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 Contributing Authors

MAJED H. ALGHAMDI, MBBS SCOTT MOORE, DO

King Abdulaziz University College of Medicine Assistant Professor of Medical Laboratory Sciences
Weber State University
VIJAY BALAKRISHNAN
Emory University School of Medicine JUN YEN NG, MBBS
Class of 2018 Princess Alexandra Hospital

BRIAN BALLARD CONNIE QIU

Michigan State University School of Osteopathic Medicine Lewis Katz School of Medicine at Temple University
Class of 2018 MD/PhD Candidate, Class of 2021

HUMOOD BOQAMBAR KALLI A. SARIGIANNIS

Royal College of Surgeons in Ireland Oakland University William Beaumont School of Medicine
Class of 2018 Class of 2018

TARUNPREET DHALIWAL SARAH SCHIMANSKY, MB BCh BAO

St. George’s University School of Medicine Resident, Department of Ophthalmology
Class of 2018 Gloucestershire Hospitals NHS Foundation Trust

RACHEL L. KUSHNER, MSc JESSE D. SENGILLO

Mercer University School of Medicine SUNY Downstate College of Medicine
Class of 2018 Class of 2018

LAUREN N. LESSOR ISABELLA T. WU

St. George’s University School of Medicine Tulane University School of Medicine
MD/PhD Candidate, Class of 2018 Class of 2019

JONATHAN LI VAISHNAVI VAIDYANATHAN

University of Michigan Medical School University of Missouri-Kansas City School of Medicine
Class of 2018 Class of 2018

Image and Illustration Team

ARTEMISA GOGOLLARI, MD AIDA K. SARCON

PhD Candidate St. George’s University School of Medicine
University for Health Sciences, Medical Informatics, and Technology, Class of 2018
Austria
RENATA VELAPATIÑO, MD
MATTHEW HO ZHI GUANG San Martin de Porres University School of Medicine
University College Dublin (MD), Dana Farber Cancer Institute (PhD) Hospitalist, Clinica Internacional
MD/PhD Candidate

VICTOR JOSE MARTINEZ LEON, MD

Central University of Venezuela

vii

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 Associate Authors

ANUP CHALISE, MBBS ALEX MULLEN

Nepal Medical College and Teaching Hospital University of Mississippi School of Medicine
Class of 2017 Class of 2019

CATHY CHEN VASILY OVECHKO

University of Mississippi School of Medicine Pirogov Russian National Research Medical University
Class of 2019 Class of 2019

MATTHEW S. DELFINER ERIKA J. PARISI

Resident, Internal Medicine Frank H. Netter MD School of Medicine at Quinnipiac University
Temple University Hospital Class of 2018

RICHARD A. GIOVANE, MD JOHN POWER

University of Alabama Icahn School of Medicine at Mount Sinai
Department of Family Medicine Class of 2018

JOSEPH G. MONIR MIGUEL ROVIRA

University of Florida College of Medicine University of Michigan Medical School
Class of 2018 Class of 2018

Image and Illustration Team

BENJAMIN F. COMORA ANTONIO N. YAGHY, MD

Alabama College of Osteopathic Medicine University of Balamand School of Medicine
DO/MBA Candidate

NAKEYA KHOZEMA DEWASWALA, MBBS

Lokmanya Tilak Muncipal Medical College
Class of 2016

viii

FAS1_2018_00_Frontmatter_i-xxii.indd 8 10/12/17 10:39 AM

 Faculty Advisors

MEESHA AHUJA, MD PETER V. CHIN-HONG, MD

Psychiatrist Professor, Department of Medicine
Rhode Island Hospital University of California, San Francisco School of Medicine

DIANA ALBA, MD BRADLEY COLE, MD

Clinical Instructor Assistant Professor
University of California, San Francisco Loma Linda University School of Medicine

MARK A.W. ANDREWS, PhD LINDA S. COSTANZO, PhD

Lake Erie College of Osteopathic Medicine at Seton Hill Professor, Physiology & Biophysics
Greensburg, Pennsylvania Virginia Commonwealth University School of Medicine

MARIA ANTONELLI, MD ANTHONY L. DeFRANCO, PhD

Assistant Professor, Division of Rheumatology Professor, Department of Microbiology and Immunology
MetroHealth Medical Center, Case Western Reserve University University of California, San Francisco School of Medicine

HERMAN SINGH BAGGA, MD CHARLES S. DELA CRUZ, MD, PhD

Urologist, Allegheny Health Network Associate Professor, Department of Pulmonary and Critical Care Medicine
University of Pittsburgh Medical Center, Passavant Yale School of Medicine

SHIN C. BEH, MD CONRAD FISCHER, MD

Assistant Professor, Department of Neurology & Neurotherapeutics Associate Professor, Medicine, Physiology, and Pharmacology
UT Southwestern Medical Center at Dallas Touro College of Medicine

PAULETTE BERND, PhD JEFFREY J. GOLD, MD

Professor, Department of Pathology and Cell Biology Associate Professor, Department of Neurology
Columbia University College of Physicians and Surgeons Assistant Professor, University of California, San Diego School of Medicine

ANISH BHATT, MD RAYUDU GOPALAKRISHNA, PhD

Clinical Fellow Associate Professor, Department of Integrative Anatomical Sciences
University of California, San Francisco Keck School of Medicine of University of Southern California

SHELDON CAMPBELL, MD, PhD RYAN C.W. HALL, MD

Professor of Laboratory Medicine Assistant Professor, Department of Psychiatry
Yale School of Medicine University of South Florida

BROOKS D. CASH, MD LOUISE HAWLEY, PhD

Professor of Medicine, Division of Gastroenterology Immediate Past Professor and Chair, Department of Microbiology
University of South Alabama School of Medicine Ross University School of Medicine

SHIVANI VERMA CHMURA, MD JEFFREY W. HOFMANN, MD, PhD

Adjunct Clinical Faculty, Department of Psychiatry Resident, Department of Pathology
Stanford University School of Medicine University of California, San Francisco School of Medicine

JAIMINI CHAUHAN-JAMES, MD BRIAN C. JENSEN, MD

Psychiatrist Assistant Professor of Medicine and Pharmacology
NYC Health + Hospitals University of North Carolina Health Care

ix

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 CLARK KEBODEAUX, PharmD NATHAN W. SKELLEY, MD
Clinical Assistant Professor, Pharmacy Practice and Science Assistant Professor, Department of Orthopaedic Surgery
University of Kentucky College of Pharmacy University of Missouri, The Missouri Orthopaedic Institute

MICHAEL R. KING, MD SHEENA STANARD, MD, MHS

Instructor, Department of Pediatric Anesthesiology Assistant Professor, Department of Obstetrics and Gynecology
Northwestern University Feinberg School of Medicine University of Rochester School of Medicine and Dentistry
THOMAS KOSZTOWSKI, MD
HOWARD M. STEINMAN, PhD
Spine Instructor
The Warren Alpert Medical School of Brown University Assistant Dean, Biomedical Science Education
Albert Einstein College of Medicine
KRISTINE KRAFTS, MD
Assistant Professor, Department of Basic Sciences MARY STEINMANN, MD
University of Minnesota School of Medicine Assistant Professor, Department of Psychiatry
University of Utah School of Medicine
GERALD LEE, MD
Assistant Professor, Departments of Pediatrics and Medicine RICHARD P. USATINE, MD
Emory University School of Medicine
Professor, Dermatology and Cutaneous Surgery
University of Texas Health Science Center San Antonio
KACHIU C. LEE, MD, MPH
Assistant Clinical Professor, Department of Dermatology
Brown University, Providence, Rhode Island
PRASHANT VAISHNAVA, MD
Assistant Professor, Department of Medicine
WARREN LEVINSON, MD, PhD Mount Sinai Hospital and Icahn School of Medicine
Professor, Department of Microbiology and Immunology
University of California, San Francisco School of Medicine J. MATTHEW VELKEY, PhD
Assistant Dean, Basic Science Education
PETER MARKS, MD, PhD Duke University School of Medicine
Center for Biologics Evaluation and Research
US Food and Drug Administration BRIAN WALCOTT, MD
Clinical Instructor, Department of Neurological Surgery
J. RYAN MARTIN, MD University of California, San Francisco
Assistant Professor of Obstetrics, Gynecology, and Reproductive Sciences
Yale School of Medicine
TISHA WANG, MD
DOUGLAS A. MATA, MD, MPH Associate Clinical Professor, Department of Medicine
Brigham Education Institute and Brigham and Women’s Hospital David Geffen School of Medicine at UCLA
Harvard Medical School
SYLVIA WASSERTHEIL-SMOLLER, PhD
SOROUSH RAIS-BAHRAMI, MD Professor Emerita, Department of Epidemiology and Population Health
Assistant Professor, Departments of Urology and Radiology Albert Einstein College of Medicine
University of Alabama at Birmingham School of Medicine
ADAM WEINSTEIN, MD
SASAN SAKIANI, MD
Assistant Professor, Pediatric Nephrology and Medical Education
Fellow, Transplant Hepatology Geisel School of Medicine at Dartmouth
Cleveland Clinic

ROBERT A. SASSO, MD ABHISHEK YADAV, MBBS, MSc

Professor of Clinical Medicine Associate Professor of Anatomy
Ross University School of Medicine Geisinger Commonwealth School of Medicine

