Advanced assessment interpreting findings and formulating differential diagnoses mary jo goolsby - D
Advanced Assessment
Interpreting Findings and Formulating Differential Diagnoses Mary Jo Goolsby
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Library of Congress Cataloging-in-Publication Data
Names: Goolsby, Mary Jo, editor. | Grubbs, Laurie, editor.
Title: Advanced assessment : interpreting findings and formulating differential diagnoses / [edited by] Mary Jo Goolsby, Laurie Grubbs.
Description: Fourth edition. | Philadelphia, PA: F.A. Davis Company, [2019] | Includes bibliographical references and index.
Identifiers: LCCN 2018039856 (print) | LCCN 2018041376 (ebook) | ISBN 9780803690059 | ISBN 9780803668942 (pbk.)
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Preface
A growing body of literature addresses the risks associated with clinical decision making. In 2015, the National Academy of Medicine (formerly, Institute of Medicine) identified diagnostic error as the “blind spot” in health-care delivery. The original idea for this book arose from our recognition that the many health assessment texts available lacked an essential component—content on how to narrow a differential diagnosis when a patient presented with one of the almost endless possible complaints. The response to the earlier editions of this text supported belief in the need for a text that addressed the lack of content designed to support expertise in the assessment and diagnostic process. We hope that this updated edition will continue to aid advanced practice students, new practitioners, and experienced practitioners faced with new presentations. In spite of the growth in available diagnostic technology and studies, expertise in correctly performing assessment skills, obtaining valid data, and interpreting the findings accurately is fundamental to the provision of the safe, high-quality, patient-centered, and cost-effective practice for which NPs are known. Even once these skills are accomplished, accurate diagnosis remains a difficult aspect of practice. Novice practitioners often spend much energy and time narrowing their differential diagnosis when they have no clear guidance that is driven by the patient or complaint. For this reason, our aim was to develop a guide in the assessment and diagnostic process that is broad in content and suitable for use in varied settings.
Advanced Assessment: Interpreting Findings and Formulating Differential Diagnoses has been designed to serve as both a textbook during advanced health assessment course work and subsequent clinical courses and as a quick reference for practicing clinicians. We believe that studying the text will help students develop proficiency in performing and interpreting assessments, recognizing the range of conditions that can be indicated by specific findings. Once in practice, we believe that the text will aid individualized assessment and narrowing of differential diagnosis.
The book consists of three parts. Part I provides a summary discussion of assessment and some matters related to clinical decision making. In addition to discussing the behaviors involved in arriving at a definitive diagnosis, each chapter covers some pitfalls that clinicians often experience and the types of evidence-based resources that are available to assist in the diagnostic process. This section includes a unique chapter on conducting a genetic assessment. This component of health assessment has great potential, with recent advances in the information and technology related to genetics and genomics. It is critical that clinicians be able to address the potential of hereditary diseases and genetic variations that may affect their patients. This chapter, like the one on clinical decision making, is relevant to the content of all subsequent chapters.
Part II serves as the core of the book and addresses assessment and diagnosis using a system and body region approach. Each chapter in this part begins with an overview of the comprehensive history and physical examination of a specific system, as well as a discussion of common
diagnostic studies. The remainder of the chapter is then categorized by chief complaints commonly associated with that system. For each complaint, there is a description of the focused assessment relative to that complaint, followed by a list of the conditions that should be considered in the differential diagnosis, along with the symptoms, signs, or diagnostic findings that would support each condition.
Figures within chapters are provided to better depict examination techniques or expected findings. With each edition, additional complaints and conditions have been included in several differential diagnosis sections.
Finally, Part III addresses the assessment and diagnosis of specific populations, such as those at either extreme of age (young and old) and pregnant women. This edition adds new content on the assessment of transgender individuals and persons with physical disabilities. This section places a heavy emphasis on the assessments that allow clinicians to evaluate the special needs of individuals in the populations addressed in these chapters.
To aid the reader, we have tried to follow a consistent format in the presentation of content so that information can be readily located. This format is admittedly grounded on the sequence we have found successful as we presented this content to our students. However, we have a great appreciation for the expertise of the contributors in this edited work, and some of the content they recommended could not consistently fit our “formula.” We hope that the organization of this text will be helpful to all readers.
REFERENCE
National Academies of Science (2015). Report in brief: Improving diagnosis in health care. Retrieved from nas.edu/ improvingdiagnosis. May 20, 2018.
Acknowledgments
We want to express our sincere appreciation for the support and assistance provided by so many in the development of this book. Their contributions have made the work much richer.
Particular mention goes to all at F.A. Davis for their enthusiasm, support, and patience throughout the history of this text. Special thanks to F.A. Davis staff, Susan Rhyner, our publisher, and Shana Murph, content project manager, as well as to Marsha Hall, project manager with Progressive Publishing Services.
We are immensely grateful to the contributors to this edition, who shared their expertise and knowledge to enhance the content. They were a pleasure to work with. We also acknowledge those who provided content to an earlier edition: JoEllen Wynne, Quanetta Edwards, Saundra Turner, Randolph Rasch, Karen Koozer-Olson, Diane Mueller, Phillip Rupp, and Patricia Hentz. In addition to the contributors, we also want to thank the many reviewers of this and previous editions for their timely and thoughtful feedback.
Personal Acknowledgments from Laurie Grubbs
Most of all, I would like to thank my friend and coauthor, Mary Jo, for providing the impetus to write this book—an often talked about aspiration that became a reality—and to F.A. Davis for their enthusiasm, support, and patience during the process.
I would also like to thank my children, Jennifer and Ashley, for their support and for being themselves—intelligent, talented, beautiful daughters.
Personal Acknowledgments from Mary Jo Goolsby
I must also express thanks to my dear friend and colleague, Laurie. During much of my time in academia, I have had the pleasure and honor of coteaching with Laurie, from whom I learned so much.
Above all else, I also thank my husband, H. G. Goolsby. He continues to offer constant support and encouragement, without which this and other professional achievements would not have been possible.
