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Fourth Edition

Copyright © 2018 Wolters Kluwer.

Copyright © 2012, 1997, 1992 Wolters Kluwer Health / Lippincott Williams & Wilkins. All
rights reserved. This book is protected by copyright. No part of this book may be reproduced or
transmitted in any form or by any means, including as photocopies or scanned-in or other
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987654321

Printed in China

Library of Congress Cataloging-in-Publication Data

Names: Kawamura, Diane M., editor. | Nolan, Tanya D., editor.

Title: Diagnostic medical sonography. Abdomen and superficial structures /
[edited by] Diane M. Kawamura, Tanya D. Nolan.
Other titles: Abdomen and superficial structures
Description: Fourth edition. | Philadelphia : Wolters Kluwer Health, 2018. |
Includes bibliographical references and index.
Identifiers: LCCN 2017024239 | eISBN 9781496354938
Subjects: | MESH: Abdomen—diagnostic imaging | Ultrasonography—methods |
Digestive System—diagnostic imaging | Urogenital System—diagnostic imaging
Classification: LCC RC944 | NLM WI 900 | DDC 617.5/507543—dc23 LC record available at
https://lccn.loc.gov/2017024239

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examination of each patient and consideration of, among other things, age, weight, gender,
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 To my late husband, Bryan, who provided me with confidence and who
always supported my professional endeavors. This edition was harder
without my favorite companion and best friend. To our wonderful
children, Stephanie and Nathan, who continue to inspire me to appreciate
how important it is to learn new things and to enjoy learning. To all my
colleagues on campus and in the profession who provide encouragement,
support, and stimulating new challenges.
—DIANE M. KAWAMURA

To my husband and best friend, Trent, whose unconditional love and

encouragement has sustained me through every challenge and enriched
my life’s journey. To my amazing children, Joseph, Ethan, and Spencer,
for inspiring me to become a better person and for filling my dreams
with hope and joy. To my many colleagues, for giving me the strength
and motivation to aim high, learn more, and be determined to the end.
—TANYA D. NOLAN

And to students and professionals who will use this book:

“Any piece of knowledge I acquire today has a value at this moment
exactly proportioned to my skill to deal with it. Tomorrow, when I know
more, I recall that piece of knowledge and use it better.”—Mark Van
Doren, Liberal Education (1960)
—DIANE M. KAWAMURA, TANYA D. NOLAN
 CONTRIBUTORS

Monica M. Bacani
Retired Status with ARDMS
Retired Pediatric Sonographer
Columbus, Ohio

Sara M. Baker, MEd, RT(R), RDMS, RVT, RMSKS

Senior Sonographer
University of Wisconsin Hospital and Clinics
Madison, Wisconsin

Teresa M. Bieker, MBA, RT, RDMS, RDCS, RVT

Lead Sonographer
Division of Ultrasound and Prenatal Diagnosis
University of Colorado Hospital
Aurora, Colorado

Joie Burns, MS, RT(R)(S), RDMS, RVT

Sonography Program Director
Associate Professor
Boise State University
Boise, Idaho

Catherine Carr-Hoefer, CRA, RT(R), RDMS, RDCS, RVT

Diagnostic Imaging Manager
Samaritan North Lincoln Hospital
Lincoln City, Oregon

M. Robert De Jong, RDMS, RDCS, RVT, FSDMS, FAIUM

Radiology Technical Manager, Ultrasound
Johns Hopkins Medical Institutions
Baltimore, Maryland

Kevin D. Evans, PhD, RT(R)(M)(BD), RDMS, RVS, FSDMS

Professor
School of Health & Rehabilitation Sciences
The Ohio State University
Columbus Ohio

Alyssa Frederick, BS, RT(R), RDMS, RVT

Clinical Instructor
Ultrasound Technologist
Primary Children’s Medical Center
Salt Lake City, Utah

Tim S. Gibbs, BSDMS, RT(R), RDMS, RVT, CTNM

Ultrasound Supervisor
West Anaheim Medical Center
Anaheim, California

Sasha P. Gordon, BS, RDMS, RVT

Clinical Instructor/Pediatric Ultrasound Educator
Primary Children’s Medical Center
Salt Lake City, Utah

Barbara Hall-Terracciano, BS, RT(R), RDMS

Clinical Sonographer
Author/Editor
St. George, Utah

Charlotte Henningsen, MS, RT(R), RDMS, RVT, FSDMS, FAIUM

Associate Vice President
Faculty Development in Teaching & Learning
Director and Professor
Center for Advanced Ultrasound Education
Adventist University of Health Sciences
Orlando, Florida
Terri L. Jurkiewicz, MS, RT(R)(M), RDMS, RVT
Adjunct Faculty
Department of Radiologic Sciences
Weber State University
Ogden, Utah

Diane M. Kawamura, PhD, RT(R), RDMS, FSDMS, FAIUM

Brady Presidential Distinguished Professor
Department of Radiologic Sciences
Weber State University
Ogden, Utah

George M. Kennedy-Antillon, AS, RT(R), RDMS, RDCS, RVT

Clinical Instructor
Department of Ultrasound
University of Colorado Hospital
Aurora, Colorado

Darla Matthew, BAS, RT(R)(S), RDMS

Associate Professor/Program Director
Diagnostic Medical Sonogrpahy
Doña Ana Community College
Las Cruces, New Mexico

J. P. Moreland, BS, RT(R)(CT), RDMS, RVS

Product Manager
Radiology/Vascular Ultrasound
Samsung Healthcare America
San Francisco, California

Tanya D. Nolan, EdD, RT(R), RDMS

Associate Professor
Department of Radiologic Sciences
Weber State University
Ogden, Utah