MELANIE SCHORR, MD KRISTAL YOUNG, MD

Assistant in Medicine Clinical Instructor, Department of Cardiology
Massachusetts General Hospital Huntington Hospital, Pasadena, California

FAS1_2018_00_Frontmatter_i-xxii.indd 10 10/12/17 10:39 AM

 Preface
With the 28th edition of First Aid for the USMLE Step 1, we continue our commitment to providing students with
the most useful and up-to-date preparation guide for the USMLE Step 1. This edition represents an outstanding
revision in many ways, including:
ƒƒ 35 entirely new high-yield topics reflecting evolving trends in the USMLE Step 1.
ƒƒ Extensive text revisions, new mnemonics, clarifications, and corrections curated by a team of more than 40
medical student and resident physician authors who excelled on their Step 1 examinations and verified by a team
of expert faculty advisors and nationally recognized USMLE instructors.
ƒƒ A new section on learning and memory science in Section I, Guide to Efficient Exam Preparation.
ƒƒ Updated with 35+ new full-color photos to help visualize various disorders, descriptive findings, and basic
science concepts. Additionally, revised imaging photos have been labeled and optimized to show both normal
anatomy and pathologic findings.
ƒƒ Updated study tips on the opening page of each chapter.
ƒƒ Improved integration of clinical images and illustrations to better reinforce and learn key anatomic concepts.
ƒƒ Improved organization of text, figures, and tables throughout for quick review of high-yield topics.
ƒƒ Updated with 50+ new and revised diagrams and illustrations as part of our ongoing collaboration with
USMLE-Rx (MedIQ Learning, LLC).
ƒƒ Reorganized Rapid Review section to present high-yield concepts by topic and with page numbers to the
corresponding text.
ƒƒ Revitalized coverage of current, high-yield print and digital resources in Section IV with clearer explanations of
their relevance to USMLE Step 1 review.
ƒƒ Real-time Step 1 updates and corrections can be found exclusively on our blog, www.firstaidteam.com.
We invite students and faculty to share their thoughts and ideas to help us continually improve First Aid for the
USMLE Step 1 through our blog and collaborative editorial platform. (See How to Contribute, p. xvii.)
Louisville Tao Le
Boracay Vikas Bhushan
St. Louis Matthew Sochat
New York City Yash Chavda
Ann Arbor Andrew Zureick
Pittsburgh Mehboob Kalani
San Francisco Kimberly Kallianos

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 Special Acknowledgments
This has been a collaborative project from the start. We gratefully acknowledge the thousands of thoughtful
comments, corrections, and advice of the many medical students, international medical graduates, and faculty who
have supported the authors in our continuing development of First Aid for the USMLE Step 1.
We provide special acknowledgment and thanks to the following individuals who made exemplary contributions
to this edition through our voting, proofreading, and crowdsourcing platform: Huzaifa Ahmad, Ram Baboo, Kashif
Badar, Nwamaka Bob-Ume, Paige Estave, Nathaniel Fitch, Panagiotis Kaparaliotis, Elaine Luther, Sarah Hamid
Mian, Prashank Shree Neupane, Keyhan Piranviseh, Cindy Tsui, and Ankeet Vakharia.
For support and encouragement throughout the process, we are grateful to Thao Pham, Jinky Flang, and Jonathan
Kirsch, Esq. Thanks to Louise Petersen for organizing and supporting the project. Thanks to our publisher, McGraw-
Hill, for the valuable assistance of its staff, including Bob Boehringer, Christina Thomas, Jim Shanahan, Laura
Libretti, and Jeffrey Herzich.
We are also very grateful to Dr. Fred Howell and Dr. Robert Cannon of Textensor Ltd for providing us extensive
customization and support for their powerful Annotate.co collaborative editing platform (www.annotate.co), which
allows us to efficiently manage thousands of contributions. Thanks to Dr. Richard Usatine and Dr. Kristine Krafts
for their outstanding image contributions. Thanks also to Jean-Christophe Fournet (www.humpath.com), Dr. Ed
Uthman, and Dr. Frank Gaillard (www.radiopaedia.org) for generously allowing us to access some of their striking
photographs. Thank you to Dr. Brenda Zureick for her ophthalmology review. For faculty contributions, we thank
Dr. Aditya Bardia, Dr. Christina Ciaccio, Dr. Stuart Flynn, Dr. Vicki Park, Dr. Jeannine Rahimian, Dr. Joseph
Schindler, and Dr. Stephen Thung.
For exceptional editorial leadership, enormous thanks to Christine Diedrich, Emma Underdown, and Catherine
Johnson. Thank you to our USMLE-Rx/ScholarRx team of editors, Linda Davoli, Jacqueline Mahon, Janene
Matragrano, Erika Nein, Isabel Nogueira, Sally Rineker, Rebecca Stigall, Ashley Vaughn, and Hannah Warnshuis.
Many thanks to Tara Price for page design and all-around InDesign expertise. Thank you to Ruthie Whittaker for
assistance in reorganizing the Rapid Review section. Special thanks to our indexer Dr. Anne Fifer. We are also
grateful to our medical illustrator, Hans Neuhart, for his creative work on the new and updated illustrations. Lastly,
tremendous thanks to Rainbow Graphics, especially David Hommel and Donna Campbell, for remarkable ongoing
editorial and production support under time pressure.
Louisville Tao Le
Boracay Vikas Bhushan
St. Louis Matthew Sochat
New York City Yash Chavda
Ann Arbor Andrew Zureick
Pittsburgh Mehboob Kalani
San Francisco Kimberly Kallianos

xii

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 General Acknowledgments

Each year we are fortunate to receive the input of thousands of medical students and graduates who provide new material, clarifications,
and potential corrections through our website and our collaborative editing platform. This has been a tremendous help in clarifying
difficult concepts, correcting errata from the previous edition, and minimizing new errata during the revision of the current edition. This
reflects our long-standing vision of a true, student-to-student publication. We have done our best to thank each person individually
below, but we recognize that errors and omissions are likely. Therefore, we will post an updated list of acknowledgments at our website,
www.firstaidteam.com/bonus/. We will gladly make corrections if they are brought to our attention.

For submitting contributions and corrections, many thanks to Mohammad Abbasi, Ibrahim Abdelfattah, Mostafa Ahmed Abdellah,
Omar Abdelrahim Alawadi, Sufyan Abdul Mujeeb, Omar Abu Slieh, Khalil Abu Zaina, Muhamed Abubacker, Ayman Abunimer, Terumbur
Abwa, Jesus Mauricio Acero, Raghav Acharya, Rojan Adhikari, Anisha Adhikari, Shivani Adhyaru, Kristopher Aghemo, Cassandra Ahmed,
Adiel Aizenberg, Dolani Ajanaku, Mythri AK, Ahmad Akhtar, Murad Al Masri, Mejbel Alazemi, Isam Albaba, Camilo José Albert
Fernández, Khalil Ali, Muhammed Alikhan, Mohamed Ali, Murad Almasri, Luai Alsakkaf, Vivian V Altiery De Jesus, Fazilhan Altintas,
Alvaro Alvarez, Farah Amer, Christopher Anderson, Gilberto Aquino, Jay Argue, Khashayar Arianpour, Fernando Daniel Arias, Lama Assi,
Rizwan Attiq, Scarlett Austin, Carlos Andres Avila, Zaki Azam, Sara Azeem, Parag Badami, Nadia Badar, Louis Baeseman, Karsyn Bailey,
Bryce Baird, Devin Baith, Matthew Balatbat, Vyshnavy Balendra, Ugur Berkay Balkanci, Josiah Ballantine, Muhammad Yasir Baloch,
Melissa Banez, Hari Prasad Baral, Saira Bari, Elan Baskir, Jacqueline Bekhit, Leah Beland, Jackson Bell, Elizabeth Benge, Lauren
Benning, Hussein Berjaoui, Maresa Dorothee Berns, Kulsajan Bhatia, Saravjit S. Bhatti, Navpreet Bhurji, M. Yaasen Bhutta, Jacques
Bijon, Safal Bijukshe, Jeffrey Black, Christer Blindheim, Luigi Bonini, Peter Boucas, Mary Boulanger, Alexandre Boulos, Chantal Brand,
Zachary Britstone, Aaron Brown, Conor Buckley, Natassia Buckridge, Omar Bukhari, Welland Burnside, Pavel Burskii, Avi Bursky-
Tammam, David Buziashvili, Michael Byers, Adam Cadesky, Elizabeth Cai, Alexandra Calingo, Andrei Callejas, Francisco Caraballo, Jorge
Carrasco, Esteban Casasola, Gabriel Castano, Yoly Angelina Castellanos, Marco A Castillo, Gabriel Castro Gueits, Rorigo Cavalcante,
Natalie Cazeau, Harold Viviano Cedeño, Jesse Chait, Ingita Chand, Eric Chang, Fong-Wan Chau Zhou, Jaimini Chauhan, Mit Chauhan,
Maureen Chavez, Mehmood Cheema, Christopher Chhoun, Youna Choi, Rebecca D. Chou, Erika Chow, Mahbub Chowdhury, Elizabeth
Ann Chu, Jessica Chung, Katherine Chung, Benjamin Ciccarelli, Joseph Cioffi, John Coda, Zack Cohen, Lee Colaianni, Nahimarys Colón
Hernández, Julijana Conic, Jeffrey Cooney, Erica Corredera, Cody Couperus, Eric Cox, Caitlin Crosier, Matthew Culbert, John Cummins,
Abdul Dada, Christopher Dallo, Parnaz Daneshpajouhnejad, Jason Darr, Camille Davis, Solomon Dawson, James Dee, Matthew
Derakhshesh, Rajat Dhand, Shreena Dhawan, Vijay Dhillon, Angel Joel Diaz Martinez, Luboslav Dimitrov, Lennox Din, Soraya Djadjo,
Mustafa Rıdvan Dönmez, Hima Doppalapudi, Landry Dorsett, Morgan Drucker, Elena Duca, Wesley Durand, Aaron Dwan, Marc
Egerman, Christopher El Mouhayyar, David Ellenbogen, Mahmoud Elmahdy, Ashley Ermann, Yashar Eshman, Mikael Fadoul, Joseph