Sara F. Barber, MSN, ARNP-BC
Pediatric Nurse Practitioner
Professional Park Pediatrics Tallahassee, Florida
Deborah Blackwell, PhD, WHNP, RNC-OB, CNE
Associate Clinical Professor
Northeastern University Charlotte Campus Charlotte, North Carolina
James Blackwell, DNP, FNP-BC
Nurse Practitioner
Emergency Department
WJB Dorn VA Medical Center Columbia, South Carolina
Lisa Byrd APRN, PhD, FNP-BC, GNP-BC, Gerontologist
Practice Administrator Florida Health Care Plans Lake Mary, Florida
Assistant Professor University of South Alabama
Leslie L. Davis, PhD, RN, ANP-BC, FAANP, FAHA
Associate Professor of Nursing University of North Carolina, Greensboro
Clinical Assistant Professor of Medicine University of North Carolina, Chapel Hill
Valerie A. Hart, EdD, APRN, PMHCNS-BC
Professor of Nursing Emeritus
Psychotherapist
College of Science, Technology & Health University of Southern Maine Portland, Maine
Catherine “Casey” Jones, PhD, RN, ANP-C, AE-C
Nurse Practitioner
Texas Pulmonary and Critical Care Associates, P.A. Bedford, Texas
Assistant Professor
Texas Woman’s University Dallas, Texas
Contributors
Michelle Lajiness, APRN, FNP-BC
University of Toledo Medical College Department of Urology Toledo, Ohio
Ann Maradiegue, PhD, RN, FNP-BC, FAANP
Consultant, Genetics Education and Patient Advocacy Washington, DC
Kim Pickett, PhD, APRN, BC-ADM
Nurse Practitioner
Diabetes & Endocrinology
Medical Group of the Carolinas Spartanburg, SC
Charon A. Pierson, PhD, GNP, FAANP, FAAN
Emeritus Editor, Journal of the American Association of Nurse Practitioners
Consultant, Geriatric Nursing Program Development and Evaluation Gilbert, Arizona
Susanne Quallich, PhD, ANP-BC, NP-C, CUNP, FAANP
Andrology Nurse Practitioner
Division of Andrology and Urologic Health Department of Urology University of Michigan Health System Ann Arbor, Michigan
Diane Seibert, PhD, RN, ANP, WHNP-BC, FAANP
Professor
Associate Dean for Academic Affairs
Daniel K. Inouye Graduate School of Nursing
Uniformed Services University Bethesda, Maryland
Karen J. Whitt, PhD, AGN-BC, FNP-C, FAANP
Associate Professor
George Washington University School of Nursing Washington, DC
Jordon D. Bosse, MS, RN
PhD Candidate
University of Massachusetts Amherst, Massachusetts
Patsy E. Crihfield, DNP, APRN, FNP-BC, PMHNP-BC
Associate Dean of Graduate Programs Union University Jackson, Tennessee
Reviewers
Donna M. Cullinan, RN, MS, FNP-BC
Assistant Clinical Professor Boston College Chestnut Hill, Massachusetts
Preface v
Acknowledgments vii
Contributors ix
Reviewers xi
Part I The Art of Assessment and Clinical Decision Making 1
Chapter 1. Assessment and Clinical Decision Making: An Overview 3
Part II Advanced Assessment and Differential Diagnosis by Body Regions and Systems 49
Chapter 3. Skin 51
Chapter 4. Head, Face, and Neck 89
Chapter 5. The Eye 109
Chapter 6. Ear, Nose, Mouth, and Throat 142
Chapter 7. Cardiac and Peripheral Vascular Systems 187
Chapter 8. Respiratory System 235
Chapter 9. Breasts 255
Chapter 10. Abdomen 275
Chapter 11. Genitourinary System 326
Chapter 12. Male Reproductive System 361
Chapter 13. Female Reproductive System 396
Chapter 14. Musculoskeletal System 435
Chapter 15. Neurological System 477
Chapter 16. Nonspecific Complaints 505
Chapter 17. Psychiatric Mental Health 530
Part III Assessment and Differential Diagnosis in Special Patient Populations 561
Chapter 18. Pediatric Patients 563
Chapter 19. Pregnant Patients 602
Chapter 20. Assessment of the Transgender or Gender Diverse Adult 630
Chapter 21. Older Patients 641
Chapter 22. Persons With Disabilities 676
Symptoms Index 683
Index 687
PART I
The Art of Assessment and Clinical Decision Making
Chapter 1
Assessment and Clinical Decision Making: An Overview
Mary Jo Goolsby • Laurie Grubbs •
Clinical decision making is often fraught with uncertainties. According to a recent report (Bernstein, 2017), over 20% of persons presenting for second opinions in one facility had been misdiagnosed. Pat Croskerry (2013) estimates that the diagnostic failure rate is as high as 15%. Te “Augenblick diagnosis” is one made within “the blink of an eye” based on intuition, and it is a clinically dangerous state (p. 2445). While it works the majority of the time for experienced clinicians, it fails more often than we recognize.
Croskerry (2013) describes two major types of clinical diagnostic decision making: intuitive and analytical. Intuitive decision making is consistent with the Augenblick diagnosis, in that the clinician relies on experience and intuition and the diagnosis occurs rapidly and with little effort. However, as noted, this type of decision making is less reliable and paired with fairly common errors. In contrast, analytical decision making is based on careful consideration, takes more time and effort, and has greater reliability with rare errors. Because practice settings present a number of distractors and competing demands, it is critical that diagnosticians step back, assess their processes and the data they are gathering, and attend to the possibilities.
Diagnostic reasoning involves a complex process that is quickly clouded by first impressions. Te need to ensure necessary “data” requires a measured approach, even when faced with common complaints such as chest pain. Tis requires a consistent and measured approach to symptom analysis, physical assessment, and data analysis. Expert diagnosticians are able to maintain a degree of suspicion throughout the assessment process, consider a range of potential explanations, and then generate and narrow their differential diagnosis on the basis of their previous experience, familiarity with the evidence related to various diagnoses, and understanding of their individual patient. Trough the process, clinicians perform assessment techniques involving both the history and physical
examination in an effective and reliable manner and then select appropriate diagnostic studies to support their assessment.
Te importance of diagnostic reasoning and expertise is gaining recognition. Te Society to Improve Diagnosis in Medicine (improvediagnosis.org) offers a number of resources for clinicians and educators, designed to address diagnostic error.
History
Among the assessment techniques essential to valid diagnosis is performing a fact-finding history. To obtain adequate history, providers must be well organized, attentive to the patient’s verbal and nonverbal language, and able to accurately interpret the patient’s responses to questions. Rather than reading into the patient’s statements, they clarify any areas of uncertainty. Te expert history, like the expert physical examination, is informed by the knowledge of a wide range of conditions, their physiological bases, and their associated signs and symptoms.
Te ability to draw out descriptions of the patient’s symptoms and experiences is important because only the patient can tell his or her story. To assist the patient in describing a complaint, a skilful interviewer knows how to ask salient and focused questions to draw out necessary information without straying (i.e., avoiding a shotgun approach, with lack of focus). Te provider should know, based on the chief complaint and any preceding information, what other questions are essential to the history. It is important to determine why the symptom brought the patient to the office—that is, the significance of this symptom to the patient, which may uncover the patient’s anxiety and the basis for his or her concern. It may also help to determine severity in a stoic patient who may underestimate or underreport symptoms.
Troughout the history, it is important to recognize that patients may forget details, so probing questions may be necessary. Patients sometimes have trouble finding the precise words to describe their complaint. However, good descriptors are necessary to isolate the cause, source, and location of symptoms. Often, patients must be encouraged to use common language and terminology. For instance, encourage the patient to describe the problem just as he or she would describe it to a relative or neighbor.
Te history should include specific components (summarized in Table 1.1) to ensure that the problem is comprehensively evaluated. Te questions to include in each component of the history are described in detail in subsequent chapters.
Content on communicating with patients who have physical communication deficits is provided in Chapter 22. However, clinicians may encounter patients who communicate using different languages. In these instances, alternative communication methods are critical in obtaining a necessary health history to support a valid assessment and diagnosis.
Table 1.1
Components of History
Component
Chief complaint
History of present illness
• P: precipitating and palliative factors
Purpose
To determine the reason patient seeks care. Important to consider using the patient’s terminology. Provides “title” for the encounter.