Rechelle A. Nguyen, RDMS

Clinical Sonographer
Department of Ultrasound
Nationwide Children’s Hospital
Columbus, Ohio

Aubrey J. Rybyinski, BS, RDMS, RVT

Lead Technologist/Technical Director
Navix Diagnostix
Taunton, Massachusetts

Kellie A. Schmidt, BS, RDMS, RVT, RDCS

Clinical Instructor
Division of Ultrasound and Prenatal Diagnosis
University of Colorado Hospital
Aurora, Colorado

Dana C. Walker, BS, RDMS, RVT

Radiology Manager—Ultrasound
University of Wisconsin Hospitals and Clinics
Madison, Wisconsin

Michelle Wilson, EdD, RDMS, RDCS

Clinical Sonographer/Educator
Kaiser Permanente
Napa, California

REVIEWERS

Brent Bereska, ARDMS, RDMS, RDCS

Sonography Canada: CRGS, CRCS
Northern Alberta Institute of Technology
Edmonton, Canada
Visit https://testbankfan.com
now to explore a rich
collection of testbank or
solution manual and enjoy
exciting offers!
Martie Grant, ARDMS
General and Cardiac and Breast Sonography Canada: Generalist and
Cardiac
Northern Alberta Institute of Technology
Edmonton, Canada

Dwight Gunter, BS, RDMS

Cambridge College of Healthcare and Technology
Atlanta, Georgia

Kellee Stacks, BS, RTR, RDMS, RVT

Cape Fear Community College
Wilmington, North Carolina

Stacey Rider, RDMS (Abdomen, OB/Gyn, Breast), RVT, RDCS

(Adult Echo)
Keiser University
Ft. Lauderdale, Florida
 PREFACE

T he fourth edition of Diagnostic Medical Sonography: Abdomen and

Superficial Structures is updated to reflect the major developments
that have occurred since the last edition. Educators and colleagues
encouraged us to produce a fourth edition to incorporate new advances
used to image, to refresh the foundational content, and to continue to
provide information that recognizes readers have diverse backgrounds
and experiences. The result is a textbook that can be used as either an
introduction to the profession or a reference for the profession. The
content lays the foundation for a better understanding of anatomy,
physiology, and pathophysiology to enhance the caregiving role of the
sonographer practitioner, sonographer, sonologist, or student when
securing the imaging information on a patient.
The first chapter introduces terminology on anatomy, scanning planes,
and patient positions. Adopting universal terminology permits every
sonographer to communicate consistent information on how he or she
positioned the patient, how he or she scanned the patient, and how
anatomy and pathology are sonographically represented.
The next four sections are divided into specific content areas. Doing
this allowed the contributors to focus their attention on a specific organ
or system. This simulates application in that while scanning, the
sonographer investigates the organ or system, moves systematically to
the next organ or system, and completes the examination by synthesizing
all the information to obtain the total picture.
We made every attempt to produce an up-to-date and factual textbook
while presenting the material in an interesting and enjoyable format to
capture the reader’s attention. To do this, we provided detailed
descriptions of anatomy, physiology, pathology, and the normal and
abnormal sonographic representation of these anatomic and pathologic
entities with illustrations, summary tables, and images, many of which
include valuable case study information.
Our goal is to present as complete and up-to-date a text as possible,
while recognizing that by tomorrow, the textbook must be supplemented
with new information reflecting the dynamic sonography profession.
With every technologic advance made in equipment, the sonographer’s
imagination must stretch to create new applications. With the
comprehensive foundation available in this book, the sonographer can
meet that challenge.

Diane M. Kawamura
Tanya D. Nolan
 ACKNOWLEDGMENTS

A special recognition to Bridgette Lunsford, co-editor of the third

edition. As a sonographer, educator, and author, Bridgette’s
contributions made it possible to have made the giant leap that occurred
between the second and the third editions. While preparing the fourth
edition, we appreciated the support, ideas, and collaboration of Anne
Marie Kupinski, Susan Stephenson, and Julia Dmitrieva as we worked
on the three volumes of Diagnostic Medical Sonography. Their input and
ideas were a significant contribution to the project.
Our thanks and gratitude go to all the contributors of the fourth edition
who gave of their expertise, time, and energy, updating the content with
current information to use in obtaining a more accurate imaging
examination for our patients.
The image contributions became treasured moments. We thank the
many sonographers and physicians for their assistance. A special thank
you and recognition for ongoing support in image acquisition goes to
Taco Geertsma, MD, Ede, the Netherlands, at Ultrasoundcases.info and
Siemens Medical Solutions USA, Inc. Thank you to the contributors of
the third edition: Philips Medical Systems, Bothell, Washington; GE
Healthcare, Wauwatosa, Wisconsin; Joe Anton, MD, Cochin, India; Dr.
Nakul Jerath, Falls Church, Virginia; and Monica Bacani and Rechelle
Nguyen at Nationwide Children’s Hospital in Columbus, Ohio.
Many thanks to all the production team at Wolters Kluwer, who helped
edit, produce, promote, and deliver this textbook. We especially thank in
the development of this edition Jay Campbell, acquisitions editor; Heidi
Grauel, freelance product manager; Jennifer Clements, art director; and
John Larkin, Editorial Coordinator, for their patience, follow-through,
support, and encouragement.
To our colleagues, students, friends, and family, who provide
continued sources of encouragement, enthusiasm, and inspiration—thank
you.