xiii

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 Fahmy, Giselle Falconi, Matthew Farajzadeh, Behnam Faridian, Amelia Fatsi, Rachel Fayne, Anthony Febres, Jin Feng, Brittany Fera,
Leila Ferreira, Anthony Findley, Eitan Fleischman, Thomas Flynn, Allison Forrest, Adisson Fortunel, Brandon Fram, Daniel Franco,
Gabriel Franta, Jacob Fried, Yaakov Fried, Luis Alberto Ribeiro Froes Jr., Virginia Fuenmayor, Sudha Gade, Emily Gall, Max Galvan, Nick
Gamboa, Dan Ganz, Fabian Garcia, Melanie Garcia, Okubit Gebreyonas, Nicholas Geiger, David Gelbart, Bill Gentry, Dylan Gerlach,
Brielle Gerry, Nina Gertsvolf, Sara Ghoneim, Jake Gibbons, Gobind Gill, Victoria Gonzales, Alberto Gonzalez, Mounica Gooty, Barbara
Gordon, Sophie Gottesman, Manjeet Goyal, Kylie Grady, Zacharia Grami, Mark Greenhill, Jora Singh Grewal, Harry Griffin, Maria Grig,
Vincent Grzywacz, Jinglin Gu, Leidy Laura Guerrero Hernández, James Guirguis, Nikhil Gupta, Deepak Gupta, Zarar Hafeez, Ramez
Maher Halaseh, Erik Haley, Mohanad Hamandi, Saffa Hamde, Mohammad Hamidi, Nicola Hampel, Alexandra Handy, Christine Hanish,
Mary Hanna, Laura Harding, Maxwell Harley, Glenn R. Harris, Hasanain Hasan, Danial Hayek, Corrie Hays, Luke He, Jackson Hearn, Leif
Helland, Ariana Hess, Joyce Ho, Walter Hodges, Tara Hogan, Brian Huang, Naureen Huda, Daniel Huff, Robert Huis in ‘t Veld, Frank Hurd,
Zaid Hussain, Jordan Huxall, Elizabeth Hwang, Taylin Im, Mimoza Isufi, Frank Jackson, Banafsheh Jalalian, Abbas Jama, Nader
Jamaleddine, David Janese, Jesse Jaremek, Ranjit Jasraj, Parth Javia, Kyu-Jin Jeon, Benjamin Hans Jeuk, Eric Jiang, Alfredo Joffre, Hollis
Johanson, Ryan Johnson, Sarah Johnson, Gavin Jones, Gregory Jordan, Josefina Fernandez, Michael Joseph, Pavel Kacnov, Preethi
Kamath, Irina Kanzafarova, Komal Kapoor, Egishe Karapetyan, Nikoloz Karazanashvili, Shalemar Ann Kasan, Matt Kasson, Orest Kayder,
Chelsae Keeney, Kristen Kelly, Danielle Keyes, Fahad Khan, Tamer Khashab, Susie Kim, Ann Kim, Rachel Kim, Nikhar Kinger, Mark
Kirane, Tamara Kliot, Walter Klyce, Sammy Knefati, Christopher Kocharians, Sam Kociola, Karthikram Komanduri, Nicholas Kondoleon,
David Kowal, Robert Kowtoniuk, Leonardo Kozian, Oleksandr Kozlov, Alec Krosser, Judah Kupferman, Stephanie Kuschel, Stephanie
Kwan, Nikola Kyuchukov, Ton La, Michael Landolfi, Wells LaRiviere, Matthew Lee, Sean Lee, Sun Yong Lee, Michael Lee, Daniel Leisman,
Jacob Leroux, Solomon Levin, David Li, Yedda Li, Jonathan Lieberman, Viktor Limanskiy, Meng-Chen Vanessa Lin, David Liu, Serena Liu,
Jason Livingstone, Mavis Lobo, José López, Zhuo Luan, Marcela Marie Luna, Nicolas Luzino, Miles Maassen, Emily MacDuffie, Robertson
Mackenzie, Jonathan Macleod, Evan Madill, Sergio Magaña, Marielle Mahan, Hossen Mahmud, Nodari Maisuradze, Abdallah Malas,
Genesis Maldonado, Madiha A. Malik, Margaret Maloney, Hassan Mandil, Taylor Maney, Navyata Mangu, Kori Mansfield, Lina Marenco,
John Marinelli, Laurel Mast, Micah Mathai, Anita Mathew, Candler Mathews, Fasil Mathews, John Mayfield, Guillermo Maza, Lina
Mazin, Benjamin McCormick, Luis Medina, Romy Megahed, Laura I Mendez Morente, Felipe Alonso Mercado, Haley Mertens, Raman
Michael, Amanda Miller, Joseph Mininni, Andria Marcela Miranda Chada, Thomas Mitchell, Sarah Mizrachi, Ghady Moafa, Pezhman
Mobasher, Mahmoud Mohamed, Syed Mohammad, Denelle Mohammed, Sarah Mohtadi, Agnes Mokrzycki, Guarina Molina, Austin
Momii, Eric Mong, Edgar Moradel, Andreina Moreno, Zachary Mortensen, Rachel Moss, Zachary Mostel, Turna Mukherjee, Greg Muller,
Nirav Mungalpara, John Myers, Louai Naddaf, Merna Naji, Rohit Nallani, Aram Namavar, Alex Nantsios, Anthony Naquin, Abeeha Naqvi,
Haider Naqvi, Samir Narula, Suraj Narvekar, Iraj Nasrabadi, Steven Nevers, Norman Ng, Samuel Ng, Raye Ng, Brandon Nguyen, Brian
Nguyen, Chi-Tam Nguyen, Doris Nguyen, Michael Nguyen, Vanessa Nguyen, Timothy Nguyen, Hosea Njoku, Jason Nosrati, Yoav Nudell,
Agnes Nyeck, Onyeka Olisemeka, Foluwakemi Olufehinti, Oluyinka Olutoye II, Abdillahi Omar, Nuhah Omar, Michael O’Shea, Zonghao
Pan, Abdullah Panchbhaya, Niranjan Pandey, Saurabh Pandit, Khang Wen Pang, Rajbir Singh Pannu, Brian Park, Anishinder Parkash,
Om Parkash, Jordan Parker, Matt Partan, Aaron Parzuchowski, Arpan Patel, Dharti Patel, Harshkumar Patel, Neel Patel, Tejas Patel,
Vanisha Patel, Yesha Patel, Vrutant Patel, Dwani Patel, Jayesh Patel, Savan Patel, Dipesh Patel, Shiv U. Patel, Jay Patel, Thomas Paterniti,
Priya Pathak, Saikrishna Patibandla, Iqra Patoli, Fernando Pellerano, Luke Perry, Romela Petrosyan, Jimmy Tam Huy Pham, Suzanne
Piccione, Saran Pillai, Vivek Podder, Dmitry Pokhvashchev, Marc Polanik, Chelsea Powell, Andrew Puckett, Abdulhameed Qashqary,
Carlos Quinonez, Joshua Radparvar, Shahrose Rahman, Alia Raja, Vinaya Rajan, Shayan Rakhit, Ferza Raks, Devan Ramachandran,
Bashar Ramadan, Gokul Ramani, Shandilya Ramdas, Jose Ramos, Rakin Rashid, Mikhail Rassokhin, Mohsin Raza, Yunus Raza,