To provide a thorough description of the chief complaint and current problem. Suggested format: P-Q-R-S-T.
To identify factors that make symptom worse and/or better; any previous self-treatment or prescribed treatment; and response.
• Q: quality and quantity descriptors To identify patient’s rating of symptom (e.g., pain on a 1–10 scale) and descriptors (e.g., numbness, burning, stabbing).
• R: region and radiation
• S: severity and associated symptoms
• T: timing and temporal descriptions
Past medical history
Habits
Sociocultural
Family history
Review of systems
To identify the exact location of the symptom and any area of radiation.
To identify the symptom’s severity (e.g., how bad at its worst) and any associated symptoms (e.g., presence or absence of nausea and vomiting associated with chest pain).
To identify when complaint was frst noticed; how it has changed/progressed since onset (e.g., remained the same or worsened/improved); whether onset was acute or chronic; whether it has been constant, intermittent, or recurrent.
To identify past diagnoses, surgeries, hospitalizations, injuries, allergies, immunizations, current medications.
To describe any use of tobacco, alcohol, drugs, and to identify patterns of sleep, exercise, etc.
To identify occupational and recreational activities and experiences, living environment, fnancial status/support as related to health-care needs, travel, lifestyle, etc.
To identify potential sources of hereditary diseases; a genogram is helpful. The minimum includes frst-degree relatives (i.e., parents, siblings, children), although second and third orders are helpful.
To review a list of possible symptoms that the patient may have noted in each of the body systems.
When the patient speaks a different language from the interviewer, an interpreter who is fluent in the languages of both the patient and the provider must be called upon. Te interpreter should be impartial and have experience in interpreting health-related information and understand the importance of confidentiality and accurately conveying each party’s communication. Te patient’s permission is needed prior to involving an interpreter. When using an interpreter, questions should be as succinct as possible and understanding should be validated by the interpreter. Te clinician should face and speak to the patient, rather than to the interpreter, being sensitive to body language and expressions.
Physical Examination
Te expert diagnostician must also be able to accurately perform a physical assessment. Extensive, repetitive practice; exposure to a range of normal variants and abnormal findings; and keen observation skills are required to develop physical examination proficiency. Each component of the physical examination must be performed correctly to ensure that findings are as valid and reliable as possible. Chapter 22 describes assessment of patients with physical disabilities. While performing the physical examination, the examiner must be able to
• differentiate between normal and abnormal findings.
• recall knowledge of a range of conditions, including their associated signs and symptoms.
• recognize how certain conditions affect the response to other conditions in ways that are not entirely predictable.
• distinguish the relevance of varied abnormal findings.
Te aspects of physical examination are summarized in the following chapters using a systems approach. Each chapter also reviews the relevant examination for varied complaints. Along with obtaining an accurate history and performing a physical examination, it is crucial that the clinician consider the patient’s vital signs, general appearance, and condition when making clinical decisions.
Diagnostic Studies
Te history and physical assessment help to guide the selection of diagnostic studies. Diagnostic studies should be considered if a patient’s diagnosis remains in doubt following the history and physical. Tey often help establish the severity of the diagnosed condition or rule out conditions included in the early differential diagnosis. Just as the history should be relevant and focused, the selection of diagnostic studies should be judicious and directed toward specific conditions under consideration. Te clinician should select the study (or studies) with the highest degree of sensitivity and specificity for the target condition while also considering cost-effectiveness, safety, and degree of invasiveness. Selection of diagnostics requires a range of knowledge specific to various studies and the ability to interpret the study’s results. Resources are available to assist clinicians in the selection of diagnostic studies. For example, the American College of Radiology’s Appropriateness Criteria provides guidelines on selecting imaging studies (see www.acr.org/QualitySafety/Appropriateness-Criteria). A number of texts review variables relative to the selection of laboratory studies. Subsequent chapters identify specific studies that should be considered for varied complaints, depending on the conditions included in the differential diagnosis.
Diagnostic Statistics
In the selection and interpretation of assessment techniques and diagnostic studies, providers must understand and apply some basic statistical concepts,
including the tests’ sensitivity and specificity, the pretest probability, and the likelihood ratio. Tese characteristics are based on population studies involving the various tests, and they provide a general appreciation of how helpful a diagnostic study will be in arriving at a definitive diagnosis. Each concept is briefly described in Table 1 2. Detailed discussions of these and other diagnostic statistics can be found in numerous reference texts.
Bayes’s theorem is frequently cited as the standard for basing a clinical decision on available evidence. Te Bayesian process involves using knowledge of the pretest probability and the likelihood ratio to determine the probability that a particular condition exists. Given knowledge of the pretest probability and a particular test’s associated likelihood ratio, providers can estimate posttest probability of a condition based on a population of patients with the same characteristics. Post-test probability is the product of the pretest probability and the likelihood ratio. Nomograms are available to assist in applying the theorem to
Statistic Description
Sensitivity
Specifcity
Pretest probability
Likelihood ratio
The percentage of individuals with the target condition who would have an abnormal, or positive, result. Because a high sensitivity indicates that a greater percentage of persons with the given condition will have an abnormal result, a test with a high sensitivity can be used to rule out the condition for those who do not have an abnormal result. For example, if redness of the conjunctiva is 100% sensitive for bacterial conjunctivitis, then conjunctivitis could be ruled out in a patient who did not have redness on examination. However, the presence of redness could indicate several conditions, including bacterial conjunctivitis, viral conjunctivitis, corneal abrasion, or allergies.
The percentage of healthy individuals who would have a normal result. The greater the specifcity, the greater the percentage of individuals who will have negative, or normal, results if they do not have the target condition. If a test has a high level of specifcity so that a signifcant percentage of healthy individuals are expected to have a negative result, then a positive result would be used to “rule in” the condition. For example, if a rapid strep screen test is 98% specifc for streptococcal pharyngitis and the person has a positive result, then he or she has “strep throat.” However, if that patient has a negative result, there is a 2% chance that the patient’s result is falsely negative, so the condition cannot be entirely ruled out.
Based on evidence from a population with specifc fndings, this probability specifes the prevalence of the condition in that population, or the probability that the patient has the condition on the basis of those fndings.
This is the probability that a positive test result will be associated with a person who has the target condition and a negative result will be associated with a healthy person. A likelihood ratio above 1.0 indicates that a positive result is associated with the disease; a likelihood ratio less than 1.0 indicates that a negative result is associated with an absence of the disease. Likelihood ratios that approximate 1.0 provide weak evidence for a test’s ability to identify individuals with or without a condition. Likelihood ratios above 1.0 or below 0.1 provide stronger evidence relative to the test’s predictive value. The ratio is used to determine the degree to which a test result will increase or decrease (from the pretest probability) the likelihood that an individual has a condition.
Table 1.2
Clinical Statistics
clinical reasoning. Of course, the process becomes increasingly more complex as multiple signs, symptoms, and diagnostic results are incorporated.
Reliable and valid basic statistics needed for evidence-based clinical reasoning are not always readily available. Even when available, they may not provide a valid representation of the situation at hand. Sources for the statistics include textbooks, primary reports of research, and published meta-analyses. Another source of statistics, the one that has been most widely used and available for application to the reasoning process, is the recall or estimation based on a provider’s experience, although these are rarely accurate. Over the past decade, the availability of evidence on which to base clinical reasoning is improving, and there is an increasing expectation that clinical reasoning be based on scientific evidence. Evidence-based statistics are also increasingly being used to develop resources to facilitate clinical decision making.