Diane M. Kawamura
Tanya D. Nolan
Random documents with unrelated
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added. “We can have a nice afternoon together, anyway. You can
finish reading that story aloud, and we’ll go out and take a good look
at the garden. I think the beans were planted too close under the
pear tree last year—that was the reason they didn’t come up right.
Edith Barnes and Alan Wilson are coming out from town after dinner
for the rest of the day, but that won’t make any difference to us.”
“What?”
“Now Herbert, how could I help asking them? You know the
boarding house she and her mother live in. Edith never gets a
chance to see him alone. They’re saving up now to get married—
they’ve been engaged a year—so he can’t spend any more money
for theaters and things, and they just have to walk and walk the
streets, unless they go visiting, and they’ve been almost everywhere,
Edith says. She wrote and asked me to have them for this Sunday;
he’s been away for a whole week somewhere up in the State. I think
it’s pathetic.” In the warmth of explanation Mrs. Belmore had
unwittingly removed the pile of newspapers from the floor to an
ottoman at the further end of the room. “Edith says she knows it’s
the happiest time of their lives, and she does want to get some of
the benefit of it, poor girl.”
“What do they want to be engaged for, anyway?”
“Herbert! How ridiculous! You are the most unreasonable man at
times for a sensible one that I ever laid my eyes on. Why did we
want to be engaged?”
“That was different.” Mr. Belmore’s tone conveyed a permanent
satisfaction with his own case. “If every woman were like you, petty
—I never could stand Edith, she’s one of your clever girls; there’s
something about her that always sets my teeth on edge. As for
Wilson—oh, Wilson’s just a usual kind of a fool, like myself. Hello,
where are my newspapers—and what in thunder makes it so cold?
You don’t mean to say you’ve got the window open?”
Mrs. Belmore had a habit of airing the rooms in the morning,
which her husband approved of theoretically, and combated
intensely in practice. After the window was banged shut she could
hear him rattling at the furnace below to turn on an extra flow of
heat before settling down once more in comfort. Although the April
sun was bright, there was still a chill in the air.
She looked in upon him, gowned and bonneted for church, sweet
and placid of mien, followed by two little girls, brave in their Sunday
best, all big hats and ribboned hair, and little starchy ruffles showing
below their brown coats. Mrs. Belmore stooped over her husband’s
chair to kiss him good-by.
“You won’t have to talk to Edith and Alan at all,” she said as if
continuing the conversation from where they had left off. “All we
have to do is to let them have the parlor or the library. They’ll
entertain each other.”
“Oh, don’t you bother about that. Now go ahead or you’ll be late,
and don’t forget to say your prayers for me, too. That’s right, always
go to church with your mother, girlies.”
“I wish you were going, too.” Mrs. Belmore looked at her husband
lingeringly.
“I wish I were, petty,” said Mr. Belmore with a prompt mendacity
so evidently inspired by affection that his wife condoned it at once.
She thought of him more than once during the service with
generous satisfaction in his comfortable morning. She wished she
had thought it right to remain at home, too, as she did sometimes,
but there were the children to be considered. But she and Herbert
would have the afternoon together, and take part of it to see about
planting the garden, a plot twenty feet square in the rear of the
suburban villa.
The Sunday visit to the garden was almost a sacrament. They
might look at it on other days, but it was only on Sunday, beginning
with the early spring, that husband and wife strolled around the little
patch together, first planning where to start the summer crop of
vegetables and afterwards watching the green things poking their
spikes up through the mold, and growing, growing. He did the
planting and working in the long light evenings after he came home,
while she held the papers of seeds for him, but it was only on
Sunday that he could really watch the green things grow, and learn
to know each separate leaf intimately, and count the blossoms on
the beans and the cucumbers. From the pure pleasure of the first
radish, through all the various wiltings and shrivelings incident to
amateur gardening in summer deluge and drought, to the
triumphant survival of tomato plants and cucumber vines, running
riot over everything in the fall of the year, the little garden played its
old part as paradise to these two, who became more fully one in the
watching of the miracle of growth. When they gathered the pears
from the little tree in the corner of the plot, before the frost, and
picked the few little green tomatoes that remained on the dwindling
stems, it was like garnering a store of peaceful happiness. Every
stage of the garden was a romance. Mrs. Belmore could go to
church without her husband, but to have him survey the garden
without her would have been the touch beyond.
It must be horrid, anyway, she thought, to have to go every
morning into town in those smoky cars and crowded ferry-boats;
just to run into town twice a week tired her out. Now he would have
finished the paper—now little Dorothy would have come in, red
cheeked from her walk, to kiss daddy before her nap—now he must
be pottering around among his possessions and looking out for her.
She knew so well how he would look when he came to the door to
meet her. The sudden sight of either one to the other always shed a
reflected light, like the glow of the sun. It was with a feeling of
