste, for at any moment his enemies may return upon him.”
Even as the woman spoke, the pale figure of a man tottered down the stairs. Clinging tightly to the rail, he put one weak limb before the other and reached the kitchen before they had observed him. He too was fully accomplished for the journey.
“Oh, mine own,” said the woman, tenderly, “what a foolish valour! ’Tis ever the same headstrong, wilful, heedless fellow. Did I not order you to stay upstairs until we fetched you? Thou art much too weak to use thine own legs as yet, lad.”
“Peace, Patsy woman,” said the young man. “If I can walk into this accursed place, I can walk out of it. I am hale and strong by comparison with what I was when I came here with the bullet in my side. Landlord, give me a cup of wine, and I shall be fit to encounter the perils of the sea. Deuce take me! what hath happened to the landlord?”
As pale as linen, his eyes staring and his knees knocking, the landlord still clung in silence to the wall. Diggory Fargus looked at him grimly. Lying in concealment close at hand when the soldiers rode away, he had overheard the injunctions of Captain Culpeper.
“The Cap’n left particular orders,” said the mariner to the lady, “that this ’ere son of a rum puncheon was to hold you and your mate, ma’am, against his return, by force, if necessary. And as it goes agen his principles to use violence o’ any sort, he’s asking of himself, d’ye see, whether ye would take it amiss if he invited you to tarry.”
The woman looked at the landlord. None had had a fairer opportunity of judging his character than she during her sojourn in that place. Her eyes shone through her mask; the stern lines fell about her mouth; and then she turned away from him with the same tremor of disgust as one turns away from a venomous reptile. Even to her compassion there was a limit.
“Come, my own,” she said. “It is folly in us to lose a precious moment. I wonder what hath happened to the poor King. God be with him, poor lad, this night!”
“He should make good his escape,” said Lord Farnham. “He hath a horse and a full ten minutes start of his foes.”
Leaning on the arm of his wife he passed slowly out of the door, into the night and his freedom. The landlord still leant against the wall: not a word did he speak; not a finger did he lift to stay the departing guests.
Diggory Fargus tarried behind an instant to speak a word in the landlord’s ear.
“Mate,” said he, thrusting his one eye into the quivering face of the landlord, “I said, if ye played me false I would twist your head off your body with these two hands. But I shall leave it to others, d’ye see. I shall kind o’ leave it to my deppities. They’ll make a cleaner job of it than me. They’ll do it more formal and more lawyerlike. Besides, I have hardly the time to do it now. But let me tell ye, mate, as one man to another, that when next I am around this coast, I shall make a call at this old grog shop, and if I find that them there soldiers has not done their dooty by you, ye can lay to it as Diggory Fargus is a christened man he’ll keep his word. A pleasant evenin’ to you, mate.”
The sailor spat vehemently upon the kitchen floor, and lurched out into the darkness in the wake of his companions.
CHAPTER XVII
The Landlord
GAMALIEL closed the door upon the last of his visitors. Gradually their slow footsteps receded into the roar of the sea. He listened, and fancied he could hear them long after he had ceased to do so. Insensibly his mind lingered on their sound, for when they should die away he knew that his life was at an end.
As one who has suffered the tortures and paroxysms of a disease may lose his agonies as soon as it develops mortal symptoms, so the landlord, possessed with the knowledge that his own life was the price he must pay for his weakness, sat down in his chair by the fire with a clear mind. There was no longer any need for him to torment himself. He foresaw the issue as plainly as the man in the cart when he looks upon the scaffold.
He had lost all. Events had been too great for his second-rate character. They had called for a strong man—a man of courage, of indomitable spirit and tenacity of purpose—to grapple with them. For such a one there had been a fortune. The landlord, self-deceived because all his life he had never been put to the test, had attempted to bend them to his own purposes. But they had proved too great and unwieldy; he had not had the physical strength to overcome them. Instead they had overcome him.