Clinical Decision-Making Resources
Clinical decision making begins when the patient first voices the reason for seeking care. Expert clinicians immediately compare their patients’ complaints with the “catalog” of knowledge that they have stored about a range of clinical conditions and then determine the direction of their initial history and symptom analysis. It is crucial that the provider not jump to conclusions or be biased by one particular finding; information is continually processed to inform decisions that guide further data collection and to begin to detect patterns in the data. Depending on the amount of experience in assessing other patients with the presenting complaint, a diagnostician uses varied systems through which information is processed and decisions are made. Trough experience, it is possible to see clusters or patterns in complaints and findings and compare against what is known of the potential common and urgent explanations for the findings. Experience and knowledge also provide specifics regarding the statistics associated with the various diagnostic options. However, experience is not always adequate to support accurate clinical decision making, and memory is not perfect. To assist in clinical decision making, a number of evidence-based resources have been developed to assist the clinician. Resources such as algorithms and clinical practice guidelines assist in clinical reasoning when properly applied.
Algorithms are formulas or procedures for problem-solving and include both decision trees and clinical prediction rules. Decision trees provide a graphical depiction of the decision-making process, showing the pathway based on findings at various steps in the process. A decision tree begins with a chief complaint or physical finding and then leads the diagnostician through a series of decision nodes. Each decision node or decision point provides a question or statement regarding the presence or absence of some clinical finding. Te response to each of these decision points determines the next step. (An example of a decision tree is provided in Fig. 13.5, which illustrates a decision-making process for amenorrhea.) Tese decision trees are helpful in identifying a logical sequence for the decisions involved in narrowing the differential diagnosis and providing
BOX 1.1
Online Sources of Medical Calculators
Essential Evidence Plus www.essentialevidenceplus.com
National Center for Emergency Medicine Informatics www.med.emory.edu/EMAC/curriculum/informatics.html
National Institutes of Health www.nih.gov
Note: Sites active as of May 13, 2018. Other subscription-based sites are also available.
description of their supporting evidence and the situations in which they should be applied.
Tese resources are not without limitations, and it is essential that they be applied in the situations for which they were intended. In applying these tools to clinical situations, it is essential that the diagnostician determine the population for which the tool was developed, ensure the tool is applicable to the case at hand, and have accurate data to consider in the tool’s application. For instance, a clinical prediction rule based on a population of young adult college students is not valid if applied to an elderly patient. Te provider must also recognize that these resources are intended to assist in the interpretation of a range of clinical evidence relevant to a particular problem, but they are not intended to take the place of clinical judgment, which rests with the provider.
The Diagnostic Process
As data is collected through the history and physical examination, providers tailor their approach to subsequent data collection. Tey begin to detect patterns that guide the development of a differential diagnosis that is based on an understanding of probability and prognosis. Tis means that conditions considered are those that most commonly cause the perceived cluster of data (probability) as well as conditions that may be less common but would require urgent detection and action (prognosis). When teaching health assessment, several adages are frequently used to encourage novice diagnosticians to always consider clinical explanations that are most likely to explain a patient’s situation. For instance, students often are told, “Common diseases occur commonly.” Most clinicians learn to use the term zebra to refer to less likely (and more rare) explanations for a presentation, adhering to the adage “When you hear hooves in Central Park, don’t look for zebras.” Both adages direct novices to consider the most likely explanation for a set of findings. Tis text describes common conditions that should be considered in the differential diagnosis of common complaints as well as some of the less common possibilities. With the emergence of conditions, zebras may well be responsible for findings, and providers must always maintain some level of suspicion for these less common explanations.
Even though it is appropriate that conditions with high probabilities be considered in the differential diagnosis, it is also vital in the diagnostic process to consider conditions that put the patient at highest risk. To do otherwise places the patient in jeopardy of life-threatening or disabling complications. Tese life-threatening situations are often referred to as red flags, which are clues signalling the high likelihood of an urgent situation requiring immediate identification and management. Tis text includes red flags for the various systems to promote their recognition in clinical practice.
Finally, as Chapter 2 on genomic assessment describes, some patients are at higher risk than others for certain conditions. Te ability to identify genetic patterns is becoming increasingly important as we learn more about the role genetics play in many diseases.
Common Diagnostic Errors
• Jumping to conclusions or being biased by an early finding (e.g., something in the patient’s medical history or recheck from a previous visit)
• Accepting previous diagnosis/explanation without exploring other possible explanations (e.g., diagnosis of chronic bronchitis as explanation of chronic cough in patient on angiotensin-converting enzyme [ACE] inhibitor)
• Using a shotgun approach to assessment without adequate focus
(Continued )
BOX 1.2—cont’d
• Focusing solely on the most obvious or likely explanation
• Relying solely on memory, which limits the diagnostician’s knowledge and options to only what is memorized or recalled
• Using the wrong rule, decision tree, or other resource to guide analysis or using the correct device incorrectly
• Performing skills improperly
• Misinterpreting or using wrong data
• Allowing the patient to make diagnosis (e.g., “I had sinusitis last year, and the symptoms are exactly the same.”)
• Allowing other health-care professionals to lead the diagnosis in the wrong direction
• Accepting the “horses” without contemplating the “zebras”; contemplating zebras without adequately pursuing the possibility of a more common condition
• Accommodating patient wishes against clinician judgment
• Ignoring basic findings, such as vital signs
• Failing to consider medical conditions as the source of “psychiatric” symptoms and psychiatric conditions as the source of “medical” symptoms
Summary
Te content of this book is directed toward assisting clinicians to adequately assess presenting complaints and then to consider reasonable explanations for the complaint and findings. For each complaint, a summary of the relevant history and physical assessment is provided, along with a list of conditions that should be considered in the differential diagnosis. Te lists of conditions are not exhaustive. However, by noting the possibility of those included, clinicians will consider various potential etiologies and, by weighing the likelihood of these options, begin to develop critical-thinking skills necessary for clinical decision making. Very brief descriptions of the possible findings for each of the conditions are listed to help guide the reader in recognizing definitive clusters of signs and symptoms. Above all, practice and experience provide the skills necessary for accurate diagnosis. Tese skills are supported by lifelong learning through which clinicians maintain an awareness of the highest level of evidence relative to assessment and diagnosis.
REFERENCES
Bernstein, L. (2017). 20 percent of patients with serious conditions are first misdiagnosed, study says. Te Washington Post, Retrieved from https://www.washingtonpost.com/national/health-science/20-percentof-patients-with-serious-conditions-are-first-misdiagnosed-study-says/2017/04/03/e386982a-189f-11e79887-1a5314b56a08_story.html?utm_term=.b0775c60f376 (accessed May 13, 2018). Croskerry, P. (2013). From mindless to mindful practice—Cognitive bias and clinical decision making. New England Journal of Medicine 368 (26), 2445–2448, doi: 10.1056/NEJMp1303712.