wonder that she marked its disappearance, after a brief gleam, as
he not only opened the door, but came out on the piazza to greet
her, and closed it behind him.
“They’re in there—Edith and Alan.” He pointed over his shoulder
with his thumb. “I thought they weren’t coming until after dinner.”
“Why, they weren’t.”
“Well, they’re in the parlor, just the same. Came out over an hour
ago. Great Scott, I wished I’d gone with you. I’m worn out.”
 “You don’t mean to say you’ve stayed with them all the time!” Mrs.
Belmore looked scandalized.
“I should say I had; I couldn’t lose ’em. Whichever room I went to
they followed; at least, she did, and he came after. I went from pillar
to post, I give you my word, petty, but Edith had me by the neck;
she never let go her grip for an instant. They won’t speak to each
other, you see, only to me. I haven’t had a chance to even finish the
paper. I’ve had the deuce of a time! I don’t know what you are going
to do about it.”
“Never mind, it will be all right now,” said Mrs. Belmore
reassuringly. She pushed past him into the parlor where sat a tall,
straight girl with straight, light brows, a long straight nose, and a
straight mouth with a droop at the corners. In the room beyond, a
thick set, dark young man with glasses and a nervous expression
was looking at pictures. It did not require a Solomon to discover at a
glance how the land lay.
If Mrs. Belmore had counted easily on her powers of conciliation
she was disappointed this time. After the dinner, whereat the
conversation was dragged laboriously around four sides of a square,
except when the two little girls made some slight diversion, and the
several futile attempts when the meal was over to leave the lovers
alone together, Mrs. Belmore resigned herself, perforce, to the loss
of her cherished afternoon.
“It’s no use, we’ll have to give up the reading,” she said to her
husband rapidly, in one of her comings and goings. “Perhaps later,
dear. But it’s really dreadful, here we’ve been talking of religion and
beet-root sugar and smallpox, when anyone can see that her heart is
breaking.”
“I think he is getting the worst of it,” said Mr. Belmore impartially.
“Oh, it won’t hurt him.”
“Well, you’ve given them plenty of opportunities to make up.”
“Yes, but he doesn’t know how.”
 She added in a louder tone, “You take Mr. Wilson up to your den
for a while, Herbert, Ethel and I are going to have a cozy little time
with the children, aren’t we, dear?”
“Have a cigar?” said Mr. Belmore as the two men seated
themselves comfortably in a couple of wooden armchairs in the
sunny little apartment hung with a miscellaneous collection of guns,
swords, and rods, the drawing of a bloated trout and a dusty pair of
antlers.
“Thank you, I’m not smoking now,” said Mr. Wilson with a hungry
look at the open box on the table beside him.
“Oh!” said his host genially, “so you’re at that stage of the game.
Well, I’ve been there myself. You have my sympathy. But this won’t
last, you know.”
“Does your wife like smoking?”
“Loves it,” said Mr. Belmore, sinking the fact of his official limit to
four cigars a day. “That is, of course, she thinks it’s a dirty habit, and
unhealthy, and all that sort of thing, you know, but it doesn’t make
any difference to her—not a pin’s worth. Cheer up, old fellow, you’ll
get to this place too.”
“Looks like it,” said the other bitterly. “Here I haven’t seen her for
a week—I came two hundred miles on purpose yesterday, and now
she won’t even look at me. I don’t know what’s the matter—haven’t
the least idea—and I can’t get her to tell me. I have to be off to-
morrow at seven o’clock, too—I call it pretty hard lines.”
“Let me see,” said Mr. Belmore judicially, knitting his brows as if
burrowing into the past as he smoked. “Perhaps I can help you out.
What have you been writing to her? Telling her all about what you’ve
been doing, and just sending your love at the end? They don’t like
that, you know.”
Mr. Wilson shook his head. “No, upon my soul I’ve done nothing
but tell her how I—how I was looking forward to—oh, hang it,
Belmore, the letters have been all right, I know that.”
 “H’m,” said Mr. Belmore, “there’s got to be something back of it,
you know. Seen any girls since you’ve been gone?”
Mr. Wilson hastened to shake his head more emphatically than
before. “Not one,” he asseverated with the relief of complete
innocence. “Didn’t even meet a soul I knew, except Brower—you
remember Dick Brower? I went into a jeweler’s to get my glasses
mended and found him buying a souvenir spoon for his fiancée.”
“O—o—h!” said Mr. Belmore intelligently, “and did you buy a
present for Edith?”
“No, I didn’t. She made me promise not to buy anything more for
her; she thinks I’m spending too much money, and that I ought to
economize.”
“And did you tell her about Brower?”
“Why, of course I did—as we were coming out this morning.”
Mr. Wilson stared blankly at his friend.
“Chump!” said Mr. Belmore. He bit off the end of a new cigar and
threw it away. “Wilson, my poor fellow, you’re so besotted in
ignorance that I don’t know how to let the light in on you. A man is
a fool by the side of his fiancée, anyhow.”
“I don’t know what you mean,” said the bewildered Wilson stiffly.
“I don’t know what I’m to do.”
“No, of course you don’t—but Edith does—you can just trust her
for that. A girl always knows what a man ought to do—she can give
him cards and spades and beat him every time.”
“Then why doesn’t she tell me what she wants? I asked her to,
particularly.”
“Oh, no! She’ll tell you everything the opposite—that is, half the
time. She’ll put every obstacle possible in your way, to see if you’re