The landlord did not give himself up to despair. He was too far gone for that. He was bitterly afraid of death. A death by violence would still have the power to revolt him; but the thing uppermost in his mind was his humiliation. It was so fierce and overpowering, that it became an anodyne to lull and allay all the passions of his soul. It took the sting out of death itself. He had been tried and found wanting. At the age of sixty the supreme moment of a laborious and fairly successful life had come. He had failed; let him perish.
“Finis” was about to be written to his history He had no longer to fear that awful suspense which had the power to overthrow the firmest intelligence. As plainly as he could hear the roar of the sea, he saw his doom. He sat still and thought upon it, almost calmly. Right at the very last he had emerged from the furnace, and had come out strong.
He would bare his neck, and they should do their worst. He would welcome it. He had no desire to live now; he had ceased to be swayed by his animal passions. All his life, when he could escape a moment from his greed and his sensuality, he had been a philosopher. He had warmed both hands at the fire of his own egotism. He had flattered himself that he had known his own strength and his own weakness. He knew nothing of the sort. Just as in one direction he had overestimated his resolution, he was now to prove that he had underestimated it in another.
A day ago he would probably have writhed on the ground in a fit had he been confronted by a death by violence. By now, however, he had got beyond all that. There were things a man occasionally had to submit to, which made such a thing almost a luxury He had spent that day upon the rack. The sharp rending asunder of his body and his soul would be a merciful release. His eyeballs would no longer start from their sockets; his limbs would no longer crack; nor would his blood burst through the walls of his arteries. His shuddering frame would be at peace.
The clock struck twelve. The landlord clenched his hands as he sat in his chair; a smile crept stealthily upon the dead white of his cheeks. It was the last touch of irony that he, Gamaliel Hooker, should be sitting there so calmly looking a death by violence full in the face. To think that his old pampered flesh, cossetted and cushioned for sixty winters, should accept it without a murmur! The wind is tempered to the shorn lamb: Nature has her marvellous compensations; she takes the grossness from the animal spirit, that it may be insensible to the throes of death.
About one o’clock of the wintry morning the landlord rose from his chair, and had recourse to paper, a pen, and ink. He solemnly made
his will. For the keeper of a sea tavern on a lonely coast, the home of the pirate and the smuggler, he had done excellently well in trade. He had added thrift to a natural aptitude. His money had not all been come by honestly, as the world interpreted that word. But that did not irk the landlord. All his life he had never pretended to a conscience. To him it was the hallmark of a superficial mind. And now in his last extremity he would not pretend to one. It was to be the great triumph of his life, that in his last hour he should prove to be stronger than he had ever judged himself to be. He would yield up his life calmly, without a snuffle, a whine, or a prayer
About two o’clock he had signed his name with controlled fingers to this document. He sanded it carefully and put it by. He had hardly done so, when he jumped up suddenly from his chair. An old stab returned upon him; he felt a twinge of the old agony. After all, there was a chance of life. Suppose the pursuing soldiers retook the King! They would be then in a mood to overlook all, and they might permit him to live! The landlord cursed himself for the thought. God! was he going to be tortured again before he was allowed to perish? No, it was only the last twinge of an expiring nerve. The pain passed almost in an instant. He need not be afraid.
Towards three, the old man grew very cold. He had forgotten to replenish the fire. It had gone out hours ago, leaving the ashes grey. He was getting tired; the soldiers were a long time coming; he would try to go to sleep. Soon a pleasant lassitude stole upon his weariness. He had never been so exquisitely tired in his life before. It had been a heavy day; he had taken a lot out of himself; he deserved a rest. He fell asleep.
A little after four o’clock he awoke suddenly out of a dreamless slumber, as one startled. He lifted up his ears and listened. Horses! He rubbed his eyes in bewilderment. Why should he be sleeping there, and why should these signs invade the middle of the night? Ah yes, to be sure, he remembered! The soldiers were coming back. His first thought was, had they caught the King? He banished it instantly. He had got past all that before he went to sleep. He would not go back, otherwise the last twenty-four hours had been lived in
vain. He listened calmly for their near approach, but he still kept his chair by the side of the dead embers. There was no need for him to rise to let them in, as he remembered that he had not considered it necessary to secure the door before he went to sleep. What a transcendent thing it was to have a heart utterly without bodily fear! It was rather hard, though, that he should only be allowed to experience that pleasure for so short a period in his long life. However, it was very excellent even to have known it at all. He could hardly be said to have lived in vain.