Chapter 2
Genomic Assessment: Interpreting Findings and Formulating Diferential Diagnoses
Ann Maradiegue • Diane Seibert • Karen Whitt •
Introduction
Significant advances in the field of genetics/genomics have taken place over the past decade. One of the most clinically relevant changes has been the shift toward precision medicine, defined by the National Institutes of Health (NIH) as “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle.” (U.S. National Library of Medicine, 2017h, p. 1). Precision medicine adds genomic information to the standard history, physical exam, and diagnostic findings to select more effective therapies or inform prevention strategies for an individual, rather than using the current “standard therapy” model of care. Advances in genomic information continue to transform the way health care is delivered. Studies are underway to examine how parents, clinicians, and health-care systems manage genomic information if a baby’s entire genomic profile were to be sequenced shortly after birth (Berg, et al., 2017).
Identifying the cause of diseases such as coronary artery disease, cancer, stroke, and diabetes is difficult because most common conditions are influenced by a combination of genetic and environmental factors (Muñoz, et al., 2016). Nurse practitioners (NPs) and other clinicians, therefore, need to have knowledge and skills to conduct an adequate genomic assessment, including obtaining and interpreting data, to identify individuals who are at increased risk or have symptoms of an inherited genetic disorder. Clinicians should be able to gather
a complete family health history (FHH), provide education and information about genetic inheritance patterns and conditions, offer genetic tests based on clinical practice settings, make appropriate referrals to genetic professionals, and tailor care based on genetic information (Greco, Tinley, & Seibert, 2012).
Several terms commonly used when conducting a genomic assessment or used when referring patients to genetic professionals are defined here; additional terms are described in Tables 2.1 and 2.2. Te World Health Organization (2017) defines genetics as the study of heredity, and genomics as the study of genes and their functions, noting that the primary difference between the two terms is that genomics describes the interaction of many genes and how their combined actions influence the growth and development of the organism. Genomic medicine
Selected Definitions Commonly Used in Genetics and Genomics
Genetic/Genomic Term Definition
Afected
Consanguinitya
De novo mutationsa
Expressivity (variable)a
Genesa
Geneticsa
Individual who manifests the disorder.
Related in descent by a common ancestor.
A new, spontaneous mutation (noninherited); alteration in a gene present for the frst time in the family member resulting from a germ cell mutation.
The range of clinical features observed in individuals with a particular disorder. Variable expressivity applies to disorders following all patterns of inheritance.
The functional and physical unit of heredity passed from parent to ofspring. There are approximately 20,000 to 25,000 genes in each cell of the human body.
The study of heredity, the process in which a parent passes certain genes onto their children, and how particular qualities of traits are transmitted from parents to ofspring; the study of single genes and their efects. A person’s appearance (e.g., height, hair color, skin color, and eye color) is determined by genes. Other characteristics, such as mental abilities, natural talents, and susceptibility to develop certain diseases, are also afected by heredity.
Genomea All the DNA contained in an organism or a cell, which includes both the chromosomes within the nucleus and the DNA in mitochondria.
Genomicsb The study of the functions and interactions of all the genes in the genome.
Mutationa
Pedigreec
A permanent structural alteration in DNA. In most cases, DNA changes either have no efect or cause harm, but occasionally a mutation can improve an organism’s chance of surviving and passing the benefcial change on to its descendants.
A graphic illustration of a family health history using standardized symbols. A genetic representation of a family tree that diagrams the inheritance of a trait or disease through several generations and shows relationships between members.
Penetrancea The proportion of individuals with a mutation causing a particular disorder who exhibit clinical symptoms of that disorder.
Phenotypea Observable traits or characteristics.
Probandc The afected individual by whom a family with a genetic disorder is ascertained.
aU.S. National Library of Medicine, 2017d; bNational Institute of Allergy and Infectious Diseases, 2009; cNational Human Genome Research Institute, n.d.
Table 2.1
Table 2.2
Definitions and Characteristics of Single-Gene Patterns of Inheritance
Term Definition
Autosomal dominant (AD)
Autosomal recessive (AR)
A gene on one of the autosomes that may be expressed even if only one copy is present.
Characteristics
50% chance of parental transmission; males and females afected; phenotype is observed in multiple or every generation with each afected person having an afected parent (vertical transmission on pedigree).
NOTE: Exceptions may be de novo variable expressivity; penetrance family structure, early onset of deaths, and gender-related conditions (e.g., breast and ovarian cancer syndromes) may not be observed in families with limited size or small number of females.
A genetic disorder that appears only in a patient who has received two copies of a gene mutation, one from each parent. Two genetic mutations on the autosomes.
X-linked dominant Genetic mutations located on the X chromosome requires only one copy for phenotype or disease in males or females.
X-linked recessive Genetic mutation located on the X chromosome requires both X chromosomes to be afected in females; males with afected gene will have the disorder.
Mitochondrial mtDNA Mutations located in the mitochondria inherited by the mother.
50% chance of the ofspring inheriting one gene mutation carrier; 25% chance of inheriting disease/phenotype; horizontal transmission on the pedigree proband may have afected siblings; none in parents (carriers), ofspring, or other relatives; males and females afected equally.
Disorders are rare, but most disorders are lethal in pregnancy with male fetus; no male-to-male transmission; there is no carrier state; afected males transmit to afected daughters only.
Typically males are afected (rare in females) with transmission from the mother (carrier); 50% of females will inherit the gene from their father and are unafected carriers; no male-to-male transmission.
All ofspring of afected females; none of the ofspring of afected males.
includes the use of genomic data when making diagnostic, prognostic, prevention, or therapeutic decisions (Manolio, et al., 2013). Genomic science, often referred to as omics-based medicine, includes the genome as well as concepts such as polymorphisms (small, and often silent, genetic “spelling differences”), the interactome (the totality of molecular interactions in an organism), and proteome (all the proteins) to name a few (BioLicense, 2013; Khoury, et al., 2007). Using omics-based medicine increases understanding of disease processes and advances disease prediction, prognosis, drug response (pharmacogenetic/pharmacogenomics), and offers the opportunity to personalize care (Redekop & Mladsi, 2013; Tanaka, 2010).
Tis chapter emphasizes assessment techniques such as collecting and interpreting the family history and using risk assessment to help NPs more rapidly and effectively identify patients who might be at increased risk for a genetic
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Title: The man in grey
Author: Baroness Emmuska Orczy Orczy
Release date: May 25, 2022 [eBook #68172] Most recently updated: July 3, 2022
Language: English
Original publication: United States: A. L. Burt Company, 1918
Credits: Al Haines
*** START OF THE PROJECT GUTENBERG EBOOK THE MAN IN GREY ***
The Man In Grey
Being Episodes of the Chovan Conspiracies in Normandy During the First Empire.
By BARONESS
ORCZY
AUTHOR OF "Lord Tony's Wife," "Leatherface" "The Bronze Eagle," etc.