man enough to walk over ’em; that’s what she wants to find out; if
you’re man enough to have your own way in spite of her; and, of
course, if you aren’t, you’re an awful disappointment.”
 “Are you sure?” said Mr. Wilson deeply, after an awestruck pause.
“Half the time, you say. But how am I to find out when she means—
I give you my word, Belmore, that I thought—I suppose I could have
brought her a small present, anyway, in spite of what she said; a
souvenir spoon—but she hates souvenir spoons.”
“You’ll have to cipher it out for yourself, old man,” said Mr.
Belmore. “I don’t set out to interpret any woman’s moods. I only
give you cold, bare facts. But if I were you,” he added impartially,
“I’d go down after a while and try and get her alone, you know, and
say something. You can, if you try.” A swish of skirts outside of the
open door made Mr. Wilson jump forward as Mrs. Belmore came in
sight with her friend. The latter had her arm around the older
woman, and her form drooped toward her as they passed the two
men. The eyes of the girl were red, and her lips had a patient quiver.
Mr. Wilson gave an exclamation and sprang forward as she
disappeared in the further room.
It was some hours later that the husband and wife met
unexpectedly upon the stairs with a glad surprise.
“You don’t mean to say it’s you—alone!” he whispered.
“Wait—is she coming up?” They clutched each other spasmodically
as they listened to the sound of a deflecting footstep. There was a
breathless moment, and then the chords of a funeral march boomed
forth upon the air. The loud pedal was doing its best to supplement
those long and strenuous fingers.
The listeners breathed a sigh of relief.
“He’s gone to the station for a time table,” whispered the husband
with a delighted grin: “though I can stand him all right. We had a
nice walk with the little girls, after he got tired of playing hide and
seek. I wished you were with us. You must be about used up. How
are you getting along with her?”
“Oh, pretty well.” She let herself be drawn down on the hall
window seat at the top of the landing. “You see, Edith really feels
dreadfully, poor girl.”
 “What about?”
“Herbert, she isn’t really sure that she loves him.”
“Isn’t sure! After they’ve been engaged for a year!”
“That’s just it. She says if they had been married out of hand, in
the first flush of the novelty, she wouldn’t have had time, perhaps,
to have any doubts. But it’s the seeing him all the time that’s made
her think.”
“Made her think what?”
“Whether she loves him or not; whether they are really suited. I
remember that I used to feel that way about you, dear. Oh, you
know, Herbert, it’s a very serious thing for a girl. She says she knows
her whole life is at stake; she thinks about it all the time.”
“How about his?”
“Well, that’s what I said,” admitted Mrs. Belmore. “She says that
she feels that he is so rational and self-poised that she makes little
difference in his life either way—it has come to her all at once. She
says his looking at everything in a matter-of-fact way just chills her;
she longs for a whole-souled enthusiasm that can sweep everything
before it. She feels that if they are married she will have to keep up
the ideal for both of them, and she doesn’t know whether she can.”
“No, she can’t,” said Mr. Belmore.
“She says she could if she loved him enough,” pursued Mrs.
Belmore. “It’s the if that kills her. She says that when she wakes up
in the morning that she feels as if she’d die if she didn’t see him
before night, and when she does see him it’s all a dreadful
disappointment to her; she can’t talk to him at all, she feels perfectly
hard and stony; then, the moment he’s gone, she’s crazy to have
him back again. She cries herself thin over it.”
“She’s pretty bony, anyway,” said Mr. Belmore impartially.
“Even his appearance changes to her. She says sometimes he
looks like a Greek god, so that she could go down on her knees to
him, and at other times—Once she happened to catch a glimpse of
him in a horrid red sweater, polishing his shoes, and she said she
didn’t get over it for weeks, he looked positively ordinary, like some
of the men you see in the trolley cars.”
“Oh, good gracious!” protested Mr. Belmore feebly. “Oh, good
gracious, petty! This is too much.”
“Hush—don’t laugh so loud—be quiet,” said his wife anxiously.
“If Wilson ever looks like a Greek god to her, she’s all right, she
loves him—you can tell her so for me. Wilson! Here are we sitting up
here like a pair of lovers, and they—Hello!”
The hall door opened and shut, the piano lid closed
simultaneously with a bang, and there was a swirl of skirts again
towards the staircase that scattered the guilty pair on the landing.
The hostess heaved a patient sigh.
“They shall speak,” said Mrs. Belmore when another hour had
gone with the situation still unchanged. Her gentle voice had a note
of determination. “I can’t understand why he doesn’t make her. She
is literally crying her eyes out, because the whole day has been lost.
Why didn’t you send him into the parlor for a book as I told you to,
when I came up to take care of Dorothy?”
“He wouldn’t go—he said he wasn’t doing the kindergarten act
any more. Hang it, I don’t blame him. A man objects to being made
a fool of before people, and he’s tired of it. Here he goes off again
to-morrow for two weeks, and she with no more heart than—”
“Where is he now?” asked Mrs. Belmore.
“Upstairs in my room, smoking.”
“Smoking! I thought he’d promised her solemnly not to.”
“Yes, he did; but he says he doesn’t care a—red apple; he’s going
to have some comfort out of the day. I’ve left him with a box of
cigars; good ones, too. He’s having the time of his life.”
 “O—o—h!” said Mrs. Belmore with the rapt expression of one who