xiv

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 Dheevena Reddy, Lenisse Miguelina Reyes Reyes, Peter Rezkalla, Beatriz Rivera, Dalianne Rivera, Chelsea Roberts, Moshe Roberts,
Lydia Robles, Alexander Rodriguez, Daniel Rodriguez Benzo, Daniel Enrique Rodríguez Benzo, Evgeny Romanov, Lukas Ronner, Geoffrey
Rosen, Max Rosenthal, Yuan Ross, Lindsay Rothfield, Cody Russell, Anas Saad, Rorita Sadhu, Anna Sadovnikova, Dev Sahni, Kamal Sahu,
Hemamalini Sakthivel, Abid Saleem, Ololade Saliu, Julienne Sanchez, Mason Sanders, Roshun Sangani, Michael Santarelli, Theodore
Schoenfeldt, Kyle Scott, Arshiya Sehgal, Anand Sewak, Congzhou Sha, Nazila Shafagati, Anna Shah, Nauman Shah, Shaili Shah, Ahmed
Shah, Abdulla Shaheen, Milton Shapiro, Kanika Sharma, Elizabeth Shay, Derek Sheen, Daniel Sherwood, David Shieh, Scott Shuldiner,
Sunober Siddiqi, Gabriel Silva, Matthew Simhon, Bhart Singal, Amadeldin Singer, Amitoj Singh, Chandandeep Singh, Shivreet Singh,
Steven Siragusa, Ramzi Y. Skaik, Christina Small, Conor Smith, Destini Smith, Will Smith, Austen Smith, Benjamin Smood, Hannah
Snyder, Anubhav Sood, Benjamin Rojas Soosiah, Wilfredo Soto-Fuentes, Matthew Spano, Phalguni Srivastava, Tina Stanco, Josiah
Strawser, Thomas Strobel, Annie Suarez, Zoilo Karim Suarez Yeb, Akhil Sureen, Gorica Svalina, Kayley Swope, Laura Szczesniak, Aboud
Tahanis, Jayul Tailor, Austin Tam, Ming Yao Jonavan Tan, Olive Tang, Asna Tasleem, Sara Tavarez, Claudia Tejera, Anand Tekriwal, Priyesh
Thakurathi, Vaishakh Tharavath, Chris Thomas, Lanice Thomas, Karima Thompson, John Tiang-Leung, Alvin Trieu, Michelle Trieu, Birva
Trivedi, Katie Truong, Akshit Tuli, Marcia E. Uddoh, Nneamaka Ukatu, Johnson Ukken, Claire Unruh, Adelynn Vadrar, Andrew Valliyil,
Vivek Vallurupalli, Blanca Vargas, Vandana Vekariya, Erick Candido Velasquez Centellas, Michael Venincasa, Michael Villalba, Marcos
Villarreal, Phuong Vo, Steven Vuu, William Waddell, Holden Wagstaff, Nicholas Walther, Tony Wang, Jason L. Wang, Jonathan Warczak,
Jacob Warner, Eric Wei, Paul Wei, Ronald Weir, Garrett Welle, Matthew Wells, Allison Williams, Michael Winter, Adriana Wong, Donald
Wright, Brian Wu, Lawrence Wu, Michael Wydeko, Catherine Xie, Tamar Yacoel, Dong-han Yao, Alexander Yevtukh, Jaemin Yim, Raquel
Yokoda, Sadaf Younis, Christopher Yun, Nicholas Yurko, Mubarak Hassan Yusuf, Pavel Zagadailov, Alireza Zandifar, Batool Zehra, Xue
Zhang, Eric Zhang, Angie Zhang, Jasmine Zhao, Mohammad Zmaili, Spyridon Zouridis, Andrew Zovath, and Kathleen Zuniga.

xv

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FAS1_2018_00_Frontmatter_i-xxii.indd 16 10/12/17 10:39 AM

 How to Contribute

This version of First Aid for the USMLE Step 1 incorporates thousands of contributions and improvements suggested
by student and faculty advisors. We invite you to participate in this process. Please send us your suggestions for:

ƒƒ Study and test-taking strategies for the USMLE Step 1

ƒƒ New facts, mnemonics, diagrams, and clinical images

ƒƒ High-yield topics that may appear on future Step 1 exams

ƒƒ Personal ratings and comments on review books, question banks, apps, videos, and courses

For each new entry incorporated into the next edition, you will receive up to a $20 Amazon.com gift card as well as
personal acknowledgment in the next edition. Significant contributions will be compensated at the discretion of the
authors. Also, let us know about material in this edition that you feel is low yield and should be deleted.

All submissions including potential errata should ideally be supported with hyperlinks to a dynamically updated Web
resource such as UpToDate, AccessMedicine, and ClinicalKey.

We welcome potential errata on grammar and style if the change improves readability. Please note that First Aid style
is somewhat unique; for example, we have fully adopted the AMA Manual of Style recommendations on eponyms
(“We recommend that the possessive form be omitted in eponymous terms”) and on abbreviations (no periods with
eg, ie, etc).

The preferred way to submit new entries, clarifications, mnemonics, or potential corrections with a valid,
authoritative reference is via our website: www.firstaidteam.com.

This website will be continuously updated with validated errata, new high-yield content, and a new online platform
to contribute suggestions, mnemonics, diagrams, clinical images, and potential errata.

Alternatively, you can email us at: [email protected].

Contributions submitted by May 15, 2018, receive priority consideration for the 2019 edition of First Aid for the
USMLE Step 1. We thank you for taking the time to share your experience and apologize in advance that we cannot
individually respond to all contributors as we receive thousands of contributions each year.

xvii

FAS1_2018_00_Frontmatter_i-xxii.indd 17 10/12/17 10:39 AM

 NOTE TO CONTRIBUTORS
``

All contributions become property of the authors and are subject to editing and reviewing. Please verify all data and
spellings carefully. Contributions should be supported by at least two high-quality references.

Check our website first to avoid duplicate submissions. In the event that similar or duplicate entries are received,
only the first complete entry received with valid, authoritative references will be credited. Please follow the style,
punctuation, and format of this edition as much as possible.

JOIN THE FIRST AID TEAM

``

The First Aid author team is pleased to offer part-time and full-time paid internships in medical education and
publishing to motivated medical students and physicians. Internships range from a few months (eg, a summer) up
to a full year. Participants will have an opportunity to author, edit, and earn academic credit on a wide variety of
projects, including the popular First Aid series.

For 2018, we are actively seeking passionate medical students and graduates with a specific interest in improving our
medical illustrations, expanding our database of medical photographs, and developing the software that supports our
crowdsourcing platform. We welcome people with prior experience and talent in these areas. Relevant skills include
clinical imaging, digital photography, digital asset management, information design, medical illustration, graphic
design, and software development.

Please email us at [email protected] with a CV and summary of your interest or sample work.

xviii

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 How to Use This Book
CONGRATULATIONS: You now possess the book that has guided nearly two million students to USMLE success
for over 25 years. With appropriate care, the binding should last the useful life of the book. Keep in mind that putting
excessive flattening pressure on any binding will accelerate its failure. If you purchased a book that you believe
is defective, please immediately return it to the place of purchase. If you encounter ongoing issues, you can also
contact Customer Service at our publisher, McGraw-Hill Education, at https://www.mheducation.com/contact.html.

START EARLY: Use this book as early as possible while learning the basic medical sciences. The first semester of
your first year is not too early! Devise a study plan by reading Section I: Guide to Efficient Exam Preparation, and
make an early decision on resources to use by checking Section IV: Top-Rated Review Resources. Note that First Aid
is neither a textbook nor a comprehensive review book, and it is not a panacea for inadequate preparation.

CONSIDER FIRST AID YOUR ANNOTATION HUB: Annotate material from other resources, such as class
notes or comprehensive textbooks, into your book. This will keep all the high-yield information you need in one
place. Other tips on keeping yourself organized:

ƒƒ For best results, use fine-tipped ballpoint pens (eg, BIC Pro+, Uni-Ball Jetstream Sports, Pilot Drawing Pen,
Zebra F-301). If you like gel pens, try Pentel Slicci, and for markers that dry almost immediately, consider
Staedtler Triplus Fineliner, Pilot Drawing Pen, and Sharpies.

ƒƒ Consider using pens with different colors of ink to indicate different sources of information (eg, blue for
USMLE-Rx Step 1 Qmax, green for UWorld Step 1 Qbank).

ƒƒ Choose highlighters that are bright and dry quickly to minimize smudging and bleeding through the page
(eg, Tombow Kei Coat, Sharpie Gel).

ƒƒ Many students de-spine their book and get it 3-hole-punched. This will allow you to insert materials from other
sources, including curricular materials.

INTEGRATE STUDY WITH CASES, FLASH CARDS, AND QUESTIONS: To broaden your learning strategy,
consider integrating your First Aid study with case-based reviews (eg, First Aid Cases for the USMLE Step 1), flash
cards (eg, First Aid Flash Facts), and practice questions (eg, the USMLE-Rx Step 1 Qmax). Read the chapter in the
book, then test your comprehension by using cases, flash cards, and questions that cover the same topics. Maintain
access to more comprehensive resources (eg, First Aid for the Basic Sciences: General Principles and Organ Systems
and First Aid Express videos) for deeper review as needed.

PRIME YOUR MEMORY: Return to your annotated Sections II and III several days before taking the USMLE
Step 1. The book can serve as a useful way of retaining key associations and keeping high-yield facts fresh in your
memory just prior to the exam. The Rapid Review section includes high-yield topics to help guide your studying.