A. L. BURT COMPANY
Publishers New York
Published by arrangement with GEORGE H. DORAN COMPANY
Copyright, 1918, By George H Doran Company
CONTENTS
PROEM
CHAPTER
I Silver-Leg
II The Spaniard
III The Mystery of Marie Vaillant
IV The Emeralds of Mademoiselle Philippa
V The Bourbon Prince
VI The Mystery of a Woman's Heart
VII The League of Knaves
VIII The Arrow Poison
IX The Last Adventure
THE MAN IN GREY
PROEM
It has been a difficult task to piece together the fragmentary documents which alone throw a light—dim and flickering at the best—upon that mysterious personality known to the historians of the Napoleonic era as the Man in Grey. So very little is known about him. Age, appearance, domestic circumstances, everything pertaining to him has remained a matter of conjecture—even his name! In the reports sent by the all-powerful Minister to the Emperor he is invariably spoken of as "The Man in Grey." Once only does Fouché refer to him as "Fernand."
Strange and mysterious creature! Nevertheless, he played an important part—the most important, perhaps—in bringing to justice some of those reckless criminals who, under the cloak of Royalist convictions and religious and political aims, spent their time in pillage, murder and arson.
Strange and mysterious creatures, too, these men so aptly named Chouans—that is, "chats-huants"; screech-owls—since they were a terror by night and disappeared within their burrows by day. A world of romance lies buried within the ruins of the châteaux which gave them shelter— Tournebut, Bouvesse, Donnai, Plélan. A world of mystery encompasses the names of their leaders and, above all, those of the women—ladies of high degree and humble peasants alike—often heroic, more often misguided, who supplied the intrigue, the persistence, the fanatical hatred which kept the fire of rebellion smouldering and spluttering even while it could not burst into actual flame. D'Aché, Cadoudal, Frotté, Armand le Chevallier, Marquise de Combray, Mme. Aquet de Férolles—the romance attaching to these names pales beside that which clings to the weird anonymity of their henchmen—"Dare-Death," "Hare-Lip," "Fear-Nought," "Silver-Leg," and so on. Theirs were the hands that struck whilst their leaders planned—they were the screech-owls who for more than twenty years terrorised the western provinces of France and, in the name of God and their King,
committed every crime that could besmirch the Cause which they professed to uphold.
Whether they really aimed at the restoration of the Bourbon kings and at bolstering up the fortunes of an effete and dispossessed monarchy with money wrung from peaceable citizens, or whether they were a mere pack of lawless brigands made up of deserters from the army and fugitives from conscription, of felons and bankrupt aristocrats, will for ever remain a bone of contention between the apologists of the old régime and those of the new.
With partisanship in those strangely obscure though comparatively recent episodes of history we have nothing to do. Facts alone—undeniable and undenied—must be left to speak for themselves. It was but meet that these men—amongst whom were to be found the bearers of some of the noblest names in France—should be tracked down and brought to justice by one whose personality has continued to be as complete an enigma as their own.
CHAPTER I
SILVER-LEG
"Forward now! And at foot-pace, mind, to the edge of the wood—or ——"
The ominous click of a pistol completed the peremptory command.
Old Gontran, the driver, shook his wide shoulders beneath his heavy caped coat and gathered the reins once more in his quivering hands; the door of the coach was closed with a bang; the postilion scrambled into the saddle; only the passenger who had so peremptorily been ordered down from the box-seat beside the driver had not yet climbed back into his place. Well! old Gontran was not in a mood to fash about the passengers. His horses, worried by the noise, the shouting, the click of firearms and the rough handling meted out to them by strange hands in the darkness, were very restive. They would have liked to start off at once at a brisk pace so as to leave these disturbers of their peace as far behind them as possible, but Gontran was holding them in with a firm hand and they had to walk—walk! —along this level bit of road, with the noisy enemy still present in their rear.
The rickety old coach gave a lurch and started on its way; the clanking of loose chains, the grinding of the wheels in the muddy roads, the snorting and travail of the horses as they finally settled again into their collars, drowned the coachman's muttered imprecations.
"A fine state of things, forsooth!" he growled to himself more dejectedly than savagely. "What the Emperor's police are up to no one knows. That such things can happen is past belief. Not yet six o'clock in the afternoon, and Alençon less than five kilomètres in front of us."
But the passenger who, on the box-seat beside him, had so patiently and silently listened to old Gontran's florid loquacity during the early part of the journey, was no longer there to hear these well-justified lamentations. No doubt he had taken refuge with his fellow-sufferers down below.
There came no sound from the interior of the coach. In the darkness, the passengers—huddled up against one another, dumb with fright and wearied with excitement—had not yet found vent for their outraged feelings in whispered words or smothered oaths. The coach lumbered on at foot-pace. In the affray the head-light had been broken; the two lanterns that remained lit up fitfully the tall pine trees on either side of the road and gave momentary glimpses of a mysterious, fairy-like world beyond, through the curtain of dead branches and the veil of tiny bare twigs.
Through the fast gathering gloom the circle of light toyed with the haze of damp and steam which rose from the cruppers of the horses, and issued from their snorting nostrils. From far away came the cry of a screech-owl and the call of some night beasts on the prowl.
Instinctively, as the road widened out towards the edge of the wood, Gontran gave a click with his tongue and the horses broke into a leisurely trot. Immediately from behind, not forty paces to the rear, there came the sharp detonation of a pistol shot. The horses, still quivering from past terrors, were ready to plunge once more, the wheelers stumbled, the leaders reared, and the team would again have been thrown into confusion but for the presence of mind of the driver and the coolness of the postilion.
"Oh! those accursed brigands!" muttered Gontran through his set teeth as soon as order was restored. "That's just to remind us that they are on the watch. Keep the leaders well in hand, Hector," he shouted to the postilion: "don't let them trot till we are well out of the wood."
Though he had sworn copiously and plentifully at first, when one of those outlaws held a pistol to his head whilst the others ransacked the coach of its contents and terrorised the passengers, he seemed inclined to take the matter philosophically now. After all, he himself had lost nothing; he was too wise a man was old Gontran to carry his wages in his breeches pocket these days, when those accursed Chouans robbed, pillaged and plundered rich and poor alike. No! Gontran flattered himself that the rogues had got nothing out of him: he had lost nothing—not even prestige, for it had been a case of twenty to one at the least, and the brigands had been armed to the teeth. Who could blame him that in such circumstances the sixty-two hundred francs, all in small silver and paper money—which the collector of taxes of the Falaise district was sending up to his chief at Alençon—had passed from the boot of the coach into the hands of that clever band of rascals?
Who could blame him? I say. Surely, not the Impérial Government up in Paris who did not know how to protect its citizens from the depredations of such villains, and had not even succeeded in making the high road between Caen and Alençon safe for peaceable travellers.
Inside the coach the passengers were at last giving tongue to their indignation. Highway robbery at six o'clock in the afternoon, and the evening not a very dark one at that! It were monstrous, outrageous, almost incredible, did not the empty pockets and ransacked valises testify to the scandalous fact. M. Fouché, Duc d'Otrante, was drawing a princely salary as Minister of Police, and yet allowed a mail-coach to be held up and pillaged—almost by daylight and within five kilomètres of the county town!
The last half-hour of the eventful journey flew by like magic: there was so much to say that it became impossible to keep count of time. Alençon was reached before everyone had had a chance of saying just what he or she thought of the whole affair, or of consigning M. le Duc d'Otrante and all his myrmidons to that particular chamber in Hades which was most suitable for their crimes.