sees beyond the veil. When she spoke it was with impressive
slowness. “When you hear me come downstairs with Edith and go in
the parlor, you wait a moment and then bring him down—with his
cigar—into the library. Do you understand?”
“No,” said Mr. Belmore.
“Oh, Herbert! If she sees him smoking—! There’s no time to lose,
for I have to get tea to-night. When I call you, leave him and come
at once, do you hear? Don’t stop a minute—just come, before they
get a chance to follow.”
“You bet I’ll come,” said Mr. Belmore, “like a bird to its—I will,
really, petty.”
That he nearly knocked her down by his wildly tragic rush when
she called from the back hall—“Herbert, please come at once! I can’t
turn off the water,” was a mere detail—they clung to each other in
silent laughter, behind the enshrouding porti—res, not daring to
move. The footfall of the deserted Edith was heard advancing from
the front room to the library, and her clear and solemn voice, as of
one actuated only by the lofty dictates of duty, penetrated distinctly
to the listeners.
“Alan Wilson, is it possible that you are smoking? Have you broken
your promised word?”
“Well, they’re at it, at last,” said Mr. Belmore, relapsing into a chair
in the kitchen with a sigh of relief, and drawing a folded newspaper
from his pocket. “I wouldn’t be in his shoes for a farm.”
“Oh, it will be all right now,” said Mrs. Belmore serenely. She
added with some irrelevancy, “I’ve left the children to undress each
other; they’ve been so good. It’s been such a different day, though,
from what we had planned.”
“It’s too bad that you have to get the tea.”
“Oh, I don’t mind that a bit.”
 She had tucked up the silken skirt of her gown and was deftly
measuring out coffee—after the swift, preliminary shaking of the fire
with which every woman takes possession of a kitchen—pouring the
water into the coffee-pot from the steaming kettle, and then
vibrating between the kitchen closet and the butler’s pantry with the
quick, capable movements of one who knows her ground thoroughly.
“Really, it isn’t any trouble. Margaret leaves half of the things ready,
you know. If you’ll just lift down that dish of salad for me—and the
cold chicken is beside it. I hate to ask you to get up, but—Thank
you. How good the coffee smells! I know you always like the coffee I
make.”
“You bet I do,” said Mr. Belmore with fervor. “Say, petty, you don’t
think you could come out now and take a look at the garden? I’m
almost sure the peas are beginning to show.”
“No, I’m afraid there isn’t time. We’ll have to give it up for this
Sunday.” She paused for a great effort. “If you’d like to go by
yourself, dear—”
“Wouldn’t you mind?”
She paused again, looking at him with her clear-eyed seriousness.
“I don’t think I mind now, but I might—afterwards.”
If he had hesitated, it was for a hardly appreciable second. “And I
don’t want to go,” he protested stoutly, “it wouldn’t be the same
thing at all without you.”
——“Everything is ready now,” said his wife. “Though I do hate to
disturb Edith and Alan. I’ll just run up and hear the children say their
prayers before I put those things on the table. If you would just take
a look at the furnace—” it was the sentence Mr. Belmore had been
dreading—“and then you can come up and kiss the children good
night.”
Mr. Belmore, on his way up from stoking, caught a glimpse
projected from the parlor mirror through an aperture in the doorway
which the porti—res had left uncovered. The reflection was of a girl,
with tear-stained face and closed eyes, her head upon a young
man’s shoulder, while his lips were touchingly pressed to her hair.
The picture might have been called “After the Storm,” the wreckage
was so plainly apparent. As Mr. Belmore turned after ascending the
flight of stairs he came full in sight of another picture, spread out to
view in the room at the end of the hall. He stood unseen in the
shadow regarding it.
His wife sat in a low chair near one of the two white beds; little
Dorothy’s crib was in their room, beyond. The three children were
perched on the foot of the nearest bed, white-gowned, with rosy
faces and neatly brushed hair. While he looked, the youngest child
gave a birdlike flutter and jump, and lighted on the floor, falling on
her knees, with her bowed head in the mother’s lap, her hands
upraised. As she finished the murmured prayer, helped by the tender
mother-voice, she rose and stood to one side, in infantine
seriousness, while the next one spread her white plumes for the
same flight, waiting afterwards in reverent line with the first as the
third hovered down.
It was plain to see from the mother’s face that she had striven to
put all earthly thoughts aside in the performance of this sacred office
of ministering to innocence; her eyes must be holy when her
children’s looked up at her on their way to God.
This was the little inner chapel, the Sanctuary of Home, where she
was priestess by divine right. It would have been an indifferent man,
indeed, who had not fallen upon his knees in spirit, in company with
this little household of faith, in mute recognition of the love and
peace and order that crowned his days.
He kissed the laughing children as they clung to him, before she
turned down the light. When she came out of the room he was
waiting for her. He put his arm around her as he said, with the
darling tenderness that made her life,
“Come along, old sweetness. We’ve got to go down and stir up
those lunatics again. Call that ‘the happiest time of your life!’ We
know better than that, don’t we, petty? I’ll tell you what it is: I’ll go
to church with you next Sunday, if you say so!”
In the Married Quarters
 In the Married Quarters