The landlord, still in his chair by the dead fire, watched the kitchen door. He saw it open. He saw Captain Culpeper appear, stiff and cold with riding, and very morose. His men, stiff and cold and morose too, crowded in behind him. The landlord neither moved nor spoke; he seemed wholly indifferent to their entrance.
“The King is escaped!” said Captain Culpeper, eyeing him savagely.
“I knew it,” said the landlord, a little wearily. He closed his eyes; almost a smile came upon his white lips.
“Oh, you knew it!” said Captain Culpeper, with a grim satisfaction. “You knew it, did you! And how did you know it, fool and poltroon as you are?”
“Poltroon I am,” said the landlord, “a thousand times a poltroon; but I am no fool. I knew it because I knew it.”
“Bah!” said the soldier, “I have not the patience to talk with you. But I trust the man and the woman are still upstairs in their chamber.”
“They are not,” said the landlord; there was a note of triumph in his voice. “A company of smugglers bore them away half an hour after your departure.”
“And you allowed them to leave your inn, after what I had said to you?” said Culpeper, striving to control the fury that was shaking him from head to foot.
“I could not help myself,” said the landlord, indifferently.
“And you could not help the King’s going, I suppose,” said the soldier, “even when he went past your very nose?”
“No, I could not help myself,” said the landlord again.
“And wherefore could you not?”
The soldier’s rage was giving place now to a self-contained harshness which did not distress the landlord to observe.
“I do not know why I could not stay the King’s going,” said the landlord.
“What do you mean?” said the soldier.
“When the King went,” said the landlord, “I was not the master of myself; but, thank God, I am master of myself now.”
“You will soon cease to be,” said the soldier, regarding him with a grim surprise.
“That is as maybe,” said the landlord.
The soldiers crowded about the landlord with sinister intention upon their faces. Captain Culpeper briefly told two of them to procure a rope.
“You will find plenty in the stable,” said the landlord.
Several of the soldiers chuckled.
“Do you know for what purpose we require it, good Master Innkeeper?” said Culpeper, laughingly.
“The signboard will suit your purpose best,” said the landlord.
“You oblige us vastly,” said the soldier.
The landlord astonished them vastly too. They had not looked for this demeanour in one who was about to undergo the penalty of death. They had never encountered such an indifference in the face of it before.
However, when the two men returned bearing a stout piece of hemp, an evidence was furnished of the price at which the landlord’s newlyacquired fortitude had been purchased. When his bloodshot eyes fell on the rope, a cord appeared to snap in the middle of his brain; his
head revolved slowly on his neck; and he pitched heavily on to the kitchen floor.
They turned him over on his back, but all attempts to restore the landlord to sensibility failed. After a while he appeared to grow dimly conscious of his surroundings; but he was bereft of speech, and he had not the power to move. It mattered not what remedies they had recourse to, the horrible, convulsed white face still had the vacancy and the inanimation of death without the repose of it.
“’Tis a pity we could not hang the old rogue more prettily,” said Captain Culpeper, when all their exertions had failed of their effect. “For if ever a man did merit a hanging, here he lies. He hath played a double game all through. But what he could have hoped to gain by it, for the life of me I cannot see. He must have been a sanguine fellow to think that he could run with the hare, and hunt with the dogs. He must have known that he went in danger of being torn to pieces. But why he should first betray the King, and then promote his escape, passes me completely. A queer old rogue, this landlord. Now then, lift him up, lads, and set him in the place he himself did choose.”
They placed the noose around the landlord’s neck and bore him out into the shrewd air of the morning. It was still as dark as pitch; never a star looked out of the sky; mercifully the moon had hidden her face; and thus the body of the landlord was unregarded, as it swung in the wintry darkness from the signboard of the “Sea Rover.”
THE END.
TRANSCRIBER’S NOTES:
Obvious typographical errors have been corrected. Inconsistencies in hyphenation have been standardized.
Archaic or variant spelling has been retained.
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