CONTRIBUTE TO FIRST AID: Reviewing the book immediately after your exam can help us improve the next
edition. Decide what was truly high and low yield and send us your comments. Feel free to send us scanned images
from your annotated First Aid book as additional support. Of course, always remember that all examinees are under
agreement with the NBME to not disclose the specific details of copyrighted test material.

xix

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 Selected USMLE Laboratory Values

* = Included in the Biochemical Profile (SMA-12)

Blood, Plasma, Serum Reference Range SI Reference Intervals

*Alanine aminotransferase (ALT, GPT at 30°C) 8–20 U/L 8­–20 U/L

Amylase, serum 25–125 U/L 25–125 U/L
*Aspartate aminotransferase (AST, GOT at 30°C) 8–20 U/L 8–20 U/L
Bilirubin, serum (adult)
Total // Direct 0.1–1.0 mg/dL // 0.0–0.3 mg/dL 2–17 µmol/L // 0–5 µmol/L
*Calcium, serum (Total) 8.4–10.2 mg/dL 2.1–2.8 mmol/L
*Cholesterol, serum (Total) Rec: < 200 mg/dL < 5.2 mmol/L
*Creatinine, serum (Total) 0.6–1.2 mg/dL 53–106 µmol/L
Electrolytes, serum
Sodium (Na+) 136–145 mEq/L 136–145 mmol/L
Chloride (Cl–) 95–105 mEq/L 95–105 mmol/L
* Potassium (K+) 3.5–5.0 mEq/L 3.5–5.0 mmol/L
Bicarbonate (HCO3–) 22–28 mEq/L 22–28 mmol/L
Magnesium (Mg2+) 1.5–2 mEq/L 0.75–1.0 mmol/L
Gases, arterial blood (room air)
PO 2 75–105 mm Hg 10.0–14.0 kPa
PCO2 33–45 mm Hg 4.4–5.9 kPa
pH 7.35–7.45 [H+] 36–44 nmol/L
*Glucose, serum Fasting: 70–110 mg/dL 3.8–6.1 mmol/L
2-h postprandial: < 120 mg/dL < 6.6 mmol/L
Growth hormone − arginine stimulation Fasting: < 5 ng/mL < 5 µg/L
provocative stimuli: > 7 ng/mL > 7 µg/L
Osmolality, serum 275–295 mOsm/kg 275–295 mOsm/kg
*Phosphatase (alkaline), serum (p-NPP at 30°C) 20–70 U/L 20–70 U/L
*Phosphorus (inorganic), serum 3.0–4.5 mg/dL 1.0–1.5 mmol/L
Prolactin, serum (hPRL) < 20 ng/mL < 20 µg/L
*Proteins, serum
Total (recumbent) 6.0–7.8 g/dL 60–78 g/L
Albumin 3.5–5.5 g/dL 35–55 g/L
Globulins 2.3–3.5 g/dL 23–35 g/L
*Urea nitrogen, serum (BUN) 7–18 mg/dL 1.2–3.0 mmol/L
*Uric acid, serum 3.0–8.2 mg/dL 0.18–0.48 mmol/L
(continues)

xx

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 Cerebrospinal Fluid Reference Range SI Reference Intervals

Glucose 40–70 mg/dL 2.2–3.9 mmol/L

Hematologic

Erythrocyte count Male: 4.3–5.9 million/mm3 4.3–5.9 × 1012/L

Female: 3.5–5.5 million/mm3 3.5–5.5 × 1012/L
Erythrocyte sedimentation rate (Westergen) Male: 0–15 mm/h 0–15 mm/h
Female: 0–20 mm/h 0–20 mm/h
Hematocrit Male: 41–53% 0.41–0.53
Female: 36–46% 0.36–0.46
Hemoglobin, blood Male: 13.5–17.5 g/dL 2.09–2.71 mmol/L
Female: 12.0–16.0 g/dL 1.86–2.48 mmol/L
Hemoglobin, plasma 1–4 mg/dL 0.16–0.62 µmol/L
Leukocyte count and differential
  Leukocyte count 4,500–11,000/mm3 4.5–11.0 × 109/L
    Segmented neutrophils 54–62% 0.54–0.62
    Band forms 3–5% 0.03–0.05
    Eosinophils 1–3% 0.01–0.03
    Basophils 0–0.75% 0–0.0075
    Lymphocytes 25–33% 0.25–0.33
    Monocytes 3–7% 0.03–0.07
Mean corpuscular hemoglobin 25.4–34.6 pg/cell 0.39–0.54 fmol/cell
Mean corpuscular volume 80–100 μm3 80–100 fL
Partial thromboplastin time (activated) 25–40 seconds 25–40 seconds
Platelet count 150,000–400,000/mm3 150–400 × 109/L
Prothrombin time 11–15 seconds 11–15 seconds
Reticulocyte count 0.5–1.5% of red cells 0.005–0.015
Sweat

Chloride 0–35 mmol/L 0–35 mmol/L

Urine

Creatine clearance Male: 97–137 mL/min

Female: 88–128 mL/min
Osmolality 50–1,400 mOsmol/kg H2O
Proteins, total < 150 mg/24 h < 0.15 g/24 h

xxi

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 First Aid Checklist for the USMLE Step 1

This is an example of how you might use the information in Section I to prepare for the USMLE Step 1. Refer
to corresponding topics in Section I for more details.

Years Prior
□□ Select top-rated review resources as study guides for first-year medical school courses.
□□ Ask for advice from those who have recently taken the USMLE Step 1.

Months Prior
□□ Review computer test format and registration information.
□□ Register six months in advance. Carefully verify name and address printed on scheduling permit. Call
Prometric or go online for test date ASAP.
□□ Define goals for the USMLE Step 1 (eg, comfortably pass, beat the mean, ace the test).
□□ Set up a realistic timeline for study. Cover less crammable subjects first. Review subject-by-subject
emphasis and clinical vignette format.
□□ Simulate the USMLE Step 1 to pinpoint strengths and weaknesses in knowledge and test-taking skills.
□□ Evaluate and choose study methods and materials (eg, review books, question banks).

Weeks Prior
□□ Simulate the USMLE Step 1 again. Assess how close you are to your goal.
□□ Pinpoint remaining weaknesses. Stay healthy (exercise, sleep).
□□ Verify information on admission ticket (eg, location, date).

One Week Prior

□□ Remember comfort measures (loose clothing, earplugs, etc).
□□ Work out test site logistics such as location, transportation, parking, and lunch.
□□ Call Prometric and confirm your exam appointment.

One Day Prior

□□ Relax.
□□ Lightly review short-term material if necessary. Skim high-yield facts.
□□ Get a good night’s sleep.
□□ Make sure the name printed on your photo ID appears EXACTLY the same as the name printed on your
scheduling permit.

Day of Exam
□□ Relax. Eat breakfast. Minimize bathroom breaks during the exam by avoiding excessive morning caffeine.
□□ Analyze and make adjustments in test-taking technique.

After the Exam

□□ Celebrate, regardless.
□□ Send feedback to us on our website at www.firstaidteam.com.

xxii

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 SECTION I

Guide to Efficient
Exam Preparation

“I don’t love studying. I hate studying. I like learning. Learning is ``Introduction2

beautiful.”
—Natalie Portman ``USMLE Step 1—The
Basics2
“Finally, from so little sleeping and so much reading, his brain dried up
and he went completely out of his mind.” ``Defining Your Goal 12
—Miguel de Cervantes Saavedra, Don Quixote
``Learning Strategies 13
“Sometimes the questions are complicated and the answers are simple.”
—Dr. Seuss ``Timeline for Study 16
“He who knows all the answers has not been asked all the questions.” ``Study Materials 20
—Confucius
``Test-Taking
“It’s what you learn after you know it all that counts.”
Strategies22
—John Wooden

“A goal without a plan is just a wish.” ``Clinical Vignette

Strategies23
—Antoine de Saint-Exupéry

“I was gratified to be able to answer promptly, and I did. I said I didn’t ``If You Think You
know.” Failed24
—Mark Twain
``Testing Agencies 24

``References25

FAS1_2018_00_Section_I_indexed_1-26.indd 1 10/12/17 10:37 AM

 2 SECTION I Guide to Efficient Exam Preparation

INTRODUCTION
``

Relax.

This section is intended to make your exam preparation easier, not harder.
Our goal is to reduce your level of anxiety and help you make the most of
your efforts by helping you understand more about the United States Medical
Licensing Examination, Step 1 (USMLE Step 1). As a medical student, you
are no doubt familiar with taking standardized examinations and quickly
absorbing large amounts of material. When you first confront the USMLE
Step 1, however, you may find it all too easy to become sidetracked from your
goal of studying with maximal effectiveness. Common mistakes that students
make when studying for Step 1 include the following:

ƒƒ Starting to study (including First Aid) too late

ƒƒ Starting to study intensely too early and burning out
ƒƒ Starting to prepare for boards before creating a knowledge foundation
ƒƒ Using inefficient or inappropriate study methods
ƒƒ Buying the wrong resources or buying too many resources
ƒƒ Buying only one publisher’s review series for all subjects
ƒƒ Not using practice examinations to maximum benefit
ƒƒ Not understanding how scoring is performed or what the score means
`` The test at a glance: ƒƒ Not using review books along with your classes
ƒƒ 8-hour exam ƒƒ Not analyzing and improving your test-taking strategies
ƒƒ Up to a total of 280 multiple choice items ƒƒ Getting bogged down by reviewing difficult topics excessively
ƒƒ 7 test blocks (60 min/block) ƒƒ Studying material that is rarely tested on the USMLE Step 1
ƒƒ Up to 40 test items per block ƒƒ Failing to master certain high-yield subjects owing to overconfidence
ƒƒ 45 minutes of break time, plus another 15 ƒƒ Using First Aid as your sole study resource
if you skip the tutorial ƒƒ Trying to prepare for it all alone

In this section, we offer advice to help you avoid these pitfalls and be more
productive in your studies.

USMLE STEP 1—THE BASICS

``

The USMLE Step 1 is the first of three examinations that you must pass in
order to become a licensed physician in the United States. The USMLE is
a joint endeavor of the National Board of Medical Examiners (NBME) and
the Federation of State Medical Boards (FSMB). The USMLE serves as the
single examination system for US medical students and international medical
graduates (IMGs) seeking medical licensure in the United States.