R. BROOKTON RIVERS watched the spark at the end of his cigar

as he held the short stub between his thumb and forefinger. It
was going out. While he had had that cigar to smoke his mind had
been at rest, for he knew that he was going to sit in that particular
angle in the piazza until he finished it, which would be about half-
past eight. After that—what?
He threw away the cigar and leaned meditatively forward to catch
a glimpse of the moon as it rose over the patch of straggling woods
next to the Queen Anne cottage opposite him. It showed a deserted
piazza, and a man and his wife and two small children walking past
it. The man walked with the heavy, shuffling steps of a laborer, and
the woman, in a white shirt-waist and a dragging skirt, held one
child by the hand, while the other, in tiny trousers, toddled bow-
leggedly behind. As they vanished down the street, two silent men
on bicycles sped past, their little lamps twinkling in the shadows;
then half a dozen more, laughing and calling to each other, then a
swiftly driven buggy that sent the dust flying up on the vines that
were already laden with it. The prevailing smell of the humid night
was of damp weeds. It was also very hot.
There were no lights in the house opposite, nor in the one next to
it, or in the one next to that, nor were there any, as he knew without
seeing, in either of the houses next to his own. From farther down
the street came the sound of a jangling piano, obstructed
intermittently by the loud, unvaried barking of a melancholy dog.
From nearer by the persistent wail of a very young infant, protesting
already against existence in such a hot world, became more and
more unbearable each instant. Mr. Rivers absent-mindedly killed
three feasting mosquitoes at a blow, and rose to his feet with
determination. He could stay here no longer. Should he go out, or
retire to his room in the doubtful comfort of extreme negligee, and
read?
It will, of course, be evident to the meanest suburban intelligence
that the month was August, and that Mrs. Rivers was away, as were
most of her immediate neighbors, enjoying a holiday by either
mountains or seashore. Rivers could see in imagination how glorious
this moonlight became as the waves rolled into its path and broke
there on the wet sands into a delicious rush and swirl of silvery
sparkling foam. He could smell the very perfume of the sea, and feel
the cold breath that the water exhales with one’s face close down by
it, no matter how warm the night. It had been a pretty bad day in
town. He was glad, very glad, that Elizabeth had the change. She
needed it. He had said this stoutly to himself many times in the last
six weeks, and knew that it was true. She had protested against
going, and only yielded at last for the children’s sake and in wifely
obedience to lawful masculine authority. He had insisted on sleeping
in the house alone, in defiance of her pleading, alleging an affinity
for his own bed, his own belongings, and an individual bath tub. A
woman came once a week to sweep and straighten up the house.
He had repeatedly declared there would be really nothing to do after
business hours but to go around and enjoy himself. He had made
her almost envious of these prospective joys. He would take little
trips to Manhattan Beach with “the boys” and go to Bronxville to see
Tom Westfield, as he had been meaning to for five years, and visit
the roof garden with the Danas, who were on from St. Louis, and
take dinner at the Café Ruritania. On the between nights he would
visit the neighbors. All these things he had done, more or less
disappointingly, but what should he do to-night?
“I beg your pardon, Rivers, but have you any paregoric in the
house? We’ve got to get something to quiet the baby.”
 A tall, thin, wearied-looking young man had come up the steps,
hidden by the vines in which dwellers in a mosquito country are
wont to picturesquely embower themselves, defiant of results.
“Why, how are you, Parker?” said Rivers cordially. “Paregoric is it
that you want? Come inside, and we’ll have a look for it, old man.”
He led the way, scratching matches as he went to relieve the
darkness, dropping them on the floor as they went out, and finally
lighting the gas in the butler’s pantry.
“My wife keeps the medicines on the top shelf here to be out of
the way of the children,” he explained. “I don’t know about the
paregoric, though. I seem to remember that she didn’t believe much
in using it for babies.”
“We’ve had a fight with the nurse about it,” said the other man,
gnawing at a very light mustache as he leaned against the door, “but
Great Scott, Rivers, we’ve got to do something. I would have
murdered anybody whose child cried like this one. We’ve been
complained of as it is. That’s paregoric, isn’t it?”
“It was, but the bottle’s empty,” said Rivers, who was standing on
the rung of a chair, holding out a vial now and then from an inner
recess to read the name on it. “That’s another empty bottle—and
here’s another empty bottle—and, this is—another. Bottle of sewing
machine oil. Prescription for neuralgia, 178, 902, empty. Bottle of
glycerine—confound the thing! the cork was out of it; get my
handkerchief for me out of my pocket, will you? Prescription for hair
tonic; empty bottle—another empty prescription bottle—dregs of
cough medicine. What in thunder does Bess want with all these
empty bottles? I’m awfully sorry, Parker, but we don’t seem to have
the stuff you want, or any other, for that matter.”
“Never mind,” said Parker. “I’ll ride down to the village and get
some. I’d have gone there first, but the tire of my wheel wants
blowing up.”
“I’d lend you my wheel, but it’s at the shop,” called Rivers as they
disappeared out of the door.
 He put the bottles back, upsetting, as he did so, a package of
some white powder, out of which ran three cockroaches. As he
stooped to gather it up again in the paper he disturbed a half-eaten
peach which he remembered leaving there the night before, and a
small colony of ants that had made their dwelling in it scuttled
cheerily around. He uttered an exclamation of disgust, and shut the
door of the butler’s pantry upon them. The whole house seemed
given up to a plague of insects, utterly unknown in the reign of its
careful mistress. In spite of screens, small stinging mosquitoes
whizzed out from everything he touched; spiders hung down from
webs in the ceiling, and a moth had flown from his closet that very
morning. He kept the blinds and windows closed while he was away
all day; he had begun by leaving them open, but a slanting shower
had made havoc in his absence and also flooded the cellar through
the open cellar door. It had not dried up since, and he was sure that
there were fleas down there.
There was a deadly hot damp and silence in the dining-room and
parlor as he came through them, and the same unnatural
atmosphere in the rooms above as he drearily invaded them for a
clean collar. Every place was shut up and in order; the tops of the
dressing tables even were bare save for the clean towel laid over
each. His own room was in an ugly, disheveled confusion, and
though his windows were open, no air came through the wire
screens. He opened a closet door inadvertently, and the sight of a
pink kimono of his wife’s, and the hats of the two little boys hanging
up neatly beside it, emphasized his solitude. His latent idea of
spending the rest of the evening at home was gone from him—he
felt that he could not get out of this accursed house quickly enough,
although he had not made up his mind where to go; he did not feel
up to cheering the sick man in the next street, or equal to a gentle
literary conversation with the two elderly ladies beyond who had
known his mother. He wanted to go somewhere where he could
smoke and have some pleasing light drink for refreshment, and be