Outside the "Adam et Ève," where Gontran finally drew rein, there was a gigantic clatter and din as the passengers tumbled out of the coach, and by the dim light of the nearest street lantern tried to disentangle their own belongings from the pile of ransacked valises which the ostlers had unceremoniously tumbled out in a heap upon the cobble stones. Everyone was talking—no one in especial seemed inclined to listen—anecdotes of former outrages committed by the Chouans were bandied to and fro.
Gontran, leaning against the entrance of the inn, a large mug of steaming wine in his hand, watched with philosophic eye his former passengers, struggling with their luggage. One or two of them were going to spend the night at the "Adam et Ève": they had already filed past him into the narrow passage beyond, where they were now deep in an altercation with Gilles Blaise, the proprietor, on the subject of the price and the situation of their rooms; others had homes or friends in the city, and with their broken valises and bundles in their hands could be seen making their way up the narrow main street, still gesticulating excitedly.
"It's a shocking business, friend Gontran," quoth Gilles Blaise as soon as he had settled with the last of his customers. His gruff voice held a distinct note of sarcasm, for he was a powerful fellow and feared neither footpads nor midnight robbers, nor any other species of those satané Chouans. "I
wonder you did not make a better fight for it. You had three or four male passengers aboard——"
"What could I do?" retorted Gontran irritably. "I had my horses to attend to, and did it, let me tell you, with the muzzle of a pistol pressing against my temple."
"You didn't see anything of those miscreants?"
"Nothing. That is——"
"What?"
"Just when I was free once more to gather the reins in my hands and the order 'Forward' was given by those impudent rascals, he who had spoken the order stood for a moment below one of my lanterns."
"And you saw him?"
"As plainly as I see you—except his face, for that was hidden by the wide brim of his hat and by a shaggy beard. But there is one thing I should know him by, if the police ever succeeded in laying hands on the rogue."
"What is that?"
"He had only one leg, the other was a wooden one."
Gilles Blaise gave a loud guffaw. He had never heard of a highwayman with a wooden leg before. "The rascal cannot run far if the police ever do get after him," was his final comment on the situation.
Thereupon Gontran suddenly bethought himself of the passenger who had sat on the box-seat beside him until those abominable footpads had ordered the poor man to get out of their way.
"Have you seen anything of him, Hector?" he queried of the postilion.
"Well, now you mention him," replied the young man slowly, "I don't remember that I have."
"He was not among the lot that came out of the coach."
"He certainly was not."
"I thought when he did not get back to his seat beside me, he had lost his nerve and gone inside."
"So did I."
"Well, then?" concluded Gontran.
But the puzzle thus propounded was beyond Hector's powers of solution. He scratched the back of his head by way of trying to extract thence a key to the enigma.
"We must have left him behind," he suggested.
"He would have shouted after us if we had," commented Gontran. "Unless——" he added with graphic significance.
Hector shook himself like a dog who has come out of the water. The terror of those footpads and of those pistols clicking in the dark, unpleasantly close to his head, was still upon him.
"You don't think——" he murmured through chattering teeth.
Gontran shrugged his shoulders.
"It won't be the first time," he said sententiously, "that those miscreants have added murder to their other crimes."
"Lost one of your passengers, Gontran?" queried Gilles Blaise blandly.
"If those rogues have murdered him——" quoth Gontran with an oath.
"Then you'd have to make a special declaration before the chief commissary of police, and that within an hour. Who was your passenger, Gontran?"
"I don't know. A quiet, well-mannered fellow. Good company he was, too, during the first part of the way."
"What was his name?"
"I can't tell. I picked him up at Argentan. The box-seat was empty. No one wanted it, for it was raining then. He paid me his fare and scrambled up beside me. That's all I know about him."
"What was he like? Young or old?"
"I didn't see him very well. It was already getting dark," rejoined Gontran impatiently. "I couldn't look him under the nose, could I?"
"But sacrebleu! Monsieur le Commissaire de Police will want to know something more than that. Did you at least see how he was dressed?"
"Yes," replied Gontran, "as far as I can recollect he was dressed in grey."
"Well, then, friend Gontran," concluded Gilles Blaise with a jovial laugh, "you can go at once to Monsieur le Commissaire de Police, and you can tell him that an industrious Chouan, who has a wooden leg and a shaggy beard but whose face you did not see, has to the best of your belief murdered an unknown passenger whose name, age and appearance you know nothing about, but who, as far as you can recollect, was dressed in grey—— And we'll see," he added with a touch of grim humour, "what Monsieur le Commissaire will make out of this valuable information."
II
The men were cowering together in a burrow constructed of dead branches and caked mud, with a covering of heath and dried twigs. Their heads were close to one another and the dim light of a dark lanthorn placed upon the floor threw weird, sharp shadows across their eager faces, making them appear grotesque and almost ghoulish—the only bright spots in the surrounding gloom.
One man on hands and knees was crouching by the narrow entrance, his keen eyes trying to pierce the density of the forest beyond.
The booty was all there, spread out upon the damp earth—small coins and bundles of notes all smeared with grease and mud; there were some trinkets, too, but of obviously little value: a pair of showy gold ear-rings, one or two signets, a heavy watch in a chased silver case. But these had been contemptuously swept aside—it was the money that mattered.
The man with the wooden leg had counted it all out and was now putting coins and notes back into a large leather wallet.
"Six thousand two hundred and forty-seven francs," he said quietly, as he drew the thongs of the wallet closely together and tied them securely into a knot. "One of the best hauls we've ever had. 'Tis Madame who will be pleased."
"Our share will have to be paid out of that first," commented one of his companions.
"Yes, yes!" quoth the other lightly. "Madame will see to it. She always does. How many of you are there?" he added carelessly.
"Seven of us all told. They were a pack of cowards in that coach."
"Well!" concluded the man with the wooden leg, "we must leave Madame to settle accounts. I'd best place the money in safety now."
He struggled up into a standing position—which was no easy matter for him with his stump and in the restricted space—and was about to hoist the heavy wallet on to his powerful shoulders, when one of his mates seized him by the wrist.
"Hold on, Silver-Leg!" he said roughly, "we'll pay ourselves for our trouble first. Eh, friends?" he added, turning to the others.
But before any of them could reply there came a peremptory command from the man whom they had called "Silver-Leg."
"Silence!" he whispered hoarsely. "There's someone moving out there among the trees."
At once the others obeyed, every other thought lulled to rest by the sense of sudden danger. For a minute or so every sound was hushed in the narrow confines of the lair save the stertorous breathing which came from panting throats. Then the look-out man at the entrance whispered under his breath:
"I heard nothing."
"Something moved, I tell you," rejoined Silver-Leg curtly. "It may only have been a beast on the prowl."
But the brief incident had given him the opportunity which he required; he had shaken off his companion's hold upon his wrist and had slung the wallet over his shoulder. Now he stumped out of the burrow.
"Friend Hare-Lip," he said before he went, in the same commanding tone wherewith he had imposed silence awhile ago on his turbulent mates, "tell Monseigneur that it will be 'Corinne' this time, and you, Mole-Skin, ask Madame to send Red-Poll over on Friday night for the key."