FAS1_2018_00_Section_I_indexed_1-26.indd 2 10/12/17 10:37 AM

Exploring the Variety of Random
Documents with Different Content
Agatha tried to understand him. Finally, as if dimly aware that his
cries and gestures conveyed no meaning to her, the idiot seized her
by both arms and turned her in the direction from which he had just
come. Then he waited a moment, but seeing her immovable, an
access of fury seemed to take hold of him, and catching her by her
arm and shoulder, he began to drag her forcibly along with him, so
forcibly that Agatha felt she had no power to battle with him, and
that it would be useless to resist.

She did resist, however, with all her might, useless as it was. She
herself was young, strong, and lithe, but this squat, broad creature,
over whose head she could look, held her powerless in his grasp.

With fierce impatience he hurried her forward, in spite of her now

almost frantic struggles to free herself from the clasp of his long
arms.

His eyes were always staring straight before him as though he were
looking at something that affrighted him. His strength was
superhuman, and he had now dragged Agatha with him half across
the lawn. She could not reason with him, as he could not hear, and
she felt her strength grow less every moment. Where was he going?
Where was he taking her?

She looked down at the stunted figure beside her, at the rough,
unkempt head. She felt the long, sinewy arms tighten round her, and
suddenly a sensation of faintness overcame her. What was it her
aunt had said? That he was mad! That he would murder somebody!
Was he going to murder her?

By this time Mrs. Greatorex's terrified shrieks were resounding

across the lawn. But the servants, two small maidens, were evidently
too frightened to attempt a rescue. They hung back, and clung to
each other, and whimpered sympathetically.

In the meantime Agatha had been dragged to the borders of the

wood. Another minute would take her out of the view of those
watching from the windows.
CHAPTER IX

At this moment a young man pushed his way vigorously through a

thick hedge of laurel, and, springing forward, intercepted the idiot.
He stood before him in an authoritative manner, and made a strange
little gesture. Evidently Edwy understood it. He came to a sudden
standstill.

The new-comer was Dr. Dillwyn. He went up to the poor boy, and
laid his hand upon his shoulder and made a sign or two to him with
his fingers. Edwy let Agatha go, and the girl, sick and faint with the
terror, fell back against a tree behind her.

The idiot caught Dillwyn by the shoulder, looking at him and

mouthing beseechingly.

"Sho! Sho! Sho!" moaned he.

He had now, however, grown calmer, and presently his face regained
its usual placid look. Dillwyn's appearance had had some
extraordinary effect upon him. The terror disappeared from his eyes,
and they were now fixed on the young doctor with the steady gaze
of a dumb animal.

The poor idiot had learned in some blind way to like and believe in
Dillwyn. In the same strange unreasoning fashion he had grown to
like Agatha. These two he clung to of all those that surrounded him
in his silent life. There was another, and that was "Sho," his mother.
To him, however, she was light and life and all things. And she loved
him. And now "Sho" was in danger— was lying there at home in a
darkened room silent, without a look, a word for him, for the first
time in all his blighted existence. It was to that darkened room he
would have carried Agatha, some unformed thought of help for his
mother stirring him.

Again Dillwyn made some signs, pointing towards the direction from
which the unfortunate lad had come, and after a minute or two the
idiot turned and shuffled rapidly away towards his home.

Dillwyn went towards Agatha. His face was as white as death. He

caught her hand.

She felt that he was trembling even more than she was. He let her
hand go, and it occurred to the girl that he made a step towards her
with his arms a little outheld, as though he would have clasped her
to his heart. Her late danger had perhaps made him bolder—for the
moment. He could dare the strong idiot, but what man could dare
his love?

"Don't be frightened," said he in a low tone. "He meant nothing.

Nothing, really. But I thank God I arrived in time. You must have had
a great shock."

"Yes, yes," said Agatha, who was trembling still. The tears rose to
her eyes. "I am not really a coward," said she very bravely, "and at
first I didn't mind. I bore it quite well; but he was so strong, and I
didn't know where he was going, and"—with a shudder—"it was so
horrid being rushed along like that." Here she covered her eyes with
her hands and burst into tears. "Oh! now you will think me a
coward," sobbed she like any child.

"I know what I think you, long ago," said Dillwyn.

"Let me tell you how it all was," said he; "and sit down while I tell
you. You are quite unstrung, and no wonder. You are, in my opinion,
the bravest girl I ever met."
"Oh no!" said she.

"The bravest girl I ever met," repeated he firmly. "Poor Edwy! Who
would not be horrified by him in his excited moments? But the fact
is, his mother has met with an accident, and is, I fear, at death's
door."

"Mrs. Darkham!" Agatha roused herself from her nervous agitation

and looked at him.

"Yes. She went out early this morning shopping in the town, and
coming down that hilly part of the High Street she slipped on an
orange-peel, and came with fearful force upon the flags. You know
what a heavy woman she is?"

"Yes, yes. Poor thing!"

"She was taken home quite insensible. Darkham was out, but was
sent for, and it appears it was some time before he returned. In the
meantime poor Edwy had crept into the room where she was lying,
and the servants told me the sight of the blood—she had cut the
back of her head slightly—affected Edwy horribly. First he flew to her
and then recoiled. They said he did not know her lying there so still.

"He went away, but came back again and flung himself upon her,
and great, difficult tears fell from his eyes. I was there then, and so
was the father. It was pitiful beyond words. I raised him and tried to
calm him.

"He got up suddenly and ran round the bed to me. He took my arm
and pointed to the door. I believe now he was trying to tell me that
he was going to bring you to the succour of his mother."

"Poor, poor boy!" Agatha sighed quickly. "It is not hopeless, at all
events?" questioned she.
"Who can say? Darkham thinks it is, and I—well, I have seen cases
as bad recover. But that is nothing. It is undoubtedly a very bad
case. She is a heavy woman, you know, and a fall like that—and
concussion—I am going up there again this evening in consultation
with Dr. Bland."

"Ah!" said Agatha quickly. There was relief in her tone. She could not
have explained it to herself, but she was glad that so respectable a
man as Dr. Bland had been called in for consultation.

Dillwyn looked at her questioningly.

"You thought it would be some other man?"

"Yes. But I am glad it is Dr. Bland. He—-"

"Is not so old as most of the old figure-heads in the county," said
Dillwyn with a smile, who had suffered a good deal from the medical
fossils in the surrounding neighbourhood since he came to Rickton.
"Darkham sent for me first. I was the nearest, you know."

"Yes," said Agatha. "And the cleverest," she would have added had
she dared to give her heart carte blanche.

"It was all very sad, and the poor boy so helpless. I am sure I am
reading the riddle correctly when I say he ran to you to get you to
come to his mother in her extremity—-"

"I wish I had gone," Agatha said quickly. She half rose. "Oh, perhaps
I ought to go. Has she no woman with her?"

"She has two," said Dillwyn quietly. "You would be in the way if you
went there now. Two nurses engaged by Darkham are in constant
attendance on her. Don't distress yourself about that—and will you
think of yourself a little now? If you won't, I shall think for you. You
must go back to the house, and to your room, and try to sleep, if
possible, for the next two or three hours."
"As for that!" said she—a faint laugh broke from her.

"You won't do what I tell you, then?" said he. He had taken her hand
as if to draw it within his arm, but he held it now in his own whilst
questioning her.

"To do what you tell me?" She reddened vividly.

"Yes; why not?" His tone was calm, but the hand clasping hers
tightened its grasp. It was as though he could not let her go.

There was a pause. Agatha made an effort to draw her hand from
his, but he held it manfully.

"Why shouldn't you do what is good for you?" asked he at last.

"And what is the good of a doctor if he can't suggest useful

remedies? I am a doctor, and, therefore, why shouldn't you do what
I tell you?"

"Oh, if you put it that way," said she.

"Then you are going to obey me?"

She gave him a little glance.

At this they both laughed. Agatha still a little nervously. She did not,
however, resist him any further, and presently he had taken her back
across the lawn and on to the balcony, where Mrs. Greatorex met
them.

She had seen Dillwyn spring though the laurels, and had known
Agatha was safe. She met him now with extended hand.

"Thank you a thousand times, Dr. Dillwyn," said she, "for your happy
appearance on the scene a moment ago. I warned Agatha about
that repulsive boy, but she would not listen to me. However, I am
sure there was nothing really serious about it."
Her manner was kind, but reserved. She had noticed his attentions
to Agatha, and was not yet sure whether they ought to be
encouraged or rejected.

He was poor, and though Reginald Greatorex had, in a sense, placed

him here, still, she knew that "old skinflint"—I regret that that was
the name she applied to her brother-in-law in her private hours—
was certainly not to be depended upon. This rather presumptuous
young doctor would never get a penny out of Reginald Greatorex if
he hoped for a thousand years. Had she not hoped?

And yet, though she assured herself Dillwyn had no chance of old
Reginald's money, still, the very fact that he might have a chance
rendered the young man distasteful in her eyes. A protege of
Reginald's would always be a blur upon the landscape of her life.

"No, I think not," said Dillwyn; "yet your niece has certainly been
subjected to a severe shock. That unfortunate boy was greatly
disturbed in mind, and, as it appears, ran to Miss Nesbitt at once for
comfort. He meant nothing beyond a desire to gain help for his
mother, who is very ill."

"Mrs Darkham is ill?"

"Yes, seriously so."

"Good heavens! Nothing infectious, I hope? Oh, Agatha! And you

have been with her son just now! My dear"—drawing herself back
hurriedly—"had you not better go in and get disinfected? Sulphur is
very good, and—-"

"I don't think you need be alarmed in this instance," said Dillwyn
coldly; "concussion of the brain is not catching."