cheered and amused himself.
 The Callenders! If he only had his wheel—it was nine o’clock now,
and the place was away over on the other side of town. Never mind,
he would go, and chance their being at home and out of bed when
he got there. Anything to get away from this loathsome place,
although coming back to it again seemed suddenly an impossible
horror. He wondered if he were getting ill. The night before—
As he walked, the shadows of the moonlight lengthened his long
legs, and their dragging strides. His face, with its short brown beard
and the hollows under his dark eyes, was bent forward. He figured
out anew the income there would be from his insurance money, and
how it might be supplemented for Bess and the children. Clearly, he
would have to earn more before he died. And oh, the burden, the
burden, the burden was his! The thought leaped out like a visible
thing. Her sweet presence, her curling hair, her dimples, her loving
feminine inconsequence, with the innocent, laughing faces of the
little boys, overlaid the daily care for him, but with these appointed
Lighteners of Life away it loomed up into a hideously exaggerated
specter that seemed to have always had its hand upon his fearsome
heart, and only pressed a little closer upon him now in this hot
windless night. Even his wilted collar partook of the tragic; he might
as well have kept on the first one.
“Hello! Hello! Where are you going? This is the place.” A shout of
laughter accompanied the words. “Come up, brother, we’ve been
waiting for you!”
He looked up to see that he was in front of Callender’s house, and
that the piazza, a large square end of which was screened off into a
room, held a company in jovial mood, under moonlight as bright as
day. The women were in white, with half bare neck and arms,
rocking and fanning themselves, and the men in tennis shirts and
belts, two of them smoking pipes, and the other a cigar. A tray,
holding a large crystal bowl and glasses, stood on a bamboo table at
one side, half shielded by jars of palms whose spiked shadows
carpeted the floor and projected themselves across the white dress
and arms of Mrs. Callender, while she held the door open with one
hand, and half welcomed, half dragged him in with the other, amid a
chorus of voices,
“Come in, come in, you’re one of us.”
“If you let a mosquito in—Take that chair by Mrs. Weir if you feel
up to it; she wants to be entertained.”
“I feel up to anything—now,” said Rivers, taking with alacrity the
seat allotted to him, after shaking hands with pretty Mrs. Waring,
who lived next door, and her cousin, Mrs. Weir. “Same old crowd, I
see.”
The laughter broke out anew as his wandering eyes took tally of
the group, and he said, “Where’s Callender? and Weir? What’s the
joke?”
“Oh, don’t ask for any woman’s husband or any man’s wife,” said
Mrs. Callender despairingly, with her graceful figure reclining back in
the low chair. “Can’t you see that we’re all detached?” Her charming
smile suddenly broke forth. “It’s really too absurd.”
“No!” said Rivers, a light dawning on him. “Nichols, you don’t
mean that you are on the waiting list too?”
Mr. Nichols, a large man with a grizzled head, nodded and helped
himself to the contents of the suggestive bowl. “The missus and the
kids went off last week; I’m detained for a while longer. As for
Callender; he got a summons from the company, and he’s half way
to Chicago by this time, I hope. I came over on purpose to tell his
last words to his wife, who didn’t want them.”
“Ned had already brought them,” said Mrs. Callender, turning to
the tall, quiet man of the cigar, Mr. Atwood, who was her brother.
“It’s such a mercy that he happened to come on, or I’d have been
here all alone.”
“Looks like it,” said Mr. Porter, a stout fair gentleman with a cool
gray eye, a bald head, and a gurgling laugh. “What do you think,
Rivers, these girls here”—he waved his hand—“had been counting
on seeing the whole lot of us to-night, and brewed that lemonade on
purpose.”
“Everyone has come now but the Martindales,” said Mrs. Weir, a
little woman with loosely piled dark hair, and a gentle, winning voice,
occasionally diversified with a surprising shriek of laughter.
“The Martindales! Why, they only returned this evening—I met
them on the boat,” said Rivers.
“Yes, we know that, but one of them will be over here just the
same,” said Mrs. Callender placidly. “They’ll want to see what we’re
doing. Do somebody pay a little attention to Mrs. Waring; she hasn’t
said a word for half an hour. I believe she’s hoping that Henry’ll be
too homesick to stay away.”
“Not quite,” said Mrs. Waring with a little tremble of her lower lip.
“Nice, kind little woman you are,” said Porter severely. “Want to
enjoy yourself thinking how unhappy Waring is. Well, I’m glad he
went, and I hope he’ll stay until he’s well; if any man needed a
change, he did.”
“He would have taken me with him if I could have left the
children,” murmured Mrs. Waring.
“Yes, the children win every time,” said Porter with easy
philosophy. “You think you’re important, my brothers, until you’re
confronted with your own offspring, and then you’re not in it.”
“I don’t see,” said Mr. Nichols, filling his pipe again, “why a man’s
family should stay in town and broil because he has to. It wouldn’t
be any satisfaction to me, I know that. My little girls write to me
every day.”
“I remember,” said Rivers, leaning forward, “once when Bess and I
took a trip together we had to come home just when the fishing was
at its height, because she imagined what it would be like if a
menagerie broke loose and a tiger got at little Brook when he was
asleep in his crib. She said she knew it was perfectly absurd, but she
couldn’t stand it a moment longer. So we came home.”
 He laughed tenderly at the reminiscence, and the other men
laughed with him, but the women, even Mrs. Callender, who had no
children, were serious, and Mrs. Weir said, as if speaking for the
rest,
“Yes, one does feel that way sometimes.”
The men looked at each other and nodded, as in the presence of
something known of old, something to be smiled at, and yet
reverenced. The fierce maternal impulses of his wife were divine to
Rivers, he loved her the more for her foolishness; it seemed fitting,
and all he could expect, that the children should be her passion, as
she was his. If he had once dreamed that it would be otherwise, he
knew better now. Women were to be taken care of and loved for
their very limitations, even if one bore a little sense of loss and
soreness forever in one’s own heart. What could they know?
“Why don’t you take a vacation, Mr. Rivers?” asked Mrs. Weir later
as the others had fallen into general conversation. “You look as if
you needed it. Mr. Nichols says it was dreadful in town to-day; forty-
seven heat prostrations.”
“Oh, I can’t get off,” said Rivers with unconscious weariness in his
voice. “It makes an awful lot of difference when you’re running the
business yourself. If I were working for somebody else I’d take my
little two weeks the way my own clerks do, without caring a hang
what became of the concern in my absence. I thought I was going
to get up to Maine over the Fourth, and after all I couldn’t leave in
time. It’s quite a journey, you know. Bess and the boys were as
disappointed as I was,” he added conscientiously. “But they’re
getting along finely. Sam and Jack are learning to swim, she says—
pretty good for little shavers of five and six! They’re as brown as
Indians. She says—” he began to laugh as he repeated confidentially
some anecdotes of their prowess to which Mrs. Weir apparently
listened with the deeply interested attention that is balm to the
family exile, only asking him after a while irrelevantly, as he pushed
back the hair from his forehead,
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