The others growled in assent and followed him out of their hiding-place. One of the men had extinguished the lanthorn, and another was hastily collecting the trinkets which had so contemptuously been swept aside.
"Hold on, Silver-Leg!" shouted the man who had been called Hare-Lip; "short reckonings make long friends. I'll have a couple of hundred francs now," he continued roughly. "It may be days and weeks ere I see Madame again, and by that time God knows where the money will be."
But Silver-Leg stumped on in the gloom, paying no heed to the peremptory calls of his mates. It was marvellous how fast he contrived to hobble along, winding his way in and out in the darkness, among the trees, on the slippery carpet of pine needles and carrying that heavy wallet—six thousand two hundred francs, most of it in small coin—upon his back. The others, however, were swift and determined, too. Within the next minute or two they had overtaken him, and he could no longer evade them; they held
him tightly, surrounding him on every side and clamouring for their share of the spoils.
"We'll settle here and now, friend Silver-Leg," said Hare-Lip, who appeared to be the acknowledged spokesman of the malcontents. "Two hundred francs for me out of that wallet, if you please, ere you move another step, and two hundred for each one of us here, or——"
The man with the wooden leg had come to a halt, but somehow it seemed that he had not done so because the others held and compelled him, but because he himself had a desire to stand still. Now when Hare-Lip paused, a world of menace in every line of his gaunt, quivering body, Silver-Leg laughed with gentle irony, as a man would laugh at the impotent vapourings of a child.
"Or what, my good Hare-Lip?" he queried slowly.
Then as the other instinctively lowered his gaze and mumbled something between his teeth, Silver-Leg shrugged his shoulders and said with kind indulgence, still as if he were speaking to a child:
"Madame will settle, my friend. Do not worry. It is bad to worry. You remember Fear-Nought: he took to worrying—just as you are doing now— wanted to be paid out of his turn, or more than his share, I forget which. But you remember him?"
"I do," muttered Hare-Lip with a savage oath. "Fear-Nought was tracked down by the police and dragged to Vincennes, or Force, or Bicêtre—we never knew."
To the guillotine, my good Hare-Lip," rejoined Silver-Leg blandly, "along with some other very brave Chouans like yourselves, who also had given their leaders some considerable trouble."
"Betrayed by you," growled Hare-Lip menacingly.
"Punished—that's all," concluded Silver-Leg as he once more turned to go.
"Treachery is a game at which more than one can play."
"The stakes are high. And only one man can win," remarked Silver-Leg dryly.
"And one man must lose," shouted Hare-Lip, now beside himself with rage, "and that one shall be you this time, my fine Silver-Leg. À moi, my mates!" he called to his companions.
And in a moment the men fell on Silver-Leg with the vigour born of terror and greed, and for the first moment or two of their desperate tussle it seemed as if the man with the wooden leg must succumb to the fury of his assailants. Darkness encompassed them all round, and the deep silence which dwells in the heart of the woods. And in the darkness and the silence these men fought—and fought desperately—for the possession of a few hundred francs just filched at the muzzle of a pistol from a few peaceable travellers.
Pistols of course could not be used; the police patrols might not be far away, and so they fought on in silence, grim and determined, one man against half a dozen, and that one halt, and weighted with the spoils. But he had the strength of a giant, and with his back against a stately fir tree he used the heavy wallet as a flail, keeping his assailants at arm's length with the menace of death-dealing blows.
Then, suddenly, from far away, even through the dull thuds of this weird and grim struggle, there came the sound of men approaching—the click of sabres, the tramp and snorting of horses, the sense of men moving rapidly even if cautiously through the gloom. Silver-Leg was the first to hear it.
"Hush!" he cried suddenly, and as loudly as he dared, "the police!"
Again, with that blind instinct born of terror and ever-present danger, the others obeyed. The common peril had as swiftly extinguished the quarrel as greed of gain had fanned it into flame.
The cavalcade was manifestly drawing nearer.
"Disperse!" commanded Silver-Leg under his breath. "Clear out of the wood, but avoid the tracks which lead out of it, lest it is surrounded. Remember 'Corinne' for Monseigneur, and that Red-Poll can have the key for Madame on Friday."
Once again he had made use of his opportunity. Before the others had recovered from their sudden fright, he had quietly stumped away, and in less than five seconds was lost in the gloom among the trees. For a moment or two longer an ear, attuned by terror or the constant sense of danger, might have perceived the dull, uneven thud of his wooden leg against the soft carpet of pine needles, but even this soon died away in the distance, and over the kingdom of darkness which held sway within the forest there fell once more the pall of deathlike silence. The posse of police in search of human quarry had come and gone, the stealthy footsteps of tracked criminals had ceased to resound from tree to tree; all that could be heard was the occasional call of a night-bird, or the furtive movement of tiny creatures of the wild.
Silence hung over the forest for close upon an hour. Then from behind a noble fir a dark figure detached itself and more stealthily, more furtively than any tiny beast it stole along the track which leads to the main road. The figure, wrapped in a dark mantle, glided determinedly along despite the difficulties of the narrow track, complicated now by absolute darkness. Hours went by ere it reached the main road, on the very spot where some few hours ago the mail-coach had been held up and robbed by a pack of impudent thieves. Here the figure halted for awhile, and just then the heavy rain clouds, which had hung over the sky the whole evening, slowly parted and revealed the pale waning moon. A soft light gradually suffused the sky and vanquished the impenetrable darkness.
Not a living soul was in sight save that solitary figure by the roadside—a man, to all appearances, wearing a broad-brimmed hat casting a deep shadow over his face; the waning moon threw a cold light upon the grey mantle which he wore. On ahead the exquisite tower of the church of Notre Dame appeared vague and fairylike against the deep sapphire of the horizon far away. Then the solitary figure started to walk briskly in the direction of the city.
III
M. le Procureur Impérial, sitting in his comfortable armchair in the wellfurnished apartment which he occupied in the Rue St. Blaise at Alençon, was surveying his visitor with a quizzical and questioning gaze.
On the desk before him lay the letter which that same visitor had presented to him the previous evening—a letter penned by no less a hand than that of M. le Duc d'Otrante himself, Minister of Police, and recommending the bearer of this august autograph to the good will of M. de Saint-Tropèze, Procureur Impérial at the tribunal of Alençon. Nay, more! M. le Ministre in that same autograph letter gave orders, in no grudging terms, that the bearer was to be trusted implicitly, and that every facility was to be given him in the execution of his duty: said duty consisting in the tracking down and helping to bring to justice of as many as possible of those saucy Chouans who, not content with terrorising the countryside, were up in arms against the government of His Impérial Majesty.
A direct encroachment this on the rights and duties of M. le Procureur Impérial; no wonder he surveyed the quiet, insignificant-looking individual before him, with a not altogether benevolent air.
M. le préfet sitting on the opposite side of the high mantelpiece was discreetly silent until his chief chose to speak.
After a brief while the Procureur Impérial addressed his visitor.
"Monsieur le Duc d'Otrante," he said in that dry, supercilious tone which he was wont to affect when addressing his subordinates, "speaks very highly of you, Monsieur—Monsieur— By the way, the Minister, I perceive, does not mention your name. What is your name, Monsieur?"
"Fernand, Monsieur le Procureur," replied the man.