At this moment the sound of footsteps on the gravel outside could

be heard, and a laugh—gay, sweet.
CHAPTER X

Round the corner now came the elder Miss Firs-Robinson, with
Elfrida in her train, and Mr. Blount, the curate, in Elfrida's. And after
them a young man—rather short and stout, with clothes that
suggested London, and an unfathomable air. It was Mr. Browne,
who, when anything was on, could never keep his finger out of the
pie.

Mrs. Greatorex turned quickly to Agatha.

"Not a word about that wretched idiot," she said in a low tone.

"And stay for awhile; the servants will be sure to talk, and I should
like these people, who"—with a contemptuous shrug— "are
inveterate gossips, to see that nothing really has happened."

"But your niece—-" protested Dillwyn, seeing Agatha's exhausted air.

"My aunt is right," said Agatha quickly, fearing a collision between

the two—the young doctor's eyes, indeed, were burning fiercely. She
moved forward at once to meet the coming guests, greeted old Miss
Firs-Robinson with calm courtesy, and kissed Elfrida—Elfrida, who
looked back at her keenly for a moment, then pressed her into a
seat beside her, and pulled up a cushion behind her back. It
occurred to Dillwyn that he rather liked Elfrida. He bade good-bye to
Mrs. Greatorex, who seemed delighted to say good-bye to him. And
another good-bye to Agatha, holding her hand until he met her eyes.

As he went another guest came—Lord Ambert.

Mrs. Greatorex received him with effusion, and gave him a chair
near herself.

"A frightful thing, dear Mrs. Greatorex!" said Miss Firs-Robinson. She
sank into a wicker seat upon the balcony with tremendous effect.
Every one thought the balcony was going down. Providentially, it
rebounded from the shock, and was itself again.

"A frightful thing, indeed!" said Mr. Browne, who had subsided near
Agatha and Elfrida. "It has been a most merciful deliverance. I
thought we were all going to the lower regions, didn't you?"

"After all, it wouldn't be far!" said Agatha, thinking of the depth of

the small balcony—one so near the ground.

"My dear girl, consider! Even the very doughtiest scientists have
failed to find the number of descending acres that divide our
comparatively pleasant home from—-"

"From what?"

"Well," said Mr. Browne, "really I hardly like to name it in a select

assembly like this. But I believe nasty people call it— hell!"

"Oh, Dicky!" said Agatha. He was an old friend of hers. He was an

old friend of a lot of people. One had only to know Dicky Browne for
ten days to be quite a century-old friend of his. At this moment Lord
Ambert strolled towards them and up to Elfrida.

"I knew it would startle you, but you insisted," said Dicky Browne
reproachfully.

"What nonsense!" said Elfrida. "You know auntie was talking of this
sad affair about Mrs. Darkham."

"Yes," said the curate gravely. "She is dying, I hear, poor soul!"
"Oh no!" from all, which did not mean a contradiction.

"I am sorry to say it is true. I heard this morning there was no

hope."

"After all, she is no great loss," said Elfrida, with a sort of

determination in her tone.

"She is a loss," said the curate, defying her valiantly, openly, and to
her face. "She will be a loss to that poor son of hers, whom Heaven,
in a wisdom unknown to us, has afflicted."

"Oh, you know everything," said Elfrida, with a shrug of her dainty
shoulders. She almost turned her back on him. Lord Ambert came
forward and whispered a word or two in her ear. She laughed. The
curate fell back. Dicky, laying a hand upon his arm, drew him away
from the group and into the shadow of some large tubs filled with
shrubs.

Miss Firs-Robinson had been gaining a loose rein to her sympathetic

tendencies. And to Mrs. Greatorex!

"A shocking affair! Poor dear creature! Rather—er— behindhand in

some little ways; but such an end! Of course, Dr. Dillwyn has told
you all the facts of the case, but the details, they are so interesting;
but no doubt you've heard 'em."

Mrs. Greatorex, who would have given worlds to say she had, was
so carried away by her desire to learn the smallest minutiae of the
tragedy upon the spot that she gave way, and confessed that she
knew little or nothing of the terrible affair. She made the handsome
admission with quite an air, however. She did it admirably, but she
played rather above the head of her companion, who did not
understand her in the least.

"Law, my dear, how out of the world you are!" said that worthy, with
a patronising smile that filled the soul of Mrs. Greatorex with wrath.
"Well, I keep my eyes open and my ears too, and now I'll tell you."

Mrs. Greatorex made a movement as if to crush her with a well-

applied word or two, but she checked herself. If she offended old
Miss Firs-Robinson, she would learn nothing about Mrs. Darkham's
accident. If she endured her in silence, all the gossip of the
neighbourhood would be hers in five minutes. And five minutes was
not long to endure any one. Dr. Dillwyn had been vague, and too
much taken up with Agatha (she would have to put an end to that
presently) to tell her anything worth hearing, and so she had heard
nothing beyond the mere fact of the fall.

"Yes?" said she carefully.

Tea had been brought out by one of the small maids, who had now
ceased from her trembling, and Mrs. Greatorex stood up to pour it
out.

"She's dying," said Miss Firs-Robinson; "not a doubt of it! She's

heavy, you know; and her head came with an awful thud on the
ground. Concussion, that's what it is. They say the boy—that
unfortunate creature, you know—was in a frightful state; but they do
say that the husband bore it wonderfully."

"Scandalous gossip!" said Mrs. Greatorex, drawing back and letting

the tea overflow in the cup.

"Why?" asked Miss Firs-Robinson, who, if a gossip, was, at all

events, not a hypocrite. "I should think he'd be glad enough to get
rid of her—decently, you know—decently."

"Dear Miss Firs-Robinson, surely you don't quite mean what you
say!"

"Indeed I do, my dear. If people are tied together, and don't like
each other, they had better be separated."
"Good heavens, this is heresy!" said Mr. Browne. "You'll get taken
up, Miss Robinson, if you don't look out."

"Not me!" said the old maid, with her loud, hearty laugh. "No such
luck. Nobody ever wanted me in all my born days, except 'Frida. And
I stick to what I say. It's my opinion that poor Mrs. Darkham didn't
have altogether a good time with her husband."

"Ah, you are evidently prejudiced!" said Mrs. Greatorex sweetly.

"And prejudiced people, you know, have no opinions."

"I don't agree with you there."

"It is true, nevertheless. They merely adopt the thoughts of those

who think as they do, and suit their opinions to their likes and
dislikes. Unbiased judgement is beyond them."

"Then I'm not prejudiced," said old Miss Firs-Robinson, with another
laugh. "Your words prove it, because I beg you to understand I have
as sound an opinion as any one I know on most matters. And I don't
suit it to my likes or dislikes either, because I never could bear Mrs.
Darkham; yet I think there is some good in her."

"Who is Mrs. Darkham?" asked Mr. Browne. "That big red woman
with the voice of a costermonger I met here last year?"

"Yes. She slipped on an orange-peel yesterday, and is now hardly

expected to recover."

"After all, there is something in orange-peel," said Mr. Browne

thoughtfully.

"You think her death will be welcomed by some people?" asked Miss
Firs-Robinson, pushing up her pince-nez into better position for
battle. She had always suspected Mrs. Darkham's relations with her
husband; though, evidently, Mrs. Greatorex had not.
"By herself! Herself!" said Mr. Browne severely. "Just think of the
burden she has had to carry about with her for all these past years."

"There, you see!" cried Miss Firs-Robinson triumphantly to Mrs.

Greatorex. "Dicky has noticed it too."

It was delightful for her to know that somebody besides herself had
seen that the poor woman now lying low had not been altogether
kindly treated by her husband.

"I don't know what he has noticed," said Mrs. Greatorex coldly.

"And I think, Richard," casting a chilly glance at Mr. Browne, who

took it and apparently was lost in wonder over it, "it would be wiser
if you abstained from open condemnation of things of which you
know absolutely nothing!"

"I'm in it, as usual," said Mr. Browne, with an air of tender

resignation. "But why these cold glances? I've seen her, you know,
and seeing is believing. Surely, I must know something— some little
thing!"

"Of course," said Miss Firs-Robinson triumphantly. "To see her was
enough, poor creature! So dull—so sat upon!"

"Did he do that?" asked Mr. Browne, with perhaps too lively an

interest. "Dared he sit upon her? Well, she'd tempt one that way,
you know."

"I agree with you, Richard," said Mrs. Greatorex, with a friendly
inclination towards him.

"Dicky does not mean that," said Miss Firs-Robinson angrily. "He
knows, because I've told him, that her husband made her life a
burden to her."
"Oh, but, really, it was her flesh I alluded to, you know, not her
husband—not her husband, you know!" said Mr. Browne, with a
reproachful glance at the irate dames on his left, and a sharp attack
on the sponge-cake on his right. The tea-table is fatally near him.
"Her—eh—well, it must be a burden to her, you know, and no doubt,
poor creature! she'll be glad to lay it down."

He has now got a considerable portion of the sponge-cake in his

possession, and is waxing quite Christian in his air and smile. The
smile, indeed, is seraphic.

"I believe you've been taking us in all the time," said Miss Firs-
Robinson at last. She was broad-minded, and could laugh at her own
small defects at times. Mrs. Greatorex could not, however, and had
turned away, and was talking to Lord Ambert, who was giving her
rather curt replies, as he wanted to make the running with the small
heiress as strong as possible, and grudged a moment taken from his
stride. The small heiress, who was flirting assiduously with the
unfortunate curate, was well aware of his impatience with Mrs.
Greatorex, and laughed in her dainty lace sleeves about it.

"I am afraid auntie is not orthodox," said she, looking at Tom Blount,
who was still hovering round her, out of two very unorthodox blue
eyes. She was alluding to her aunt's late openly-expressed opinion
that married people unsuited to each other were better apart. "Are
you, auntie?"

Auntie drew near at this challenge; when would she not draw near
when that pretty voice summoned her?

"I don't know what I am," said that stout lady, with a beneficent
smile. "But, 'on my, if it came to living with Dr. Darkham all my life,
I'd cry 'No, thank you!'"

"Oh, auntie, now you are giving yourself away indeed! You are
uncharitable, and Mr. Blount will put you down as incorrigible," said
her niece, retreating behind the fan she held, as if horrified.
Evidently, she was ashamed of herself, thought her aunt. Blount,
however, was filled with unhappy certainty that she was laughing.

"Don't mind her, Mr. Blount," said old Miss Robinson very kindly.

"I know you won't do anything of the kind."

"Ah, Lord Ambert—going?"

"Yes—aw—just dropped in for a moment, you know. Good-bye," to

Elfrida, who smiled at him.

"See you at the Stackfords' on Tuesday?"

"I think not." She still smiled at him, her lovely little face a picture.
"This sudden illness of Mrs. Darkham's—it casts a sort of gloom, you
see."

"Yes; it would be inhuman," said the curate suddenly, "to go to a

tennis-party, or a party of any kind, when that poor woman is lying
at death's door."

"A merely plebeian idea, I assure you, Miss Robinson," said Ambert,
taking Elfrida's hand and pressing it in a tender fashion. "I trust you
will not let yourself be influenced by it, and that I shall see you on
Tuesday." He paused. "I shall see you to-morrow, at all events!"

He pressed her hand again, bowed to Agatha—he had already made

his adieux to Mrs. Greatorex—gave a nod to Dicky Browne, who
seemed delighted with him in some strange way, and without so
much as a glance at the curate, though, certainly, courtesy
demanded as much as that, he went his way.
CHAPTER XI

It was quite true: Mrs. Darkham was at the very portals of death.
Whether those great gates were to be opened for her, or she could
be dragged back from them, was the question that troubled the
physicians who attended her.

Perhaps it troubled her husband more than them. He was sitting

now in his library, in the big chair, with his arms hanging listlessly
over the arms of it, and his head pushed somewhat forward. He was
thinking.

The doctors had come and gone, and both were agreed. It was
almost an impossibility, but not quite; she might, if such and such a
change occurred, live. If not, death lay before her—a death into
which she would enter without revisiting, even in thought, this world
again. Dr. Bland, an elderly man, and one of great and deserved
reputation, gave it as his opinion that if death did not ensue in a
very few hours, hope might be entertained. Dillwyn had nodded an
assent, and had said a few words too—to the effect that such grave
cases had been known to recover even after hope seemed at an
end. He had kept his eyes carefully averted from the husband of the
injured woman whilst saying this. He had looked at him when he
first entered the room, but he could not trust himself to look again.
There was something terrible in Darkham's face, something hungry,
ravenous. An animal stalking its prey might have looked like that.

And now Darkham sat alone in his library thinking—thinking. They

had given it as their opinion that she would die—those two who left
—that she would die! Would leave him free— free of her accursed
company!

A sort of fierce joy rose up and seized upon him. It caught and
shook him. Free! free! After all these years! Free! She was dying.
Surely, certainly! In a few hours her breath would cease, and no
more would her odious, vulgar words and accents make him shrink
and shudder. She would be gone to the Great Unknown, and he—-

And it would be none of his doing—none! Here the great passionate

joy that thrilled him seemed to culminate. He would be rid of her,
without a single effort of his own. Had he even dreamed of making
an effort?.... He would be quit of her in an hour or two—a day at
latest. Surely the stars in their courses were fighting for him!

What was it they had said, those two? that if—if—he pressed his
hands, both of them, to his head—that if she lasted until morning
she might recover! Fools! She would not recover. Death was on her
face when last he saw her. Pshaw! he was a better judge than either
of them. Bland—an old man, too old; and Dillwyn—a young idiot,
who followed his leader naturally! But he—he knew!—he who was in
the prime of life, and had studied death—and life—in all their varied
ways.

Yes, he knew! Siva, the Destroyer, lay hovering above the woman —
whom the law called his wife—with outspread wings, awaiting the
moment to descend and clutch his prey. Soon—soon—let it be!

Oh, to be delivered from her! From this creature who made life a
torture; who had dragged him with a chain all these interminable
years—the years of a marriage that had damned him! When he
could have risen, that chain had nailed him to the earth, had clipped
his soaring wings, had withered every moment of his life. Truly a
young man starting in life should look well to the way he is going,
and should choose a wife meet for him. Marriage is not for an hour,
but for all eternity—sometimes!
This one, however! It will not last so long. This marriage will end
soon, thank—-

He broke off abruptly. Who was he thanking?

He rose suddenly and went to the door. He would go upstairs and

see how things were going on. He shook a little as he put his foot
upon the first step of the stairs, and looked back as if he would
willingly change his mind and return to the library. But he overcame
himself, and went steadily upstairs.

So he went, and entered the room, and beckoned to the nurse in

charge that she need not stay. She rose at his bidding, and slipped
through the farther door, glad enough to get away for and hour or
so. Her employer was a doctor and the husband of the sick woman
under her charge, and so she felt safe in leaving her. Besides which,
it was a hopeless case. The nurse had seen many such in the
London hospitals, and though some as bad had pulled through, still,
the percentage lay the other way.

Darkham went up to where the silent figure lay, and ruthlessly pulled
back one of the curtains at the end of the old-fashioned bedstead.

The light from the dying day streamed in through the window, and
lay on the dull, yellow face that rested on the pillow. It lit it up and
showed it in all its ugliness.

Darkham bent over it—lower—lower still, and looked—and looked

again. Was there a change? was there?

Already the face looked like that of a corpse. The lips were a little
parted, as if the strength to close them was gone, and the upper
teeth showed through them in a ghastly fashion.

And yet it seemed to the husband bending over her that there was
some slight return of strength, of consciousness, in the face beneath
him. It was so slight as to be all but unseen by any, save one
passionately interested either in her recovery or her death. If, after
all—-

He bent still lower, and then raised himself with a frown and a quick
sigh. No, he had been mistaken. Death would be her portion this
night. The two men who had just left had said it. Well, they were
right. She would die to-night.

He sat down in a distant arm-chair that still gave him a full view of
the bed, and gazed with uncompromising sternness at the form
thereon.

He fell a-musing again. How death-like she looked! How close to the
last breath! Just a step one way or the other—this way to life, that
way to the grave. A touch, a single movement, and she would be
beyond the line that divides the darkness from the light.

Great heavens! how, even in the helplessness of her, her face retains
its old expression! The vulgar sneer still dominates it, the drawn lips
are still replete with venom. What a life he has had with her! A life?
Nay, a death.

The night was descending, but out of the misty darkness of the
room a girl's face stood—calm, cold, lovely. There from the end of
the room it looked at him, the eyes shining clear as day and full of
truth.

He turned uneasily, and rose and began to pace the room stealthily,
silently, yet with a sort of cruel spring in every step. It was as
though he could hardly keep himself in; as if some vitality within him
was at work, and urged him forward— forward—always forward.

Why had the accident been so slow a thing? Death—instantaneous

death—how much more merciful it would have been to her, to him!
A heavier fall, by half an inch or so, and all would have been at an
end. There would have been no more room left for doubt, for fear,
or for joy. He did not mince matters to himself as he walked there to
and fro like a caged lion. He was strong enough to tell himself the
truth.

He stopped himself in his strange hurrying up and down, and once

more approached the bed. He bent over her and lifted her hand that
lay so miserably helpless within his, and then let it fall again.

It sank upon the coverlet with a little dull thud, scarce audible, save
to him whose ears were strained to hear, whose senses were so
preternaturally on the alert. Why had her head been so hard, or else
those flags so soft! A less thing had killed a score of fools before
this.

Something in her face again arrested him. Surely there was a

change. He placed his ear close to her mouth and listened. When he
uplifted himself presently his face had taken a grayish tinge. Her
breath was certainly stronger and steadier.

He went back to the arm-chair and seated himself slowly in it.

He rose, as though he found it impossible to be still, and laid his

hand upon the mantelpiece. His grasp was so hard that his knuckles
stood out white against the black marble. That devil, Dillwyn, had
said she might recover. No doubt his hope was father to his opinion.
He would do him, Darkham, a bad turn wherever he could. There
had been occasions lately in the neighbourhood when this young
fool thought—strove—to wrestle with him in professional matters.
There was that affair of General Montgomery's the day before last
when Dillwyn had been called in to the Cedars. The general was an
important person in the place, and though scarcely en rapport with
Darkham, had generally employed him up to this. He thought of
Dillwyn, of Agatha's face as he had seen it at Miss Firs-Robinson's
dance—looking into Dillwyn's—of the preference shown to the latter
by General Montgomery and a few other unimportant people, but
people who always mean the thin end of the wedge in such affairs,
and his clasp upon the arms of the chair grew tighter.
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